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HomeMy WebLinkAbout1074 CRAIGVILLE BEACH ROAD - Health r 1074 CRAIGVILLE BEACH RD., C'VILLE A= w. e •, o r f 1 a t K ® z IN UPC 12534 No.24 `a�,�L�.s MA�TIMO�.YN i a .. y ,,..---....,,,_ ,..�.,.,......�.-. ._.._..,.,,__ C' —�, COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 282-6600 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. ST&L Hfi Governer SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Cornt:uas:oaer PART A Q'71.j- Cr,,jt✓�I je CERTIFICATION Property Add►ass.CeA2 rvj'11i P1,q 02 4 3a • Nama of Owner Data of arts /a vao Address; er:ct Own _�{fS Inspection: Ya� Narna of Inspector:(Please Prim) 4111 l 0 e// I stm a DEP„_pjxoved system inspecto►pursuant to Section 15.340 of IW*51310 CMR 15.0001 Company Name: V l o - TEG lY Maifiry Adrirm: P0 � � Teleprftone Number: aS 5-�0� C Sob) a onq q40 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system-at this address and that the information reported below is true, accurate and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sew& disposal systems. The system: Passes Conditionally Passes _ Needs Further Ev stion By the cal Approving Authority Fails Inspector's Signature: Date: �O.O The System Inspector shall ubmit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 shell submit the report to the appropriate regional office of the Department ofrEnvironmental Protectlun. The original should'ba sent lo't►ri7 system owner and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS 49 0 .,� °ter revised 9/2/98 Page Ior11 `�Printed on Recycled Pape, I SUBOURFACE SEWAGE DISPOSAL GY07 M IfMPECTION FORM MART A /0 7/�f Cr 101111FICATIOW(oWdnued) uw`i lfe �� Vvop,orty AddrNa: Ce-n4i?,,✓,Ile 1/4,-^ Od b.34 Owner: j'CJ G Dsa of ksepecllon: 11/A i d 000 INSPECTION sUMIMARY: Check A, A C, or 0: �. SYti ASSES: not found any Informatlon which indicates that any of the failure eo»dleione doewlbed in 210 CMR 16.302 exist. Any feliwe criteria not evaluated ars Indicated below. , COMMENTS: B. sySTE M CONDITIOfIIALLY PASSES: _Al Ora or more system components as described In the"Conditional Pass"Nation need to be replaced or repaired. The system,upon completion of the replacement or,repair,as approved by the Board of Health,wql pose. lndicoto yes,no, or not detsrmined(Y.N.or NDI. Describe basis of determination In all Instances. if "not detertnined",explain why not. _ The septic tank Is metal, unless the owner or operator hot provided the system Inspector with to copy of a cartMooto of Compliance tatteched)Indicating that the tank was Installed witMn twettly(20)Yeats prior to the data of the inspection;or the septic tank, whether of not metal,Is cracked,structurally unsound,shows substantial Infiltration or oxfiltration,or tank failure is imminent, The syetem will poll Inspection if the existing septic tank Is replaced with a complying septic tank to approved by the Board of Health. _ Sewage backup or breakout at high static water level observed In the distribution box Is due to broken or obstructed pips(a) or due to a broken, settled or uneven distribution box. The system will pass Inspection If(with approval of the Board of Health) broken pipets)a►e replaced obstruction Is removed distribution box is Isvolled or replaced P The system requtrad pumphtylno'e then fourVmes a yeardus to bro*m or vtntrnoted plpetst. Tho trysfsrtn wllt�es•, inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed a :�':;$ed 9/2/96 Page 2ol11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address•1Ce04e-yr11g /17.t ©a 00�,_ Owner: C / Date of Inspection. aoQ0 C.,AlFURTHER EVALUATIO 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 the public health, safety and the environment. 11 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 WHICHJMLL.PRQTECT THE PUBLIC HEALTHAND SAFETY AND THE ENVJBONMEKT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). r 3) OTHER revised 9/2/98 Page 3of11 e e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:Ce-,4,V-1/e Pv?. oat�vT� Owner: Pe c 4-, Date of Inspection: lf/�/ 0 D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: /V I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No/ �• Backup of sewage into fecility-or-o,stem component due tto an overloaded orcbgged SAS,or�ceaspool. ✓/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ _✓/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). �. Number of times pumped j Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. ny portion of a 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 I of a public well. j� 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for •-coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen. r E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: Al The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system ie•wiIWn 200 feetvf-o-tfibutary-teaeurfoo"Wriking-water•6upply 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further inforuiation. revised 9/2/98 Page 4oriI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 10/n Y CM+S,I ll e Ad Property Address: C .14er•v;Ne VI-, Owner: e c G►� Date of Inspection: Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes,/ No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system compoaants.kameAmen pnarpad.for-atJaast two%veWw and•the system hasbwaaeceiwogwmusial flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. jZ _ The system does not receive non-sanitary or industrial waste flow. V _ The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. V _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on-the site has been determined based on:- Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) 115.302(3)(b)I _ The facility owner(and.occupants.if differeW from-.owner)rwwareprouided.withinfnrmalioavn.tha4mmper�aintanaaoa,of SubSurface Disposal Systems: revised 9/2/98 Page 5of11 h� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Cr��V�(/ SYSTEM INFORMATION Property Address: -i e, brl f IQ VVI,, Owner: Date of Inspection4/.)— 1/��� FLOW CONDITIONS RESIDENTIAL /� Design flow: g.p.d./bedroom. Number`of bedrooms(design): Number of bedrooms(actual):- Total DESIGN flow Number of current residents: Q Garbage grinder(yes or no): A/O Laundry(separate system) (yes or no):IV2); If yes,separate inspection required _ Laundry system inspected (yes o v Seasonal use(yes or no): SO /Llll� Water meter readings,if available(last two year's usage(gpd): N Sump Pump lyes or no):A10 Last date of occupancy: Z, /9 /9// COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: 9pd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present:(yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: - Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Q /, Q y v'^ ki -eu00 System pumped as part of inspection: (yes or not If yes, volume pumped: gallons Reason for pumping: TYPE 9"YSTEM V 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installediif known)-and source ofdnformation: - /6061 ' Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 Page 6of11 o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l o'24 C/u5(r.�(� / SYSTEM INFORMATION(continued) Property operty Address: (e,,,��V,ll� tM� OZ63�, Date of Inspection: !'f° I,,- BUILDING SEWER: �/dl��oco (Locate on site plan) Depth below grade:/� Material of construction:_'cast iron_`� O PVC_other(explain) Distance from private water supply well or suction line Diameter 171-1V Comments: (condition of joints, venting, evidence of faakage,etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_Fiberglass ,Polyethylene_other(explain) If tank is metal,list age_, J�s.age confirmed by Certificate of Compliance_(Yes/No) Dimensions:_ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: 5r/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of out t tee 6�� How dimensions were determined:f�� ; P.5 ,e. Comments: (recommendation for pumping, c dition of inlet and outle)tees or-be les-depth of liquid level in relati n to utlet inv�pft,structuraWn grity, evidence of leakag�e++etc.) vc�y,� .�s kilo 1/lC���!� %,e lc DD Loll- GREASE TRAP: (locate on site plan) Depth below grade:_ 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: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/98 Page 7ofI �e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM / p � PART C t�//r�rJlV,�I? Imo' SYSTEM INFORMATION(continued) Property Address: Owner: Ae c 4-- Date of Inspection:: T/�l �000 TIGHT OR HOLDING TANK: A/ (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) / Depth of liquid level above outlet invert:i 'M� Comments: (note if level p9d distribution is equJ�{, evidence DDf solids cy vey, evident of leakage into or out of box, etc.) — O �X ��y /i /(/t7 �GJI[Cis P J^Ci �� :✓S e PUMP CHAMBER:_ (locate on site plan) L Pumps in working order:(Yes or No)�J Alarms in working order(Yes or No) is Comments: 77— CO(note gdit' n of pump cha er,condition of pumpq and appurtenances,etc.) Z,✓`r C�el1.7 ze ✓1E i^ revised 9/2/98 Page 8orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l SYSTEM INFORMATION(continued)� C�u I Property Address:Gelr(/el� 01,1 06,3, Owner:Ina EC 4 Date of -0 SOIL ABSORPTION'S S CS S):_ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ / — leaching trenches,number,length: �� vc V`'1 v�n C,. leaching fields,number,dimensions: / ?TO— � " overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note conditio ot�oil,signslot by lic failure,Ityrebof ponding,Flamp soil,condition of v getption, etc.) ev d o�7 L /QG i Cr " ♦ /ji 0 CY4 r lr— 4 • /Y"D O in r CESSPOOLS:/_ (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(cesspool must be pumped as part of inspection) 0 Comments: (note condition of soil, signs of hydraulic failure,level of pending,.condition of-vegetation, etc.) - PRIVY: N (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ce , .��, Owner: /� Date of Inspection. clyll SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Fpl� o� use Q +3 h. t Cry N" /.id- - revised 9/2/98 Page 10of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /O? (,_a hf SYSTEM INFORMATION(continued) Pr Address Cen94cr(/J�e e, U Property ✓� d-4�aL Owner: `I ` Date of b apection. � �� 'o C+f1 NRCS Report name Soil Type_ Typical depth to groundwater USGS. Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater , -Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions t//Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers I//Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) J l Jo /oti��l/Yi��F✓, ✓eCp✓'C'e� A,� l0 Ccr / � I,✓��-� �' � f4 ��J • �,r9,�, �S G, )Mop�►� ��S�e�• �pTTiO✓''l lt°GrGs1�►1 1 S` .Ga GJ/Gi4, J�3�i/i✓l� °� Zone revised 9/2/98 Page ll_of11 r Commonwealth of Massachusetts Title 5 Official Inspection pection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. enterville, M 02632 Property Address Susan Bloom 2644 Main St. '•Q Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When e A. Inspector Information r filling out forms p on the computer, O use only the tab Paul C. Martin key to move your Name of Inspector cursor-do not Cape Cod Septic Services Inc. use the return Company key, p y Name 350 Main St. rab Company Address West Yarmouth MA 02673 Cityrrown State Zip Code 508-775-2825 S15016 Telephone Number 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 " 1/22/2019 Inspector's Signat re 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <F� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. Cltyrrown 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: System is in working condition. 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•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1074 Crai ville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of inspection- C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ 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 0 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: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . / 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. Cltyrrown 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 soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well`*. Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official ' icial Inspection Form tia Subsurface Sewage Disposal System Form-Not for Voluntary Assessments <I" rY 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary 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 1/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 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 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 II of a public water supply well Lt5,..p..doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts _ I? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town 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 all 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form- a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. Cltyrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x2= Description: 220gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage(gpd)): 2017=41gpd Detail: 2018=41gpd Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form S Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1074 Crai ville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 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: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Crai ville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of Inspection 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: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ❑cast iron ED 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean properly pitched with no sign of root intrusion. t5insp.doc-rev.7/26/201 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,A Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6„ 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: 1000Gal Sludge depth: 1-2" Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0" 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? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal tank in good condition. PVC tees inn place and clean. Tank at normal operating level. Covers 6" below grade. I 15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. Cltyrrown 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: 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.): 8. 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 El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form h�4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. Cltyrrown 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 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 3 lines out in good condition. 2" Inlet line has tee in place. Box is clean and level with minimal solids carryover. Outlet inverts equal. No sign of overloading or hydraulic failure. 15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 . Commonwealth of Massachusetts l? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name inormation is requiredforevery Barnstable MA 02630 1/11/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): Pump and alarm in working condition. Chamber is clean. * 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: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t� 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of Inspection 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.): Mounded leach field was found dry during inspection. Lines were viewed with camera and found to be clean and dry. No sign of overloading or hydraulic failure. 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.): l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ," 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): Lt5inv.,doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Crai ville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every. MA 02630 1/11/2019 page. Cltyrrown 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 f Commonwealth of Massachusetts lip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1074 Craigville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 4.5' below sas 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: 1990 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Prior report ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file at BOH and prior report on file at BOH. 4.5' separation to adjusted groundwater from bottom of SAS. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 ' Commonwealth of Massachusetts I'� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� •� 1074 Crai ville Beach Rd. Centerville, MA 02632 Property Address Susan Bloom 2644 Main St. Owner Owner's Name information is Barnstable required for every MA 02630 1/11/2019 page. City/Town 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Page 1 of 1 looms „. .'aRr'85.+nYF—A-LWiL"T(it.V±ff,'fS')iP4r�4SAf..$X'°ti'1u'hi'3MFS3+ �, q, 4 Y _ `'!kjVAR l'7�Xk' �s•• `Y'S"�i'7H1'1'NGLbRi1AAT3LSr"F`(s1IDvi+llsllm@J . A -f§aita+RS'`Aiaii 'L" 'AR^d� a $ +' i a'tdw,ree dd_— ' t G bw i r AY Ann 2 a a s: w 6.. _ � A•' ':,,. �' =�ncfraal®u:a c+;y�+i laa�,a.iwa)van urrrns p�amcadFc� � � � ' faiwp all%'^Iis r.3tttdre'Y40 i6c�see, pp -.:w-.-.... , ""'•"w`Aw"'�.'v',r�r.�-�� W f 4 f Not, � ,+ F + 1` oil https://mail-google.com/` /scs/mail-static/ /js/k=gmail.main.en.gNJGSxrCYso.0/m=pds,p... 12/14/2017 Commonwealth of Massachusetts -: . Executive Office of Environmental Affairsslit �� 'i� Department of .. Environmental Protection Wlillam F.Weld �' e..Zd%�-Struhs yCoxe fiiorsrrar S!usfatY AMso Paul Cellucci U.Gommor vrdsd rw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Jody Dupuis 1074 Craigville Beach Rd y Property Address: Centerville Address of Owner. 65 Lurton St Date of Inspection: 9—1 9—9 6 (If different) Quincy MA 01269 Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8 ) 7 7 5—8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on.a sew disposal systems. The system: asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority —. Fails Inspector's Signature: /IV J �, Date— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B, C,or D: A] tl PASSES: ve not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or exffitration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) -1 One Winter Street • Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-5500 Printed on Recycled Paper i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 1074 Craigville Beach Rd Centerville Property Address: Jody DuPui s Owner. Date of Inspection: 9-1 9-9 6 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(@) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will paw inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C1 FUR ER 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. 2) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND_PUBLIC WATER SUPPLIER,IF APPROPRIATE) ETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. 3) O ER (revised 11/03/95) 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) 1074 Craigville Beach �Rd Centerville Property Add1°°°° Jody DuPuis Owner. 9-1 9-9 6 Date of Inspeetion: D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 16.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for ooliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE YSTEM FAILS: e following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: 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) The o r or operator of any such system shall bring the system and facility into hill compliance with the groundwater treatment program require m me of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 1074 Craigville Beach Rd Centerville Property Addrom Jody D u P u i s Owner. 9—1 9—9 6 Date of Inspection: Check if the following have been done: 14ping information was requested of the owner,occupant,and Board of Health. _PAqone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓Asbuilt plans have been obtained and examined. Note if they are not available with N/A. /Thesb facility or dwelling was inspected for signs of sewage back-up. _jAe system does not receive non-sanitary or industrial waste flow _LAe site was inspected for signs of breakout. system components,excluding the Soil Absorption System, have been located on the site. L11The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. °/The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. "e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddreas: 1074 Craigville Beach Rd Centerville Owner. Jody DuPuis Date of Inspection: 9-1 9-9 6 FLOW CONDITIONS RESIDENTIAL:- Design flow:_?3A gallons Number of bedrooms: Number of current residents: Garbage grinder(yes or no):,je 16 _ Laundry connected to system(yes or no): Seasonal use(yes or no):-x� 1994 14, 000 gal Water meter readings,if available: g 995 22 , 000 gal / 1996 1 ,.000 gal ( 6 mo) Last date of occupancy:&,s1t CO1 MERCIAL INDUSTRIAL Type establisme hnt: Design ow:__gellons/day Grease t p present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non waste discharged to the Title 5 system: (yes or no)_ Water readings,if available: Last date o occupancy: OTHER:( •be) Last da f occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: - 1A System pumped as part of inspection: (yes or no)_ If yes,volume pumped: gallons Reason for pumping: TYP!78te =distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yea or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: ci /a.. < Sewage odors detected when arriving at the site: (yes or no)LL (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1074 Craigville Beach Rd Centerville Property Address: Jody DuPu i s Owner. 9-19-96 Date of Inspection: SEPTIC T ANK.•_V(locate on site plan) Depth below grader _ Material of construction:W concrete_metal_FRP_other(e:plam) Dimensions: t!; Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:Ll 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:LPL Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) �e t: �-t J c� •�c� G E TRAP:_ (locate n site plan) Depth ow grade: Material f construction:_concrete_metal_FRP_other(e:plain) Dimena no: Scum from top of scum to top of outlet tee or baffle: from bottom of scum to bottom of outlet tee or baffle: Commen (recomme tion for pumping, condition of inlet and outlet toes or banes,depth of liquid level is relation to outlet invert,structural integrity, evidence o leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) 1074 Craigville Beach Rd Centerville Property Address: Jody DuPuis Owner. 9-19-96 Date of Inspection: TIGHT OR HOLDING TANK:_ ( site plan) Depth grade: Material construction:_ooacrete_metal_FRP_other(explain) Capacity: ons Design flo gallons/day Alarm Comments (oondition f inlet tee,condition of alarm and float switches,etcAll DISTRIBUTION BOX: (� (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP C BER:_ (locate on its plan) Pumps' working order:(yes or no) ts: (note ndition of pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addrem 1074 Craigville Beach Rd Centerville Owner. Jody DuPuis Date of Inspection: 9—1 9—9 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possibl;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number:_ leaching chambers,number•. _ leaching galleries,number leaching trenches, number,length: --k `�.-4- leaching fields, number,dimensions: overflow cesspool,number: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) C LS:_ (locate on 'te plan) Number an configuration: Depth-top o liquid to inlet invert: Depth of so layer- Depth of layer: Dimensio of cesspool: Materials construction: Indication of groundwater: ow(cesspool must be pumped as part of inspection) Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: (locate on plan) Material f oonstruction: Dimensions: Depth of lids: Common note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) (revised 11/03/95) g w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 1074 Craigville Beach Rd Centerville Property Address` Jody DuPu i s Owner. 9-19-96 Date of Inspection: SI(EPCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 1 r rrO4. 1 g / 16 a-d C1 4 i DEPTH TO GROUNDWATER y Depth to groundwater:_feet method of determination or approximation: b (revised 11/03/95) e No._�..�.:.s�.:`z�.. G iM��CLq c%v�c y Fss ©. THE COMMONWEALTH OF MASS_AtHUSETTS BOARD OF HEALTH .�J.. .1.1 .......OF. ,.� V1 .Y ........................................ Appliratiurt for Disposal lVarkil Tonstrurttun jJrrmft Application is hereby made for a Permit to Construct ( ) or Repair ('Nf an Individual Sewage Disposal System at: ..R. ............. . s Cagy==,. ....................__------- ocati -Address or Lot No. -------....:M�..1��1:_...:.1��. :�.� --- ................... ..................�!s!!�—�.�_. .................................... _....... Owner Address W �.lr's�P � � — ............P,.6j.�... SL..... <1 ,�_......---•--------------------------- .... .... - ... pq Installer Address VType of Building Size Lot............................Sq. feet ►4 Dwelling—No. of Bedrooms------3-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) p,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------•---•---•................................... W Design Flow.f.' ..........................gallons per person er day. Total daily flow.._ . .......................gallons. WSeptic Tank—Li quid'cap acity.f4ZZ).gallons Length....pf........ Width....___._._ Diameter................ Depth................ x Disposal Trench No.._..�----------- Width....Q.......... Total Length..p;Ld........ Total leaching area_-"-�`�..JY13. ft. 3 Seepage Pit No---------------_---- Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0.4 Percolation Test Results Performed by-----•-----•••-•••-•••-•--•-••••--•--•---••-----•..............•••....... Date........................................ 0.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -•.....................•-.--.------ ......------.-----*-------------------------------- 0 Description of Soil........................................................................•-••-•------------------------------•---------..............-----------------•-••••---••---•-_.. W U ...... ------------------------------- ---------------- ----------- ---------- ....... -------------------------------- ------------------- .._...------- ----------------- •- ------------ W UNature of Repairs or Alterations—Answer when ap licable..-_=A4it-l..._..LAlTV- snK_ 7*_41 K---------------•. 1 4c.......fit " -.o --------------------------------------•------------------.............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITLU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board pf health. _ Signed- ---- ------ -• ----•�-Z------�-- - --------•---------------•---.... _ - Date Application Approved By.............. �-...... �t:�o.._r�--% ----------------------------------- ----------- -- t?.1 _ 4� Date Applieatio Disapproved for the following reasons:---. T-4 __ �lr .....:r•�P!1 .. --- -.. P- 1_ 2 A -------- PermitNo........... .' -- ---------•---------- Issued........................................................ Date /fit+^.'�F<•ar-,,.�r r ,�•.r f�--�•�•�7+'.r;7g. rn'4.�,- :art .1. .-''1': `�r^1 . .#.-ate f - ��.,�t;k;;-.� '`R'�3: THE COMMONWEALTH OF MASSACHUSETTS V BOARD~ OF HEALTH r '.... .......OF....... .................................. Appl ration for Disposal Works•T nstrudion 11rrm # .. Application,is hereby made for a Permit to Construct ( ) o Repair I( Van Individual Sewage Disposal System at:' - -` _.. �A.. .... .e-1, M~• - R ors► ��1 . _ :: Add - T . . •------------ ,• :- �, ........................._.._..._.. 0..... Location- ress I- or Lot No. _tom r ... .. ....... ..... .:�.a i tlu.-�................ `! Owner Address.........................»................ W .......................... � u L1 Cam, ,.a +..�_ Installer Address 2 Type of.Building r= Size Lot........P:..................Sq. feet ►.. Dwelling—No. of Bedrooms.... ............................:......Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building ..._... No. of g ----•-•-•-------•-•-- persons............................ Showers ( ) — Cafeteria ( ) 14, Other fixtures ..•-•---------------------------------------•--------.-----••----------------.------- .............................................................. Design ' 'Flow....<- . ...................gallons per person per day. Total daily flow._.���n._..........................gallons. W Septic Tank L uid'capacity. gallons Length.... .---.:. Width.... Diameter................ Depth................ x Disposal Trench No. .......... Width....c ........... Total Length.. d........ Total leaching area../.--.ear--A q. ft. 3 Seepage Pit No..........:.......... Diameter.................... Depthlbelow inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank (/ ) aPercolation Test Results Performed by..............;/........................................................ Date........................................ 04 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f�. Test Pit No. 2................minutes per,,inch Depth of Test Pit.................... Depth to ground water........................ a ......................e:..................................................................................................................................... D Description of Soil............................ . .•-•-•---••------............-----•-•----•---•-----••------•-----------•-••--•---------•.............----......------••---•---...----... U --•----•----------------------------•--------------•--......----------...............•-•--• •----------......-•-----------•-•--........-•----•--•-------...•-•..I._.........-••--•-•...._ W x U 4 Nature of Repairs or Alteration$—Answer when applicable.-'�! TI `..._t of a`- y (,c.( :.............. -'�'�%'v.-•.--'Thin e X-��-"r/ - ...9.:�w��4zc-C---------------------------•-•-•------•-•-------.............------...........-...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT!.z . 5 of the,State Sanitary Code— The undersigned further agrees not to place the system in :,operation,-until.4 Certificate of Compliance;has been issued by,theL oard health q -, "-..' -"T'9- "e• ....:.a._ ..�}.» ,a.Me.n. 7..r� Signed_..�...0 G�....`--7 0 r � -• .- -- --- �•.----- -----• - - • •-• -- ---� •Date - Application Approved BY .3� _n..d ---•-----------•-•-------•----•- = ! Date Application Disapproved for the following reasons:....�l- ..� ^ -•-�` /a.. . ......-,tr;�s!�, D -- Permit No........ s :•��..................- Issued-_ i' .................••-•-D •- au THE COMMONWEALTH OF MASSACHUSETTS M L BOARD OF HEALTH 7..71 .W.N.......'OF-; r 4- ............... Trrtif irate of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by----------------------------G!( �P c:1:�v w -cove T�------------------------------------=-•.:......-•--------------•------......---------......---...--•------- Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---------- ----=. ..... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. '. DATE...... � ��........ ......... --• ...... Ins ectos' ... G . __.._..__...—._...--- P THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH` No.. / `.:. .?. .............0F .1 ! �c?.4 .............................. / FEE..6 ........ Disposal Works Tonstrirtion f rrmit Permissionis hereby granted......................................................................................................................................... to Construct ( ) or Repair (1)an,Individual Sewage Dispo System at No...._.......,..h...77.q........�! 1A.�i.?��� ?...... P s.. G' y :`(L * ' --- --- ----------•--- Street as shown on the application for Disposal Works Construction Permit No Dated.......................................... ---•.............•-•...... 0-•-••----•.....-•-•----•---••-••-•---••......•- p ! uI rd of Hcalth DATE.............. ���'_�_I ....................... ••-•-•--- a cCb �< on v i e. Vft VV ell l —21 !� •Ma. t a a z -t p �a 66 N� In �? to — m 939 main street rt 6a 362-4541 ' yarmouth port mass 02675 down cope engineering civil engineers& land surveyors structural design May 18, 1990 Arne H.Ojala P.E.,R.L.S. land court Richard R.Fairbank P.E. surveys Tom McKeon Barnstable Health Department site planning Barnstable Town Hall 367 Main Street Hyannis, MA 02601 sewage system designs Reference: 1074 Craigville Beach Road, Centerville Proposed addition inspections Dear Tom: permits As discussed Thursday, I have shown on a plan the intended use of Mr. Dupuis ' ,proposed addition. The Dupuis ' wish to increase the size of an existing small kitchen to create a sufficient space for kitchen use and an eating area. An existing bedroom is to be extended and additional storage and closet areas are to be created at the end of the bedroom. The existing bathroom (within the larger bedroom) is also to be . increased slightly. I have also provided septic calculations on the site plan of Mr. Dupuis ' property. The existing leaching trenches have a design flow of 300 gallons per day. The Conservation Commission is requiring a statement from the Health Department regarding the adequacy of the existing septic system for the proposed addition. I would appreciate your help in this matter. If you have any questions, please call me at 362-4541. Sincerely, Albert H. Roberti Environmental Consultant Down Cape Engineering, Inc. encl I r 362-4541 939 main street rt 6a yarmouth port mass 02675 dOWO cope engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court May 18, 1990 Richard R.Fairbank P.E. surveys site planning Dear Abutter: sewage system Acting under 310 CMR 15.00 and Town of Barnstable designs Regulations (effective November 1, 1983 and revised June 3, 1986 ) , Marvin Menzin (26 Mason Street, Lexington, MA 02173 ) has applied to the Barnstable inspections Board of Health for variance requests for ,a subsurface septic system at Lot 3, Nyes Neck Lane, (Centerville) Barnstable, MA. These requests are as follows: permits - The leach facility is to be located 130 ' from a well (a variance of 20 ' is requested under Town of Barnstable Regulation adopted 10-22-74) . - The reserve and leach facility are to be located on the abutting property, Lot 2 (10 ' variances are requested under Title V Regulation 15.03 (7 ) ) . The hearing on the above has been scheduled for June E, 12, 1990, at 7 :00 p.m. in the conference room of the Barnstable Town Hall, 367 Main Street, Hyannis. Plans are available at the Health Department for your review. Sincerely, Albert H. Roberti Environmental Consultant Down Cape Engineering, Inc. ti 362-4541 939 main street rl 6a yarmouth port mass 02675 down cape engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.•R.L.S. land court May 18, 1990 Richard R.Fairbank P.E. surveys site planning Dear Abutter: sewage system Acting under 310 CMR 15.00 and Town of Barnstable designs Regulations (effective November 1, 1983 and revised June 3, 1986 ) , Marvin Menzin (26 Mason Street, Lexington, MA 02173 ) has applied to the Barnstable inspections Board of Health for variance requests for ,a subsurface septic system at Lot 3, Nyes Neck Lane, (Centerville) Barnstable, MA. These requests are as follows: permits . - The leach facility is to be located 130' from a well (a variance of 20' is requested under Town of Barnstable Regulation adopted 10-22-74 ) . The reserve and leach facility are to be located on the abutting property, Lot 2 (10' variances are requested under Title V Regulation 15.03 (7) ) . The hearing on the above has been scheduled for June 12, 1990, at 7:00 p.m. in the conference room of the Barnstable Town Hall, 367 Main Street, Hyannis. Plans are available at the Health Department for your review. Sincerely, Albert H. Roberti Environmental Consultant Down Cape Engineering, Inc. Y 362-4541 939 main street rt 6a yarmouth port mass 02675 do wo cop a engineerhy civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court May 18, 1990 Richard R.Fairbank P.E. surveys site planning Dear Abutter: sewage system Acting under 310 CMR 15. 00 and Town of Barnstable designs Regulations (effective November 1, 1983 and revised June 3, 1986 ) , Marvin Menzin (26 Mason Street, Lexington, MA 02173 ) has applied to the Barnstable inspections Board of Health for variance requests for ,a subsurface septic system at Lot 3, Nyes Neck Lane, (Centerville) Barnstable, MA. These requests are as follows: permits' The leach facility is to be located 130' from a well (a variance of 201 is requested under Town of Barnstable Regulation adopted 10-22-74 ) . The reserve and leach facility are .to be located on the abutting property, Lot 2 (10' variances are requested under Title-V Regulation 15.03 (7) ) . The hearing on the above has been scheduled for June 12, 1990, at 7 :00 p.m. in the conference room of the Barnstable Town Hall, 367 Main Street, Hyannis. Plans are available at the Health Department .for your review. Sincerely, Albert H. Roberti Environmental Consultant Down Cape Engineering, Inc. ` 362.4541 939 main street rt 6a yarmouth port mass02675 dOwin Cope einifineeriiag civil engineers& land surveyors structural design Arne H.Ojala P.E.,R.L.S. land court May 18, 1990 Richard R.Fairbank P.E. surveys site planning Dear Abutter: sewage system Acting under 310 CMR 15.00 and Town of Barnstable designs Regulations (effective November 1, 1983 and revised June 3, 1986 ) , Marvin Menzin (26 Mason Street, Lexington, MA 02173 ) has applied to the Barnstable inspections Board of Health for variance requests for ,a subsurface septic system at Lot 3, Nyes Neck Lane, (Centerville) Barnstable, MA. These requests are as follows permits ' - The leach facility is to be located 130' from a well (a variance of 20' is requested under Town of Barnstable Regulation adopted 10-22-74) . - The reserve and leach facility are to be located on the abutting property, .Lot 2 (10' variances are requested under Title V Regulation 15.03 (7 ) ) . The hearing on the above .has been scheduled for June 12, 1990, at 7 :00 p.m. in the conference room of the Barnstable Town Hall, 367 Main Street, Hyannis. Plans are available at the Health Department for your review. Sincerely, Albert H. Roberti Environmental Consultant Down Cape Engineering, Inc. r ` 362-4541 939 main street rt 6a yarmouth port mass02675 down cape engineering civil engineers& land surveyors structural design Arne H.Ojala P.E.•R.L.S. land court May 18, 1990 Richard R.Fairbank P.E. surveys site planning Dear Abutter: sewage system Acting under 310 CMR 15. 00 and Town of Barnstable designs Regulations (effective November 1, 1983 and revised June 3, 1986 ) , Marvin Menzin (26 Mason Street, Lexington, MA 02173 ) has applied to the Barnstable inspections Board of Health for variance requests for ,a subsurface septic system at Lot 3, Nyes Neck Lane, (Centerville) Barnstable, MA. These requests are as follows: permits - The leach facility is to be located 130' from a well (a variance of 20 ' is requested under Town of Barnstable Regulation adopted 10-22-74 ) . - The reserve and leach facility are to be located on the abutting property, Lot 2 (10' variances are requested under Title V Regulation 15.03 (7 ) ) . The hearing on the above has been scheduled for June 12, 1990, at 7:00 p.m. in the conference room of the Barnstable Town Hall, 367 Main Street, Hyannis. Plans are available at the Health Department for your review. Sincerely, Albert H. Roberti Environmental Consultant Down Cape Engineering, Inc. � TOWN OF BARNSTABLE �� L-c T— LOCATION 107 Lk GvZ W�\k-e )t:Lcc� SEWAGE # qO VILLAGE ASSESSOR'S MAP Cz LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY j Orb LEACHING FACILITY:(type)-ME-NC VG a (size) NO. OF BEDROOMS-PRIVATE WELL OR,�I BLIC WATER, BUILDER OR OWNER DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No I L Si Q6 tO O O o � a o � p D Nu i D � � D k I. a �J 10 7.L( 66 We, GEORGE J. MULRENI.N an(l THERESE M. NIULRENIN, wife as Miants by the entirety, both III of Bay Road, Barnstable (0sterville), Barnstable in consideration of Thirty-nine Thousand Three IfundrQd ($30,'100-00) and OG/100 Lk-,i I ar5 grant to LINDA L. TETREAULT of 980A North Adain Street, with quildaiul r4luttlatitJ Osterville, MA 02655 the I-,nd� with the building thereon in Barnstable (Centerville), Barnstable County, Massachusetts, bounded and described as follows On the North by land now or formerly of Lytle, and being Lot 40 as shown on Land Court Plan No. 9288-S; G.- :.he East by Lot 43, as shown on a plan hereinafter and South mentioned; On the West by Craigville Beach Road. Said premises co41_aiA_.LU5. -Iqu&x_e feet, mare Qx less, and are-shown as-L6T 42 on Land Court Plan No, 9288-T. For our tile, see Certificate of Title No. 27594. Said lanu is subject to the following building and use restrictio s which shall remain in full force and e'f-f-d-c—t�-;-un-t-i--l—t-be-3-ear�2004- (1) No new building or structure shall be erected,paced or allowed to stand on the premises, nor shall any alteration to the exterior of any existing or new structure be made, until the plans and specifi- cations therefor shall have been approved in writing by the grantors, the successors in title or any party designated by the grantors to grant such approval, and until such approval has been recorded by the grantee in the Registry of Deeds for Barnstable Count;. To secure said approval, the grantee agrees to submit to the grantors or the +4+I— __ _­ .. - I I . ­ _'.J ­­� --f6ti—vu uY uie grantors to grant s uch a.pproval, a complete Set of exterior plans and specifications '0"in the exterior design, height and building material of the proposed Structure and its propc),­.ed location on the site, including location on lot and type Of the utilities serving same; and the loca- tion of any driveways serving same, such written approval to be indi- cated upon each page of all plans and specifications prepared by the grantee, its heirs, executors, administrators, successors or assigns. A COPY of such plans and specifications shall be furnished by the grantee, its executors, administrations, heirs, successors and assiFn.-,, to the grantors or their successors in title, or any party designated by the grantors to grant such approval. (2 ) No fence shall be erected on the property unIeSS Igrantors according to the same prucedure which is tc, structures or dwellings as set forth in ( 1) abovc. i (3 ) No commercial vehicles of any description shall bc- parkE;d •. ,r- night on the property or on any private: way servicing; said prr,per*; , nor shall any campers, mobile homes, trailers or unregistered be parked on the promises or on any private way servicing the f,rer i;E at any time:. (4 ) No automobile repairs shall be done on the premises nor shall � any bedding or blankets be used for lounging on the lawn. (5 ) Garbage and refuse shall be kept in sanitary containers which shall be .:ept in a clean and odor-free and sanitary condition and shay be stored at the rear of the; premises. Rubbish shall not be allowed t accumulate on the premises and the grantee agrees to dispose of all such rubbish, refuse and garbage at frequent intervals . (G) The l, rantee agrees to become a member of any Association organize for the purpose of maintaining the privat.- way or area shown within th dotted lines on the subdivision plan of which the granted premises are a part , and for the purpose of maintaining the landscaping and enforc- ing building and use restrictions. (7) The grantors herein reserve to themselves, their successors and ".i.gn& th o r i gh t..t Q__ILAke,� QLa"QEi in o Q �.P t 1Q11JrQm the.S restrictions in any subsequent deed or grants involving this subdivi- sion . Any such changes or exceptions to the restrictions shall like- wise apply to Lot 42 inccfar as they are not ,;,crc burdensome or differ- ent in kind from those initially imposed on Lot 42 . The owner or occupant of each and every Lot covered by the above restrictions by the acceptance of title thereto or by the taking possession thereof covenants and agrees to abide by and adhere to all these restrictions . (8) Said premises are alsu _sub;jec;C to au easement ot�dri4eway-fur,. foot-and vehic,ular�-tra-f•f-ie�o�r'that a.rea�'ind`icat d7b-y_dotted 'lines on ttie subd tvision plan of µhich the premises are a part , and-sa-id -- right of travel being appurtenant to the other fou: lot owners, and to have a right to park their motor veh -:es on said dotted-in area within the boundaries of each of their respective lots. Vehicles shall not be parked on that side of the dotted-in area nearest the . � • - -t- - --i_i.. _ ..--fit. , L V �. uhVIJLL& o. ALL LL ..YLA%. uLA"4 A. .,LL�.LA JLi LVaLLt, a ..onab passage of traffice over said way. The grantee herein shall have a like right of use of said dotted-in area over the other four lot; i as shown on said subdivision plan, i Said premises are also subject to the other six lots as shown on the subject subdivision plan of which the premises are a Dart being; furnished with utilities having various lines both overhead and under- ground as now exist over and under said granted premises. itt they event it is necessary to relocate existing utility lines, they maV be laid under or over the hereinbefore referred to area within the dotted lines. t 9859 c� cn cn x -- I ij COMMONWEALTH OF MASSACHUSEt1S 14, m I !� ��---��SEP•C�0 ��J 1� ;o uoe� 1I �� ! Executed as a healed instrument this ? day of . —/ 1980 Ge ge mulrenin -- Therese -i. `Sulrenin U�tf(�QImtiQ111UEN�t of ��Ill6f tt� Barnstable 1980 Then persouallynppraml the abo+rena"led George J. Mulrenin attd T' �. M�un=gin and acknowledged the foregoing instrument to ber cast and deed, /l Beim me, Notary p,-uic—Y►ViAL�iWtY]fm� My commission expires ►n MYMay 14, y62 I I i i i f i i � SUBDIVISION PLAN OF LAND IN BARNSTABI.E 9288T Down Cape Engineering, Surveyors Maroh 5, 1979 ti %j qb tA. WAYlp tip, •'' � tb, y°tJi �,e�,�a oy�A. '$ o � 0 oc 89 •� O� ��� : o Q �y 0 . �w a ��•j*� h�9'�="�qtF x^�::-'�jJ2YV6 0�``•45 �6 .p�."•`,r, ,may V �"�6��6 1i.Gb• • A0.2N8A ,�� ti s8s�2o e 46 4.11 (bard, �J w moo Subdivision Of Land, Lota 4 & 03 Shown on Plans 17531A� 9288 and 9288K Filed with Cert. of Title Nos: 5???, 27594 and 8756 Registry Distriot of Barnstable County .Separate certificate$ of tit/e����nney pe issued for land shown hereon as Atit.4.4.#dry_4'8 t•py of ,t of den By the Court. n In— LAND RMISMAUON Off/CE _t.�_ '�: Seale of this plan 80 feet to an Inch .r984/L_ISyl.41! �' i�rto�9ea AL.Woodbury,fnglneerforCourt l,S, STIRMTSION PLAN OF LAND IN PARNSTARLF. Charles N. Savory Inc. 9 28 g 41 Robert P. Bunikis, Surveyor October 9, 1973 ass F J.ce Plan APO 9P8BF �k J Carl. NO. 441? � 5 ,a5l N 57° 33' 50" E 8 00 T2.00 V.sl q Q �� ♦� N b a g oy � •►- �•p 4i 2 36 h 37 619 00 to � PM 0 N 570 33 50 ; � ` ' 0 g _ N Q o N 570 33'50'E� W 88.00 O .1 _ W 39 35 62.9 Pill JASSO 4/v' S i 5?0 33 4.z so W 03 Plan No. 9P88K Corp. Ab 8756 I Subdivision of Lot K and N Shown on Plan 9288E and 92880 Filed with Cart. of Title Noe. 4304 and 4798 Registry District of Barnstable County S parete Certlfreetes of title Mqy he issued for land show?hemmer tow--1------------------- Copy of �rofaan By the Court. LAND RIVIS R T/ON OffMI' 1974 !.T Scak of this plan 3b het to an indi "----- l�letOsotir. RL.Woedbvey, fryewrfwCbwrt �1 r,JO �Z.S 13.5' x -�, �✓ ✓ /75 Am ix kv 'AA �- s� c, h= o lV� t.ti �r itTx x v Z151- �,4t • -P- � -----ram --- ti ---- ��n ION oll ky \� >G 11A �1 a' F. �_�•i [tom -_ . 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I�I,1.1� �J��S � \ tL.3g• go -d`_ I �F� E ,-��� \�•ss £CIStER��V + L�- , :).qZ 4 AL LI►ao S= � a N ' (TIT i � I I t { i !'P�PwD 1I LA E,