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Commonwealth of Massachusetts a06--005
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4�M 158 Long Beach Road
Property Address m
�W
George Haseotes �=
Owner Owner's Name s
information is ✓ �
required for every Centerville MA 02632 8-30-17 rat
page. City/Town State Zip Code Date of Inspection t%l
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling A. General Information cS/ SCo
on the computer, �p`` ,Z11 OF rMgSs4i,���
/a
use only the tab
key to move your 1. Inspector:
cursor-do not James D.Sears = JAMESuse
key.the return Name of Inspector �*., OtARS
a
�—
Capewide Enterprises
�y Company Name �i,��(F •... G� `��.`
153 Commercial Street
Company Address 0T
raw
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
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 the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-30-17
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
I
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is Centerville MA 02632 8-30-17
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 2000 Gal. Tight Tank.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and 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):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
' Static liquid level in the distribution box above outlet invert due to an overloaded
❑ or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
iAl A ❑ than Y2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 .8-30-17
page. CityrFown State Zip Code Date of Inspection
D. System Information
Description:
H -20 2000 Gal Tight Tank.
Number of current residents:
0 ,
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
G - Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (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):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is
required for every Centerville MA 02632 8-30-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2006 Permit # 2006 - 297.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH - 40.
Septic Tank(locate on site plan):
Depth below grade: NA
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:
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: 2
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: H -20-2000 Precast
Capacity: 2000 Gal.
gallons
Design Flow: 330
gallons per day
Alarm present: ® Yes ❑ No
Alarm level: Alarm in working order: ® Yes ❑ No
Date of last pumping: NA
Date
Comments (condition of alarm and float switches, etc.):
Alarm working. Three steel covers bolted in place. Level in tank 35"from top. Alarm set at 21"
from top.
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ® No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ 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.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
H v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
158 Long Beach Road
�M
Property Address
George Haseotes
Owner Owner's Name
information is Centerville MA 02632 8-30-17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M SVB'eW 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
_ O 5/+ '-L2 S
O
�0A) JB-54CH RP
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: See Att Sheet.
feet
Please indicate all methods used to determine the 9
high round water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 158 Long Beach Road
Property Address
George Haseotes
Owner Owner's Name
information is required for every Centerville MA 02632 8-30-17
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
'.'S LICENSE NOTES: GENERAL NOTES: i_re
SUED NAY 17. 1938. TO BUILD & MAINTAIN ZONING INFORMATION: kolvc- 6 EAcff Rb
c FILL.
SUED AUGUST 14 1949. TO BUILD WALKWAY ZONING DISTRICT. RD L �^'�`
C Ir x a' FLOAT& wNGED LADDER. OVERLAY DISTRICTS:
SUED NOVE]NER $ 1966. iD BUILD
RPOD RESOURCE PROTECTION OVERLAY DISTRICT
I70N NOTES: AP AQUIFER PROTECTION OVERLAY DISTRICT
MINIMUM CURRENT ZONING REQUIREMENTS - ZONE RD
LL TAKE ALL NECESSARY MEASURES TO ENSURE MIN. LOT AREA = 2 ACRES (RPOD)
1OADWAY IS NOT UNDERMINED OR DAMAGED. ,
MIN. LOT FRONTAGE = 20
1TERNG SHALL NOT BE DISCHARGED DIRECTLY INTO RIVER. MIN. LOT WIDTH = 125'
OF TIGHT TANK MAY BE ADd1STED TO ACCOMMODATEIG FRONT YARD = 30' SIDE & REAR YARD = 15'
x SHALL BE PUMPED AND REMOVED. COMMUNITY PANEL NUMBER: 250001 0008 D
f SHALL, BE TAKEN OFF SITE THE FLOOD INSURANCE RATE MAP DEFINES THIS AREA
K SPECIFICATIONS: AS ZONE A13 (EL = 11')
BENCHMARK- DATUM: NGVD 1929
0 MIRING TD CONFORM TD APPLICABLE CODES
WAIERPR00FED AT THE MANUFACTURE'S YARD. PRIMARY BENCHMARK: RM - 18 ® FIRM MAP 250001 0008
WATERPROOM YMTN A GASKET AND WRAPPED CHISELED SQUARE IN TRAFFIC TRIANG
t. 0 INT. OF CRAIGVILLE BEACH AND LO
SHALL BE SET PRIOR TD POURING 10' CONCRETE BEACH ROADS. EL = 7.19' (NGVD)
I CAP.
SHALL WATERPROOF PROJECT BENCHMARK. CONCRETE BOUND (SEE PLAN)
XWVED AND TESTED FOR WATER TIGHTNESS EL = 4.89' (NGVD)
hTION. TIDAL RELATIONSHIP TO NGVD 1929
BASED ON 19 YEAR SERIES OF TIDAL OBSERVATIONS
ENDING 1978 BY "NOS" (FORMERLY USC & GS)
w2.2' MEAN SPRING HIGH WATER
z 1.8' MEAN HIGH WATER
z
0.4 MEAN WATER LEVEL
0.0 NGVD 1929
W-1.0' MEAN LOW WATER (EL. = 0.0')
A TITLE SEARCH HAS NOT BEEN PERFORMED FOR THIS SITE.
IF DETERMINED TO BE NECESSARY A TITLE SEARCH SHALL B
PERFORMED BY OTHERS.
31ON OF PL.
THE PROPERTY LINE INFORMATION SHOWN IS BASED
ON CURRENT AVAILABLE RECORD INFORMATION
aiT yqU� y_ CONSISTING OF PLANS AND CERTIFICATES.
�yF THE EXISTING FEATURES SHOWN HEREON WERE
OBTAINED FROM AN ON THE GROUND FIELD SURVEY
PERFORMED BY BAXTER, NYE & HOLMGREN, INC. ON
APRIL 24 & 28, 2005.
REFERENCE PLANS:
PLAN BOOK 59 PAGES 125 &127
o PLAN BOOK 110 PAGE 101
L.C. PLANS 13974 A, E-F
SIDELINES OF LONG BEACH ROAD SHOWN ON THIS PLAN ARE
AS DEFINED BY LC.. PLAN 13974 AS REFERENCED ABOVE.
OBSERI&D HIGH WAS 3.5 158 Long Beach Road
A 4-28-05 Cantarvilla. Massachusetts
4 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
SOUTHEAST REGIONAL OFFICE
20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 508-946-2700
MITT ROMNEY STEPHEN R.PRITCHARD
Governor Secretary
KERRY HEALEY ROBERT W.GOLLEDGE,Jr.
Lieutenant Governor Commissioner
December 7,2005
-Donald Pollock RE: BARNSTABLE—Subsurface Sewage
41 Stanton Street Disposal-Proposed Tight Tank forpl_58
Brookline,Massachusetts 02445 L no g Beach Road, Centerville,;
Transmittal No. W070629
Dear Mr. Pollock:
The Southeast Regional Office of the Department of Environmental Protection has received
and completed its review of the above referenced application for approval of a tight tank pursuant to
Title 5 of the State Environmental Code, 310 CMR 15.260,to serve an existing three bedroom
dwelling at the above-referenced address.
Accompanying the application was a plan titled:
"PROPOSED TIGHT TANK C.C.
158 LONG BEACH ROAD, CENTERVILLE �,
PREPARED FOR: DONALD POLLOCK C__' ~`
SCALE: 1"=10' DATE:NNE 10,2005 c»
BAXTER,NYE&HOLMGREN, INC. o� —v
828 MAIN STREET 7
N
OSTERVILLE,MA 02655» cx
w .
Based on its review of the application and accompanying plans, the Departm t recognizes
that a sewer connection is not feasible and that there is no other feasible alternative for the disposal
of sanitary sewage in accordance with 310 CMR 15.000.
The Department finds that the application and plans are in compliance with 310 CMR
15.000, and, accordingly, hereby approves your request pursuant to 310 CMR 15.260, Tight Tanks,
subject to the following provisions.•Failure to comply with these provisions may result in revocation
of this approval.
1. Prior to installation of the tight tank,the owner shall obtain a disposal system
construction permit from the Barnstable Board of Health.
This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD Service-1-800-298-2207.
DEP on the World Wide Web: http://www.mass.gov/dep
Zia Printed on Recycled Paper
2
2. This approval is limited to existing use and any change of use will require a new
approval. The tight tank shall not be used for new construction or for any increase in
flow. The facility design flow is limited to 330 gallons per day.
3. The owner shall allow representatives of the Department and the local Board of Health
access to inspect the facility during construction in order to assess compliance with the
plans as approved by the Department. It is the applicant's responsibility to ensure that
the approved plans are available at the site during construction.
4. No tight tank shall be utilized until the owner has submitted to the Department and the
Board of Health written certification by a Massachusetts Registered Professional
Engineer or Registered Sanitarian that the tight tank has been constructed and installed in
accordance with the approved plans.
5. The owner shall provide the Barnstable Board of Health with a copy of an executed two-
-year service contract with a septage hauler licensed to operate in that community, which
identifies the disposal location(s) of the tight tank contents. Failure of the owner to
properly maintain the tight tank and keep it from overflowing shall constitute grounds for
revocation of this approval.
6. Within 30 days of a sewer becoming available to the facility, the owner shall connect the
facility served by the tight tank to the sewer and shall abandon the tight tank in
accordance with 310 CMR 15.354.
7. Prior to the issuance of a certificate of compliance, the owner shall record a deed
restriction limiting the use of the dwelling to three bedrooms and shall submit to the
Department and the Barnstable Board of Health the book-and page number and the date
of such recording.
8. An operation and maintenance plan, acceptable to the local Board of Health, shall be
implemented which requires monitoring of the system at a minimum frequency of once
every three months during periods which the property is occupied to ensure proper
operationon an�amtenance.
9. Prior to the issuance of a certificate of compliance, the owner shall obtain all other
applicable permits including any permits required from the local conservation
commission and any required licenses for the dock.
10. All notices and information required pursuant to this approval letter shall be sent to the
Department at the following address:
Department of Environmental Protection
20 Riverside Drive
Lakeville, Massachusetts 02347
. 11. The owner shall submit to the Barnstable Board of Health copies of pumping records
within 14 days of each pumping date.
Please note that the conditions, outlined above,.do not supersede any conditions imposed
by the Barnstable Board of Health. The above conditions supplement any other conditions
imposed by the Barnstable Board of Health.
3
Should you have any questions regarding this matter,please contact Christos Dimisioris at
(508) 946-2736.
Sincerely,
Brian A. Dudley f
D/CD/
Bureau of Resource rotection
cc: Thomas McKean
Barnstable Public Health Division
200 Main Street
Hyannis,Massachusetts 02601
Stephen Wilson,P.E.'
Baxter,Nye &Holmgren,Inc.
828 Main Street
Osterville,MA 02655
DEP Watershed Permitting Program,Title 5 Section,Boston
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Certified Mail Provides: ,
0 A mailing receipt
it A unique identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
r For an additional fee,a Retum Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee of
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
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cle at the post office for postmarking. If a postmark on the Certified Mail.
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
PS.Form 3800,August 2006(Reverse)PSN 7530.02-ODD-9047
SENDER:COMPLETE THIS SECTION S SECTION ON DELIVERY
■ Complete items 1,2,and_3.Also complete Si t re / o
item 4 if Restricted Delivery is desired. ^ ❑Agent
■ Print your name and address on the reverse SSSUUUI�� p Addressee
f so that we can return the card to you. B. eceive by(Printed"Name) C. Date of Delivery
.
I ■ Attach this card to the back of the mailpiece,
I or on the front if space permits. d Oi i 9
D. Is delivery address different from Rem 1? ❑Yes
1. Article Addressed to: if YES,enter delivery address below: ❑No
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3. Service Type
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C �J O Registered ❑Return Receipt for Merchandise
❑Insured Mail 0 C.O.D.
4. Restricted Delivery?`(Ext►a Fee) ❑Yes
2 Article Number 000`8 323b `bdO: 15178 %3-425 i ia�
(Transfer from service label) f /f
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED STATES POSTA FR Ig.F,:;:,-, ,r;-;;z•�.:, «. ,, I s.IrAaEi�.K,;^;:
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• Sender: Please print your name, address,°and ZIP+4 inAhis bax •
Tows of Barnstable
�an..0•ii =-I
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LKE 200 Main Street ,,,j jr—_
Hyannis;MA 02601 rn
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COMPLETE •N- COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1;2,and 3.Also complete A. Si re
item 4 if Restricted Delivery is desired. ❑Agent
■ Print your name and address on the reverse ❑Addressee
so that we can return the card to you. eceived by( inted Name) C. Date of Delivery .
■ Attach this card to the back of the mailpiece,
or on the front if space permits. ®�,
D. Is e. address different from item 1? ❑Yes
1. Article Addressed to: 1— Ory If YES ' r delivery address below: ❑No
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4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(transfer from service labeq ill 1,1 7 0141 12 O O.!0 0 0.1 i i 0 3 5 8 13,3 5 l i y-" I
PS Form 381 T July 2013 Domestic Return Receipt
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• Sender: Please print your name, address, and ME 4®in this b
I `C1
I , Town of Barnstable
Health Division
200 Main Street
I
Hyannis,MA 02601
I
III'-fillI'll,lp1111 ll1
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J� J
Barnstable
.�
Town of Barnstable
Regulatory Services Department �a�j
BAMSTABM 1
9q, `'�: ,.� Public Health Division
�fDA'`0�� 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Melvin and Mary Field 11/08/10
39 Foster St.
Cambridge, MA 02138
According to our records, the tight tank owned by you located at 158 Long Beach Road,
has not been monitored and/or pumped every three months as required by the
Massachusetts Department of Environmental Protection: Therefore, you are ordered to
hire a licensed septage hauler to have the tank pumped on, or before November 15, 2010.
After that date, the tank shall be pumped once every three months.
If your tank was already pumped sometime within the past three months, please submit.a
copy of the receipt for the pumping.
Please submit a copy of the pumping record(s) to this Office at mailing address: Town of
Barnstable Health Division, 200 Main Street, Hyannis, MA 02601.
Failure to comply with an order of the Board of Health may result in the issuance of
$100.00 non-criminal ticket citations. Tickets may be issued daily until the violations are
corrected.
You may request a hearing before the Board of Health, if written petition requesting same
is received by the Board within seven days of the date of your receipt of this letter.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
ZME r
Town of Barnstable Barn
Regulatory Services Department j edcar j
a►ju nAH &
1639• Public Health Division
i6 `0�`
A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali Director
FAX: 508-790-6304 Thomas A.McKean,CHO
January 22, 2016
Kristen Williams Haseotes
P.O. Box 370
Norwell, MA 02061
Re: 158 Long Beach Road
Dear Kristen Williams Haseotes,
This is a reminder to update the Barnstable Health Division regarding the status of your property at 158 Long
Beach Road Centerville. The COMM water department reported that the water was on during the summer
and over 2,000 gallons were used from 1/15/15-6/30/15. If the tight tank was used during the year, pumping
records are required to be sent to our office at 200 Main Street.
Enclosed is the letter from 12/1/2014 which says "The Health Division should be updated annually about the
status of tight tank, unless we hear from you otherwise in regard to an upgrade."
Your prompt attention to this matter is important for your property to be in compliance with town and state
regulations.
I look forward to hearing from you.
Best wishes,
G
Karen Malkus
Barnstable Health Division
Coastal Health Resource Coordinator
200 Main St.
Hyannis, MA 02601
508-862-4644
sKE rqy�
Town of Barnstable Barnstable
. . °; Regulatory Services Department MMmericaN j
""1639.
Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali Director
FAX: 508-790-6304 Thomas A.McKean,CHO
December 01, 2014
Kristen Williams Haseotes
P.O. Box 370
Norwell, MA 02061
Re: 158 Long Beach Road
Dear Kristen Williams Haseotes,
Thank you for your recent letter regarding your property at 158 Long Beach Road, in Centerville. I have also
spoken with the property manager Chris Wells. The Health Division needed notification of the status of the
tight tank and pumping records to make sure it was operating to protect public health. Your written response
and my conversation with Chris is appropriate documentation to avoid any fines or tickets, since the property
is vacant.
The Health Division should be updated annually about the status of tight tank, unless we hear from you
otherwise in regard to an upgrade.
Sincerely,
Karen Malkus
Barnstable Health Division
Coastal Health Resource Coordinator
November 25, 2014
Town of Barnstable
Thomas McKean, R.S.,CHO,Agent
Board of Health
200 Main Street
Hyannis, MA 02601
Ref: 158 Long Beach Road, Centerville,MA
Dear Mr. McKean:
I recently received the Town's MDEP Notice to pump our septic system at the above
referred address before December 31, 2014.
Since purchasing this property,we have been in an extensive process to rehabilitate
the home, including lifting it out of the flood plane.We have primarily been working
with the Department of Environmental Protection seeking necessary approvals
before moving on to the Town.While this process has been developing,no one has
occupied the house, and plans are for it to remain vacant for the foreseeable future.
We are therefore requesting a hearing with the Board of Health,if necessary,to
address the pumping Notice requirement and to avoid any fine for failing to comply.
I can be reached by mail at: P.O. Box 370, Norwell, MA 02061.
Very truly yours,
i�� V- )*1 ell,11�
Kristen Williams Haseotes •
� -�Ck,
I
WE Town of Barnstable Barnstable
Regulatory Services Department j"nWcaC j
snMSTAst.L
MAC.i639. Public Health Division
�0
FO AA°�A 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
George and Kristen Haseotes 11/10/14
P.O. Box 370
Norwell, MA 02061
According to our records, the tight tank owned by you located at 158 Long Beach Road,
has not been monitored and/or pumped as required by the Massachusetts Department of
Environmental Protection. Therefore, you are ordered to hire a licensed septage hauler to
have the tank pumped on, or before December 30, 2014.
If your tank was already pumped sometime within the past three months, please submit a
copy of the receipt for the pumping.
Please submit a copy of the pumping record(s) to this Office at mailing address: Town of
Barnstable Health Division, 200 Main Street, Hyannis, MA 02601.
Failure to comply with an order of the Board of Health may result in the issuance of
$100.00 non-criminal ticket citations. Tickets may be issued daily until the violations are
corrected.
You may request a hearing before the Board of Health, if written petition requesting same
is received by the Board within seven days of the date of your receipt of this letter.
PER ORDER OF THE BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Transmittal Letter
To: Board of Health
�9
200 Main Street
Hyannis,MA 02601
Attn: , Z7,
From: Stephen A. Wilson, P.E.
Subject: V. Po I koek } I s S L.or.•,
Date:
We are sending you ■Attached ❑Under Separate Cover
The following documents:
®Prints❑Order of Conditions El Variance Approval❑Recording Slip ❑ Septic System Permit
❑Notice of Intent❑Other
DATE QUANTITY. DESCRIP I ION
sk,4 .-
These items are transmitted as checked below:
❑ For Your Use ❑ As Requested For Your Files
❑ For Review and Comment ❑ For Recording As Required
Other:
fir-t "lam I.i a l k o y-e.e Io�c Q roam s .
Additional Distribution D. Pe(I at a jr- L"
File No. -2.oo S-a 3 T
Baxter,Nye&Holmgren Inc. Phone:508-428-9131,ext.13
812 Main Street Fax: 508-428-3750
Osterville,Massachusetts 02655 E-Mail:swilson@jkholmgren.com
TransmWalLetter4.doc
FLOORPLAN
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Addrass: Case Na:
Kktm
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Bdh 5 be5s I
t
Bedroom LWng ROOM
►�.
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Dftk
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... C4/Vr �e vi�cr. f?►ve� I
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TOWN OF BARNSTABLE
LOCATION 0, SEWAGE#AV4 v.297
VILLAGE ASSESSOR'S MAP-'PARCEL --20 f—a
INSTALLERS NAME&PHONE NO. d!"��T1�j`
SEPTIC TANK CAPACITY eca �oC ,ors'4,1 f0-e�
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER v w�
PERMIT DATE: 9• o�6 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) ( Feet
FURNISHED BY l` - t �/��
1� I Ur
.�ivo0 GAG f�•1d
ro--c-4 b7
No. )77 >�� y Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
..PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
RpPlication for Mioogaf fpwem Congtructton Permit
Application for a Permit to Construct( ) Repair(4,K pgrade( ) Abandon( ) ❑ Complete System �ndividual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
15-Z �G�G, 163ec44 A b Z'eWy4avlle Pab4l.- I— Allw4
Assessor's Map/Parcel sue- 6p5.. Ae—az y/ 5/ ,40 ✓Q!Q
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: (�(�
Dwelling No.of Bedrooms U.l ft of Size .� /` sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons S owe/rs( ) Cafeteria( )
Other Fixtures wt?D v�IPss/�G ✓Lw �,
Design Flow(min.required) gpd Desi n flow provided gpd
Plan Date f,-/0-or Number of sheets Revision Date
Title
Size of Septic Tank v?�Gt�d ��� �v�✓ %��;t 7Itii�Iype of S.A.S.
Description of Soil
Na�tjure of Repairs or Alterations(Answer when applicable) � c�0 (�a�� �- /e � � 7��✓ ,�l
/ f wcs f�Ik,v�-►
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar of e
Signed Date
Application Approved by lq,.a. /C,_► Date
Application Disapproved by: Date
for the following reasons
Permit No. 2WG )q 7 Date Issued �2 v(v
ems`•, 1 4l` ru
Fee�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZIppYication for Oigpogal *p5tem Con5truction Permit
Application fora Permit to Construct O Repair([.Upgrade O Abandon O ❑ Complete System ,Z21ndividual Components
Location Address or Lot No. Owner.'s Name,Address,and Tel.No.
Assessor's Map/Parcel ��- ��� yJ Sr�Gd�Cai ✓� �ti/�1nr r„ii?
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. "
1. 410 }; <W��rce 0 ZnCJ✓J � ,,�
s273- ;V �'
Type of Building:
• Dwelling No.of Bedrooms �� 'Lot Size %t tF sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) C� oteria( )
Other Fixtures ftUd C/ .lafirn r`i�`If�r`nu of tlocc f v-,lP-rr 'y an/7✓ytr
��
Design Flow(min.required) gpd Design flow provided gpd
Plan Date '/�-OS� Number of sheets f Revision Date ti
Title
Size of Septic Tank a�,G� G<< ��U ����r Tlf,� ype of S.A.S.
Description of Soil �-
Nature of Repairs or Alterations(Answer when applicable) 1J��/� .� �� �f;;�`• /rr 7`cd� y,�, 4
Date last inspected:
Agreement: '
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
71,accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Boar of a -t l
,. Signed Date
l �
Application Approved by / W N,� • Z(- Date 4()6
Application Disapproved by: Date
for the following reasons
Permit No. -200G ^ q 7 Date Issued •�� ��
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
CF Certificate of Compliance
THIS IS TO CERTIFY,that theOn-site Sewage Disposal System Constructed ( ) Repaired ( 41< Upgraded ( )
>`Abandoned( )by
at )rS LynS 13z W41 /i L.,, -Nar/IC has been constructed in accordance {{ l
'.�I/with the provisions of Title 5 and the for Disposal System Construction Permit No. clo i(D ,2 7� dated &1.24/G
/� 44,4, . -4" 'O.� Designer 1 r.� 10,1+• 1-7104�i .-r'•r,
Installer .]�'r w� g ,r^'7, S
#bedrooms 3 — d_,&d rPJ rr 4 Approved d stgn flow gpd
T ec,ro f t w i
The iSsu nce.o his permit shall o b- obsttrued as a guarantee that the syste wi�tuXdpioh design d.
` Date 'J (Cl Inspector
————————————————————————————————————————————
No. dt lo` 17 Fee / b
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
0igpool,*pgtem Con.5truction Permit
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( )
System located at
and as described in the above Application for Disposal System Construction Permit:The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction m st be completed within three years of the date of tls ermit.
Date o� �'! 6 Approved by �� -
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
iARNSTAS[�: r
g Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4.644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 7 !d Sewage Permit# Z � "Z?7Assessor's Map\Parcel4 pL/9
Designer: -�hcv, A. W j l Srn P1 Installer: 13csr ha I h 'Wi Cc&,ai-
Address: 13a,44r.,- IWwg fqS - 3 S;r,l"ola Address: 6 c„c 76 q
?Fs (,fh ST 1�1�c�Vri►s ®26()k M&r�s 1 YLAS . bZ6Ve
On Z ,.}a ; er4sfr,r ha n was issued a permit to install a
(date) (installer)
fi�b�' to n It
t 158 l..o Q O ,I.Ir"Arvl1 to based on a design drawn by
(address)
A M l I s ca. .:P ff dated 6 -I o - 7-6o5
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
•- of the septic system)but in accordance with State& Local Regulations. Plan revision or
certified as-built by designer to follow.
JN Of
o� STEPH N zG
&LYN
(Installer's Signature) WILSON
`� No.30216
S
SS'ONAL
esigner's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
l' .2665- 039 J
Doc:I :037:363 06-29-2006 12: 10
BARNSTABLE LAND COURT REGISTRY
DEED RESTRICTION
WHEREAS, Donald J. Pollock and Elizabeth S. Pollock of Brookline,
Massachusetts are the owners of the property known as and numbered 158 Long Beach
Road, Centerville, Barnstable County, Massachusetts and described by deed filed with
the Barnstable Registry District of the Land Court as Document No. 951019, Certificate
of Title No. 171448 and shown as Lots A-3 and A-4 on a plan entitled"Subdivision of
Lot A-2 as Shown on plan 13974F, Filed with Certificate of Title No. 6699, Registry
District of Barnstable County, Land in Barnstable, June 24, 1950, Bearse & Kellogg,
Engineer"; and
WHEREAS, Donald J. Pollock and Elizabeth S. Pollock, as the owners of said
property, have 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 said property as a
pre-condition to obtaining a disposal works construction permit in compliance with 310
CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage; and
WHEREAS the Town of Barnstable Board of Health, as a pre-condition to
granting a disposal works construction permit for a septic system in compliance with 310
CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the
Subsurface Disposal of Sanitary Sewage and authorizing the issuance of a building
permit for the construction of a single family home on said property, is requiring that the
agreement for the restriction on the number of bedrooms in any house constructed on the
property be put on record with the Barnstable County Registry of Deeds by recording this
document;
NOW THEREFORE, Donald J. Pollock and Elizabeth S. Pollock do hereby place
the following restriction on said property in accordance with their agreement with the
Town of Barnstable Board of Health, which restriction shall run with the land and be
binding upon all successors in title:
158 Long Beach Road, Centerville, MA may have constructed
upon the lot a house containing no more than three (3) bedrooms. Donald J.
Pollock and Elizabeth S. Pollock agree that this shall be a permanent deed
restriction affecting the said property located at 158 Long Beach Road,
Centerville, MA more particularly described by deed by deed filed with
the Barnstable Registry District of the Land Court as Document No. 951019,
Certificate of Title No. 171448, and shown as Lots A-3 and A-4 on a plan entitled
"Subdivision of Lot A-2 as Shown on plan 13974F Filed with Certificate of Title
No. 6699, Registry District of Barnstable County, Land in Barnstable, June 24,
1950, Bearse & Kellogg, Engineer".
The foregoing restriction shall remain in force only so long as the said property is
serviced by a private septic system, and said restriction shall terminate and be of no force
and effect upon connection of the said property to a public sewer system.
Executed under seal this day of ffVIJ6- , 2006.
Donald J. Polloc El' h S. Pollock
COMMONWEALTH OF MASSACHUSETTS
SUFFOLK, ss
r On this T-q" day of June, 2006,before me,the anFol
reigned notary public,
personally appeared `i�Jnt/kLe) -f �b(� � �LiS s (�ccproved to me
through satisfactory evidence of identification, which was A, `T-/LiUer5 t-�� ,to
be the person whose name is signed above, and acknowledged to me that 1
signed it voluntarily for its stated purpose.
MICHAEL W.MERRILL ������
Notary Public PotPublic
Commonwealth of Massachusetts My commission expires:
My COMM19810ro Expires
July 20,2l997
i
i
BAXTER NYE ENGINEERING & SURVEYING
Registered Professional Engineers and Land Surveyors
78 North St., 3Ta Floor, Hyannis,MA 02601 Tel: (508) 771-7502 Fax: (508) 771-7622
July 13, 2006
Mr. Brian Dudley
Dept of Environmental Protection
20 Riverside Drive
Lakeville, MA 02347
RE: Transmittal No W070629
Tight Tank
158 Long Beach Road,Centerville
Dear Mr. Dudley:
As per your letter of December 7, 2005,we are forwarding to the DEP the following documents:
1. Installer&Design Certification Form for the Barnstable Board of Health(Item#4).
2. A copy of the recorded deed restriction for 158 Long Beach Road limiting the dwelling to 3
bedrooms (Item#7).
Should you require further documentation,please call.me directly at(508) 771-7502, ext 13 or via e-
mail at swilson@baxter-nye.com.
Very truly yours,
Baxter Nye Engineering& Surveying
j
Stephen A. Wilson,P. E.
(� Z7
Encl.
_ -f
P�F
lPytl 1 w
CD r1l
Cc:D.Pollock,Barnstable Board of Health
2005-039
Page 1
Land Surveys • Site Design • Subdivisions • Septic Design • Wetland Filings • Planning
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862A.644 Fax: 508-790-6304
Installer&Designer Certification Form-
Date: 7 lO Sewage Permit# Z � -�Y TAssessor's Map\Parcel_ffi a 2
Designer: . f, A, W it G �_. Iiastaller: 13x�.r 1-a 16 4f, CrAnSi-
Address:. e+oYine Alves fji 3 S►,r vq rr, Address: V.6 . 13 cic 7 A N
?_$ c , _ 4-_ 115— n 6240t y111erSJa►iS Vl dic . 02611$
On z .D 'E ( ; Cans try r ha n was issued a permit to install a
(date) (installer)
1�Sb+ t•a n k
sysidea:at 158 Lan. r_ _ mil, Q0 J to based on a design drawn by
(address)
�pV%C.4 A ; G) 15 C-A t'C� dated 6 -1 o -2 6o5
(designer)
Y I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Local Regulations. Plan revision or
certified as-built by designer to follow.
OF
STEPHENAUYN
(Installer's Signature) 0 WON 'w�
No.30216
STtP� %�
�� SS�QNAL E '
esigner's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF
COMPLIANCE WILL NOT BE ISSUED UNTEL BOTH THIS FORM AND AS-BUILT CARD ARE
RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DMSION. THANK YOU.
Q:Health/Septic/Designer Certification Form 3-26-04.doc
TOWN OF BARNSTABLE
e' r SEWAGE#, fie '" f
LOCATION
VILLAGE -�4 �:r�!/t ASSESSOR'S MAP&PARCEL �'�`` �'
y'o
INSTALLERS NAME&PHONE NO:
SEPTIC TANK CAPACITY ���
(size)
LEACHING FACILITY: (type)
--------------
NO.OF BEDROOMS f
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation.Distance Between the: Feet
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility(If any wells exist
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist
Feet
within 300 feet of leach`iing fa
cility)
FURNISHED BY I l" 7'f g/
.. ......... ....
06/28/2006 16:33 FAX 6175234893 MERRILL&MCGEARY Z 001/000
Fax Cover Sheet
:MERRILL & McGEARY
Attorneys At Law
1. State Street, Suite 15(.10
Boston, Massachusetts 02109
Tel: (617) 523-1760 Fax: (617) 523-4893
6=mail: michael_merrill @verizon.net
DATE: /?i�/d TIME:
FROM: Michael Merrill, Esquire TRANSMITTED BY: Cienise DeFreltas
TO: FAX:
TO: FAX: �C10 4250Y
TO: FAX:
RE. � � f
Number of pages including cover sheet:
Message:
(S (@-�-r�2 Gt✓dv�
A ,AA , OW
This telecopy is attorney-client privileged and contains confidential infoi-jno.tion intended only for the
person(s)named Rbove. Any other distribution,copying or disclosw.72�is strictly prohibited. If you have
received this copy in error,please notify us jinmediately by telephone.and return the original transmission to
Lis by mail without malting a copy, If you have questions regarduig the transmission,please call the
tralzsnv.ttei listed above,
06/28/2006 16:33 FAX 6175234893 MERRILL&MCGEARY 16 002/003
DEED RESTRICTION
WHEREAS, Donald J. Pollock and Elizabeth S. Pollock of Brookline,
Massachusetts are the owners Of the property known as and numbered 158 Long Beach
Road, Centerville, Barnstable County, Massachusetts and described by deed filed with
the Barnstable Registry District of the Land Court as Docuuent No. 951019, Certificate
of Title No. 171448 and shown as Lots A-3 and A-4 on a plan entitled"Subdivision of
wn
Lot A-2 as Shol on plan 13974F, Filed with Certificate•of Title No. 6699, Registry
District of Barnstable County, Land in Barnstable, June 24, 1950, Bearse&Kellogg,
Engineer"; and
WHEREAS, Donald J. Pollock and Elizabeth.S. Pollock, as the owners of said
property, have agreed with the Town of Barnstable Board of Health to a restriction as to
the number of bedrooms which can be included.in any hon:ie built on said property as a
pre-condition.to obtaining a disposal,works construction permit in compliance with 310
C.MR 15.000 State Environmental Code, Title V, Minimurn Requirements for the
Subsurface Disposal of Sanitary Sewage; and
WHEREAS the Town of Barnstable Board of Health, as a pre-condition to
granting a disposal works construction permit for a septic system in compliance with 310
CMR 15.200, State Environmental Code, Title V,Mi,niminn Requirements for the
Subsurface Disposal of Sanitary Sewage and authorizing the issuance of a building
permit for the construction of a single family home on said property, Is requiring that the
agreement for the restriction,on the number of bedrooms in,any house constructed on the
property be put on record with the Barnstable County Regi;:,try of Deeds by recording this
document;
NOW THEREFORE, Donald J_ Pollock and Elizabeth S. Pollock do hereby place
the following restrction on said property in accordance with their, agreement with the
Town of Barnstable Board of Health, which restriction shall run with the land and be
binding upon all successors in title.-
158 Long Beach Road, Centerville, MA may have constructed
upon the lot a house containing no more than three (3)bedrooms. Donald J.
Pollock and.Elizabeth S. Pollock agree that this shall be a permanent deed
restriction affecting the said property located at 158 Long Beach Road,
Centerville, MA more particularly described by deed by deed filed with
the Barnstable Registry District of the Land Court as Document No. 951019,
Certificate of Title No. 171448, and shown as Lots A.-3 and A-4 on a plan entitled
"Subdivision,of Lot A-2 as Shown on plan 13974F Filed with Certificate of Title
No. 6699, Registry District of Barnstable County, Land in Barnstable, June 24,
1950, Bearse &Kellogg, Engineer".
The foregoing restriction shall remain in force only so long as the said property is
serviced by a private septic system, and said restriction shall terminate and be of no force
and effect upon connection of the said property to a public sewer system-
06/28/2006 16:33 FAX 6175234893 MERRILL&MCGEARY 16 003/003
Executed under seal this day of ffVh'? , 2006
eN
LAV
_ ^
onald J. Polloc El." S. Pollock
COMMONWEALTH OF MASSACIMSETTS
SUFFOLK, ss
On this 1.1 day of June, 2006, before me,the un rsigned notary public,
personally appeared 'Wry S 1%(t+c2- Av) S,G+ b (proved to me
through satisfactory evidence of identification,which was jMA , TYL U" t ur.-ye'S' ,to
be the person whose naive is signed above, and acknowledged to me that
signed.it voluntarily for its stated purpose.
w.
MICHAEL W.MERRILL VW
Notary Public otany Public
Commonwealth at Massachusetts My commission expires:
My Cammi-tgibn Expires
July 29,2997
t
_I
GS
Hse# Street Village Prop Owner Date Hauler Source
121 Long Beach Road Centerville Atheson 7/11/2000 Ace Cesspool
121 Long Beach Road Centerville Atkeson 8/8/2000 Ace Cesspool
121 Long Beach Road Centerville Atkeson 7/23/2001 Ellis Cesspool
J 121 Long Beach Road Centerville Atkeson 8/31/2001. Macomber Cesspool
121 Long Beach Road Centerville Atkeson,Meade 8/11/2003 Wind River Cesspool
AA 121 Long Beach Road Centerville Atkinson 8/7/2006 Robinson Cesspool
l✓' 121 Long Beach Road Centerville Atkeson 8/3/2007 Robinson Cesspool
129 Long Beach Road Centerville Cotton 7/21/2000 Robinson Septic
129 Long Beach Road Centerville Able 8/5/2003 Pina Septic
129 Long Beach Road Centerville Able,Ron 8/7/2003 Pina Septic
153 Long Beach Road Centerville Holcomb Plumbing&He 8/8/2007 A&B Canco Cesspool
157 Long Beach Road Centerville Craigville Realty 9/1/1999 Midcape Septic
r 158 Long Beach Road Centerville Field 10/25/2006 Bortolotti Tight Tan
V
158 Long Beach Road Centerville Field _ 7/2/2007 Macomber Septic
158 Long Beach Road Centerville Field 8/25/2008 Capewide Septic
169 Long Beach Road Centerville Rudnick 8/12/1998 Macomber Cesspool
169 Long Beach Road Centerville Rudnicle 8/7/2000 Macomber Cesspool
169 Long Beach Road Centerville Rudnick 8/2/2001 Macomber Cesspool
169 Long Beach Road Centerville Rudnick 8/11/2003 Macomber Cesspool
169 Long Beach Road Centerville Rudnick 8/2/2004 Macomber Cesspool
169 Long Beach Road Centerville Rudnick 8/9/2005 Macomber Cesspool
169 Long Beach Road Centerville Rudnick 8/2/2006 Macomber Cesspool
177 Long Beach Road Centerville Birdsey 7/23/2005 Macomber Septic
177 Long Beach Road Centerville Birdsey 8/2/2006 Macomber Septic
177 Long Beach Road Centerville Birdsey 5/22/2008 Capewide Septic
189 Long Beach Road Centerville Wade 4/29/2010 Ford Septic Septic
4
: ,COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
SOUTHEAST REGIONAL OFFICE
s 20 RIVERSIDE DRIVE, LAKEVILLE,MA 02347 508-946-2700
MITT ROMNEY
STEPHEN R.PRITCuaRn
Governor
Secretary
EERRY HEALEY. : ROBERT W.GOLLEDGE,Jr.
..Lieutenant Governor
Commissioner
December 7,2005
Donald Pollock - RE: BARNSTABLE Subsurface Sewage
41 Stanton Street Disposal="Propo`sed Tight Tack for158
Brookline,Massachusetts 02445 Long Beach Road Centerville,`:
: -
Transmittal No. W070629
Dear Mr. Pollock:
The Southeast Regional Office of the Department..of Environmental Protection has received
and completed its review of the above referenced application for approval of a tight tank pursuant to
Title 5 of the State Environmental Code, 310 CMR 15.260,to serve an existing three bedroom
dwelling at the above-referenced address.
Accompanying the application was a plan titled:
"PROPOSED TIGHT TANK a
158 LONG BEACH ROAD, CENTERVILLE [ M
PREPARED FOR: DONALD POLLOCK `-'
SCALE: 1"=10' DATE: JUNE 10,2005 uZ—,� a
BAXTER,NYE &HOLMGREN, INC.
828 MAIN STREET
OSTERVILLE, MA 02655"
Based on its review of the application and accompanying plans, the Departm t recognizes
that a sewer connection is not feasible and that there is no other feasible alternative for the disposal
of sanitary sewage in accordance with 310 CMR 15.000.
The Department finds that the application and plans are in compliance with 310 CMR
15.000, and, accordingly, hereby approves your.request pursuant to 310 CMR 15.260, Tight Tanks,
subject to the following provisions.'Failure to comply with these provisions may result in revocation
of this approval.
1. Prior to installation.of the tight tank, the owner shall obtain a disposal system
construction permit from the Barnstable Board of Health.
This information is available in alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD Service-1-800-298-2207.
DEP on the World Wide Web: http://www.mass.gov/dep
Z,� Printed on Recycled Paper
2
2. This approval is limited to existing use and any change of use will require a new
approval. The tight tank shall not be used for new construction or for any increase in
flow. The facility design flow is limited to 330 gallons per day.
3. The owner shall allow representatives of the Department and the local Board of Health
access to inspect the facility during construction in order to assess compliance with the
plans as approved by the Department. It is the applicant's responsibility to ensure that
the approved plans are available at the site during construction.
4. No tight tank shall be utilized until the owner has submitted to the Department and the
Board of Health written certification by a Massachusetts Registered Professional
Engineer or Registered Sanitarian that the tight tank has been constructed and installed in
accordance with the approved plans.
5. The owner shall provide the Barnstable Board of Health with a copy of an executed two-
year service contract with a septage hauler licensed.to operate in that community, which
identifies the disposal location(s) of the tight tank contents. Failure of the owner to
properly maintain the tight tank and keep it from overflowing shall constitute grounds for
revocation of this approval.
6. Within 30 days of a sewer becoming available to the facility, the owner shall connect the
facility served by the tight tank to the sewer and shall abandon the tight tank in
accordance with 310 CMR 15.354.
7. Prior to the issuance of a certificate of compliance, the owner shall record a deed
restriction limiting the use of the dwelling to three bedrooms and shall submit to the
Department and the Barnstable Board of Health the book-and page number and the date
of such recording.
8. An operation and maintenance plan, acceptable to the local Board of Health, shall be
implemented which requires monitoring of the system at a minimum frequency of once
every three months during periods which the property is occupied to ensure proper
operation an— mamtenance.
9. Prior to the issuance of a certificate,of compliance, the owner shall obtain all other
applicable permits including any permits required from the local conservation
commission and any required licenses for the dock.
10. All notices and information required pursuant to this approval letter shall be sent to the
Department at the following address:
Department of Environmental Protection
20 Riverside Drive
Lakeville, Massachusetts 02347
1 L The owner shall submit to the Barnstable Board of Health copies of pumping records
within 14 days of each pumping date.
Please note that the conditions, outlined above, do not supersede any conditions imposed
by the Barnstable Board of Health. The above conditions supplement any other conditions
imposed by the Barnstable Board of Health.
3
Should you have any questions regarding this matter,please contact Christos Dimisioris at
(508) 946-2736.
Sincerely,
Brian A. D!Resource
ey
Bureau of rotection
D/CD/
cc: Thomas McKean
Barnstable Public Health Division
200 Main Street
Hyannis,Massachusetts 02601
Stephen Wilson,P.E.'
Baxter,Nye &Holmgren,Inc.
828 Main Street
Osterville, MA 02655
DEP Watershed Permitting Program, Title 5 Section,Boston
4
p �
Transmittal Letter
-- Board of Health' -"
200 Main Street
Hyannis, MA 02601 '''
Attn:
From: Stephen A. Wilson, P.E. a
CD
Subject: 2o l lock I s g L,or.•, 63���. Yzo��? -"
Date:
We are sending you ®Attached ❑Under Separate Cover
The following documents:
®Prints❑Order of Conditions❑Variance Approval❑Recording Slip ❑ Septic System Permit
❑Notice of Intent❑Other
DATE QUANTITY DESCRIPTION
These items are transmitted as checked below:
❑ For Your Use ❑ As Requested For Your Files
❑ For Review and Comment ❑ For Recording . As Required
Other:
-tom l � r.�, ey St I.t c� 'k',Q V'c•t ��tl►�Men•rr s
Additional Distribution p Pe t t ,a
File No.
Baxter,Nye&Hohngren Inc. Phone:508-428-9131,ext. 13
812 Main Street Fax: 508-428-3750
Osterville,Massachusetts 02655 E-Mail:swilson@jkholmgren.com
TrAmmWalLetter4.doc
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Town of Barnstable
Ati Board of Health
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,MSPH
Wayne Miller,M.D.
August 4, 2005
Mr. Stephen Wilson
Baxter, Nye, and Holmgren
812 Main Street
Osterville, MA 02655 /p
Dear Mr. Wilson,
You are granted permission on behalf of your client, Donald Pollock, to construct
a holding tank at 158 Long Beach Road, Centerville. The permission is granted
with the following conditions:
�� ✓ (1) The applicant shall submit floor plans of the existing dwelling at this
property.
p(2) No more than three (3) bedrooms maximum are authorized at this
roperty.
(3) The applicant shall record a properly worded deed restriction, signed
_,,,-�y the property owner, at the Registry of Deeds restricting the number of
bedrooms at this property to three, before the applicant obtains a disposal
works construction permit.
(4) The footprint of the building cannot be increased or changed in the
future, without prior written approval of the Board of Health.
(5) The total number of rooms cannot exceed the current number of
rooms at this property.
-46) The tank shall be properly equipped with a float switch and alarm
system.
VIIX(I) p e P
WilsonPollockHoldin jank
t >
This permission is granted because the owner's representative testified that an
onsite sewage disposal system cannot be designed to meet the minimum
standards of the State Environmental Code, Title 5. Therefore, a holding tank
appears to be the only option available for this site.
Sinc ely yours,
yne flier, M.D.
C airm
W ilsonPollo ckHoldinjank
` COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
SOUTHEAST REGIONAL OFFICE
s 20 RIVERSIDE DRIVE, LAKEVILLE, MA 02347 508-946-2700
MITT ROMNEY— — S E
Governor ec
TEPH N'R PRITCHARD
Secretary
KERRY HEALEY -
ROBERT W.GOLLEDGE,Jr.� -
Lieutenant Governor'; Commissioner
December'7,2005 ;
z 9Doiiald Pollock - -- -RE:- -BARNSTABLE=Subsurface•Sewage -- _
41 Stanton Street Disposal=Propose&Tight Tank fortl58�
Brookline Massachusetts 02445
�.. r. _. _ Long.Beacli Road Centerville'
Transmittal No. W070629
Dear Mr. Pollock:
The Southeast Regional Office of the-De_partment,_of Environmental Protection has received
and completed its review of the above referenced application for approval of a tight tank pursuant to
Title 5 of the State Environmental Code, 310 CMR 15.260,to serve an existing three bedroom
dwelling at the above-referenced address.
Accompanying the application was a plan titled:
_ N
CJ
"PROPOSED TIGHT TANK
158 LONG BEACH ROAD, CENTERVILLE
PREPARED FOR: DONALD POLLOCK c,) 7r;
SCALE: 1"=10' DATE:JUNE 10, 2005
BAXTER,NYE&HOLMGREN, INC. `cam
828 MAIN STREET ,
OSTERVILLE,MA 02655" ``� C,
r i--
c.3 M
Based on its review of the application and accompanying plans, the Departm t recognizes
that a sewer connection is not feasible and that there is no other feasible alternative for the disposal
of sanitary sewage in accordance with 310 CMR 15.000.'
_ -The Department finds that the application and_plans are_in compliance With 310 CMR
15.000, and, accordingly, hereby approves your,request pursuant to 310 CMR 15.260, Tight Tanks,
subject to the following provisions.=Failure to comply with these'provisions may result in revocation
of this approval.
1. Prior to installation of the tight tank,the owner shall obtain a disposal system
construction permit from the Barnstable Board of Health.
This information is available.in"alternate format.Call Donald M.Gomes,ADA Coordinator at 617-556-1057.TDD Service-1-800-298-2207.
DEP on the World Wide Web: http://www.mass.gov/dep
1 Z� Printed on Recycled Paper
2
2. This approval is limited to existing use and any change of use will require a new
approval. The tight tank shall not be used for new construction or for any increase in
flow. The facility design flow is limited to 330 gallons per day. .
3. The owner shall allow representatives of the Department and the local Board of Health
access to inspect the facility during construction in order to assess compliance with the
plans as approved by the Department. It is the applicant's responsibility to ensure that
the approved plans are available at the site during construction. -
4. No tight tank shall be utilized until-the owner has submitted'to.the Department"and the
Board of Health written certification by a Massachusetts Registered Professional
Engineer or Registered Sanitarian that the tight tank has been constructed and installed in
accordance with the approved plans.
5. The owner shall provide the Barnstable Board of Health with.a copy of an executed two-
year service contract with a septage hauler licensed.-to operate in that community, which
identifies the disposal location(s) of the tight tank contents. Failure of the owner to
properly maintain the tight tank and keep it from overflowing shall constitute grounds for
revocation of this approval.
6. Within 30 days of a sewer becoming available to the facility,the owner shall connect the
facility served by the tight tank to the sewer and shall abandon the tight tank in
accordance with 310 CMR 15.354.
7. Prior to the issuance of a certificate of compliance, the owner shall record a deed
restriction limiting the use of the dwelling to three bedrooms and shall submit to the
Department and the Barnstable Board of Health the book-and page number and the date
of such recording.
8. An operation and maintenance plan, acceptable to the local Board of Health, shall be
implemented which requires monitoring of the system at a minimum frequency of once -
every three months during periods which the property is occupied to ensure proper
operation an&maintenance.
9. Prior to the issuance of a certificate of compliance,the owner shall obtain all other
applicable permits including any permits required from the local conservation
commission and any required licenses for the dock.
10. All notices and,information required pursuant to this approval letter shall be sent to the
Department at the following address:
Department of Environmental Protection
20 Riverside Drive
- - Lakeville, Massachusetts 02347 -- -------
1 l. The owner shall submit to the Barnstable Board of Health copies of pumping records _
within 14 days of each pumping date.
Please note that the conditions, outlined above,.do not supersede any conditions imposed
by the Barnstable Board of Health.- The above conditions supplement any other conditions
imposed by the Barnstable Board of Health.
3
Should you have any questions regarding this matter,please contact Christos Dimisioris at
(508) 946-2736.
Sincerely,
Brian A. Dudley
Bureau of Resource rotection
cc: Thomas McKean '
Barnstable Public Health Division
_200 Mairi-Street _ -
Hyannis, Massachusetts 02601
Stephen Wilson,P.E.
Baxter,Nye &Holmgferi,'Inc.'
828 Main Street
Osterville-, MA 02655
DEP Watershed Permitting Program, Title 5 Section,Boston
BAXTER, NYE & HOLMGREN, INC.
Registered Professional Engineers and Land Surveyors
812 Main Street,Osterville,MA 02655 (508)428-9131 FAX:(508)428-3750
July 7th, 2005
Board of Health
Town Offices
200 Main Street
Hyannis,Massachusetts 02601
Re: Proposed Tight Tank
158 Long Beach Road, Centerville
Members of the Board,
On behalf of my client, Donald Pollock, I am requesting permission to install a tight tank
at the above noted location.
Enclosed please find the following items:
• Plan of the proposed holding tank
• Variance request form.
• Letter of authorization from Mr. Pollack
• Calculations for capacity and buoyancy.
I will notify the abutters of this request as per the Board's policy.
Once the Board has approved the tank we will submit an application to the D.E.P. for
approval.
I will attend the Board's public hearing to address your questions.
Sincerely,
ephen A. Wilson, P.E.
encl.
#2005-039
PollockTightTankReq.doc
Land Surveys 9 Subdivisions Septic Design • Wetland Filings Site Design
June 15th, 2005
Board of Health
Town Offices
200 Main Street
Hyannis, Massachusetts 02601
Re: 158 Long Beach Road, Centerville
Members of the Board,
This letter is to inform the Board that I have authorized Stephen A. Wilson, P.E. to represent me for
the variances being requested at the above noted location.
�I
S' re
Donald Pollo
#2005-039
PollockBOHL.etter.doc
DATE:
., FEE: AM
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* BARNSTABLF,;
MASS;
REC. BY_
Town of Barnstable
SCHED. DATE:
Board of Health
200 Main Street,Hyannis MA 02601
Office: 508-862-4644 Susan G.Rask,R.S.
FAX: 508-790-6304 Sumner Kaufman,M.S.P.H.
Wayne A.Miller,M.D.
VARIANCE REQUEST FORM
LOCATION
Property Address: I56 leae hJe2c1► (Zosc� �c.�itrd;�le
Assessor's Map and Parcel Number: M ZOS 1P.1 Size of Lot: A S.
Wetlands Within 300 Ft. Yes _ C Business Name:
No Subdivision Name:
APPLICANT'S NAME: Dana 1.4 'T, P.11 a r;C Phone
Did the owner of the property authorize you to represent him or her? Yes X _ No
PROPERTY OWNER'S NAME CONTACT PERSON
Name: Donal 3 J. E1j ..L Nk 5 Pe 11ask Name: Stephen A. Wilson,P.E.
Baxter,Nye&Holmgren
Address: V/ Address: 812 Main Street
^oolc%.0 . IVA (S2`/'Is Osterville, MA 02655
Phone: Phone: &o 8.)q.Z a— !/3/l <k f. /3
VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) `
lRin..r.tt d,d tti�l.stl 1-.a 12crntec— �x�6h►Lc C«
_�`CcMIL
NATURE OF WORK House Addition 11 House Renovation 0 Repair of Failed Septic System X
Checklist (to be completed by office staff-person receiving variance request application)
Please submit copies in 4 separate completed sets.
Four(4)copies of the completed variance request form
/t Four(4)copies of engineered plan submitted(e.g.septic system plans)
_ Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)
Signed letter stating that the property owner authorized you to represent him/her for this request
Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense
p (for Title V and/or local sewage regulation variances only)
�1 Full menu submitted(for grease trap variance requests only)
C:\Documents and Settings\decollik\Local Set tings\Temporary Internet Fi1es\OLK3\VARIREQ.DOC
C'�aoo 5-03 y�
Pollock— 158 Long Beach Road
Tight Tank Calculations
Required Capacity: 3 bedrooms x 110 gpd/bedroom x 500%= 1,650 gallons
Minimum size allowed=2,000 gallons(310 CMR 15.260(2)(a))
Buoyancy: Displacement of 2,000 gallon(H-20 tank)= 11'x 6'x 7.4'x 62.4 lbs./c.f. _
30,2301bs.
Weight of H-20 tank(empty) =25,080 lbs.
Buoyancy=30,230 lbs.—25,080 lbs= 5,150 lbs.
Unit weight of concrete= 150 lbs./c.f.
Volume of concrete required=5,150 lbs./ 150 lbs./c.f =34.3 c.f.
Surface area of tank top= 11'x 6' =66 s.f.
Thickness of concrete required=34.4 c.f/66 s.f. =0.52'—6"
Use 10"of concrete atop tank.
#2005-039
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Abutters Map
Scale 1" 200'
BAXTER, NYE & HOLMGREN, INC.
Registered Professional Engineers and Land Surveyors
Abutters List
Map Parcel Owner&Address
205 8 Charles R. Calabrese
10 Woodside Drive
Agawam, MA 01001
205 10 Nelson W. Orr
1155 High Street
Westwood,MA 02090
2005-005 /Pollock
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U.S. Postal Service,.
,J ru CERTIFIED MAIL.
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N For delivery information visit our website at www.usps.coffle
__= O U I A U S E
0 o S Postage $ 3 A 02 1,
ON
rq Certified Fee
a.tC3J ry
C3 Return Redept Fee IS
tmark
A A A C3 (Endorsement Required) 7 b e
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kfol _a (Endorsement Required)rU Total Dnstaaa S Fees 1 ` T 0
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E3 Map 205, Parcel 8
1 Charles R. Calabrese
o. I
Cil
10 Woodside Drive -------------
Agawam,MA 01001
SENDER: COMPLETE THIS SECTION
COMPLETE THIS SECTION ON DELIVERY
i
■ Complete items 1,2,.and 3.Also complete /� g ture�
item 4 if Restricted Delivery is desired. /� ❑Agent
■ Print your.name and address on the reverse X G� �—. ❑Addressee, '
so that we.can return the card to you:. B. Rec iv4d by(Printed Name) C.-Date of Delivery
■ Attach this card to the back of the mail piece,
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1 r Article Addressed to: If YES enter delivery add`ess below: ❑No
Map 205, Parcel 8
Charles R. Calabrese
10 Woodside Drive 3::Service Type'. Yw
Agawam,MA 01001 9kCerted Mai ❑EaxP,. r a
❑'Registered' Receipt'forMerchandise
❑Insured Mail . .,0 C:0 6.
4. Restricted Delivery?(6rtm Fee) ❑Yes:
2: Article Number
?003 2260 0001 1601 6032.
Mansfer from s. e
PS Form 3811,February 2004. Domestic Return.Receipt 102595-02-Fur-1540 {
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ar N C11 O Certified Fee 2 0
g� f ReturnReciept Fee V j
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- Total Pn¢faee A Fees
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E3 Map 205, Parcel 10
r` Nelson W. Orr e
� . 1155 High Street
b "---------------
Westwood,MA 02090
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SENDER: DELIVERY
f ■ Complete items 1,2,and 3.Also complete A Sign e
item 4 if Restricted Delivery is.desired. ❑Agent
■ Print-your name and address on the reverse X ❑Addressee.,
so that we can return the card to you. - Received by(Printed Name) ` C.'Date of Delivery
■.Attach this card to the back ofthe mailpiece,
or on the front if space permits.
D.Is delivery address different from item 1? ❑Yes
'I. Article Addressed to: If YES;enter'delivery address below:. ❑No
Map 205,Parcel 10
Nelson W. Orr
1155 High Street
3.',Service Type
Westwood,MA 02090 'certified Mail ❑Express Mail.
Q Registered ❑Return Receipt for Merchandise
I ❑Insured Mail., ❑C.O.D.
4: Restricted Delivery?(Extra Fee) ❑Yes.
2.ArticleNumber 7003 2260 0001 1602 4846
(Transfer from.service.,®e�
PS Form 3811,February 2004 Dornostic Return Receipt 102595-02-of-1540
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LEGEND/ABBREVIATIONS WATERWAYS LICENSE NOTES: GENERAL NOTES:
a- = UTILITY POLE ® = AIR CONDITIONING UNIT 1. LICENSE 963, ISSUED MAY 17, Naas TO BOLD wuNTAw ZONING INFORMATION:
O+W-- = OVERHEAD WIRES D4 = WATER GATE/SHUTOFF RETAiNf�IG WALL & FILL
• c` '' ---�---- = WOOD FENCE FND = FOUND 2 LICENSE t3165, ISSUED AUGUST 13, 194s. To BUILD WALKWAY ZONING DISTRICT: RD
•- . � -�� k� c = GAS LINE F.F.E. = FINISH FLOOR ELEVATION
IN REAR OF HOUSE; 8' X 8' FLOAT& HINGED LADDERR,
Y I = I LICENSE f5155, ISSUED NOVEMBER Z 1966. TO BUILD OVERLAY DISTRICTS:
.N' = SIGN EOP = EDGE OF PAVEMENT 10 X a2 DDaX. RPOD RESOURCE PROTECTION OVERLAY DISTRICT
' • . - o�" _ cEssPoa COVER RET. = RETAINING AP AQUIFER PROTECTION OVERLAY DISTRICT
MAIL BOX EL = ELEVATION CONSTRUCTION NOTES:
�` . a�• :•'. r ' El = ELECTRIC METER _ MINIMUM CURRENT ZONING REQUIREMENT'S N ZONE RD
g� • •• ® = WATER METER CB CONCRETE BOUND 1. CON7RACTOR SHALL TAKE ALL NECESSARY MEASURES TO ENSURE MIN. LOT AREA = 2 ACRES (RPOD)
METER DH = DRILL HOLE FOUNDAVON OR ROADWAY IS NOT UNDERMINED OR DAMAGED.
MIN. LOT FRONTAGE = 20'
+ ~ w •+ * = I MP
POST 2 EXCAVATION DEWAMMG SHALL NOT BE DISC14AM DIRECTLY INTO RIVER. = 1 ,
MIN. LOT WIDTH 25
3 EXACT LOCATION OF 7IGHT TANK MAY BE ADJUSTED TO ACCOMMODATE ,
• h Y
k EXISTING PLUMBING FRONT YARD = 30 SIDE & REAR YARD = 15
4' SHAM REMOVED. COMMUNITY PANEL NUMBER: 250001 0008 D
ALL EXCESS SOIL SHALL BE TAKEN OFF SITE
+ , �s r � ��, ass �> 4;p THE FLOOD INSURANCE RATE MAP DEFINES THIS AREA
% , �f; s u AS ZONE A13 (EL = 11')
TIGHT TANK SPECIFICATIONS:
EBB
BENCHMARK DATUM: NGVD 1929
a •` _ a „ 1. ALL PLUMBING AND iMRWG M COWFORM M APPLICABLE CODES
I�
2 TA SHALL BE WATERPROOFED AT THE MANUFACTURE'S YARD. PRIMARY BENCHMARK: RM - 18 ® FIRM MAP 250001 0008 D
NK(
LOCUS MAP Scale: 19 = 20W I JOINT SHALL BE WATERPROOFED VAIN A GASKET AND WRAPPED CHISELED SQUARE IN TRAFFIC TRIANGLE
CE]VT
FLOW ON 7HE EXTERIOR. O INT. OF CRAIGVILLE BEACH AND LONG
LOCUS AREA IS COMPRISED OF : 3 4 E 4 PRECAST RISERS SHALL BE SET PRIOR TO POURING 10' CMCRM BEACH ROADS. EL = 7.19E (NGVD)
ASSESSOR'S MAP 205 PARCEL 009 LETS A Ar A R VT
TLE
ANn-FLOArATroN CAP.
RI 5 ACCESS COVERS SHALL BE WATERPROOF. PROJECT BENCHMARK: CONCRETE BOUND (SEE PLAN)
3 4 L.C. PLAN 13974 F � 6. TANK MUST BE OBSERVED AND TESTED FOR WATER TIGHTNESS EL = 4.89' (NGVD)
LOTS A & A 0 L.C. PLAN 13974F COMBINE TO CREATE LOCUS -'may PRIOR M pTILIZA�
CERTIFICATE OF TITLE: 226,750 TOTAL AREA TO RET. WALL UNLICENSED ITEMS TIDAL RELATIONSHIP TO NGVD 1929
OWNERS:DONALD J. & ELIZABEIH S. POLLOCK 3,289t SQ. FT. BASED ON 19 YEAR SERIES OF TIDAL OBSERVATIONS
41 STANTON ROAD 0.08t ACRES ENDING 1978 BY "NOS" (FORMERLY USC & GS)
BROOKLINE, MA 02445 FLOAT
4 AMP w 2.2E MEAN SPRING HIGH WATER
n Z 1.8E MEAN HIGH WATER
UC# 1963 UCI 3165 F NOT Z
z ` PRESENT WOOD
aCON� . . - 5�55 Q 0.4E MEAN WATER LEVEL
sT y; 0.0E NGVD 1929
cr-
ALL _
I 5.2E �-�.„ 75 t W-1.0' MEAN LOW WATER (EL. = 0.0')
5.9
z 6 3` R -�_ 7 A TITLE SEARCH HAS NOT BEEN PERFORMED FOR THIS SITE.
S ���ap�R-.DES IF PERFORMED BY DETERMINED
TO OTHERS.BE ECESSARY A TITLE SEARCH SHAM BE
5.3E TO EXTENSION OF PL.
THE PROPERTY LINE INFORMATION SHOWN IS BASED
cAF'RAME 6.4 0 ON CURRENT AVAILABLE RECORD INFORMATION
g S T yq CONSISTING OF PLANS AND CERTIFICATES.
1 a W WAME pyy �` / 'ti'F THE EXISTING FEATURES SHOWN HEREON WERE
FFC. 158 / / OBTAINED FROM AN ON THE GROUND FIELD SURVEY
LOT AS $ +f ,: 6.70'/ n PERFORMED BY BAXTER, NYE & HOLMGREN, INC. ON
L.C. PLAN 13974 F :+' APRIL 24 & 28, 2005.
N/F CHARLES R. CAL.ABRESE 4,9 5.1
m REFERENCE PLANS:
4.7 50 5'3 a PLAN BOOK 59 PAGES 125 &127
5.2 GATE m z o PLAN BOOK 110 PAGE 101
W 3 PORCH ^� .o • L.C. PLANS 13974 A. E-F
5.0 � �� a
CB DH FND �? >� 5.5 ° F SIDELINES OF LONG BEACH ROAD SHOWN ON THIS PLAN ARE
10�88• ^' - 5.4 5. :` TO BE PUMPED C: a33.1 AS DEFINED BY LC. PLAN 13974 AS REFERENCED ABOVE.
l p 5.2
►- AND REMOVED r r.
.,`26.7 I io 4 oil y $F." '� gOBSERVED HlcFi �NA�R 158 Long Beach Road
0' 4.8 a `} LQLA r EXISTING 5,1 �. Ott
4.1 T 4,8 .D4 '�; SEPTIC COVER ' 3.3 4.1 3. 4-28-05 3.5 •
o. Centerville, Massachusetts
N 7g34'15- 8.20' 4.2 _5 5,4 �,
W 154 0' 7D ® 'PAVED P RKING� ( DEED BOOKLS�PAGE
ORR 139 PREPARED Donald Pollock
PRECAST RISERS SET BFORE
CONCRETE 5 POURED 4.1 AR O,S a: �}
CONSTRUCT ACCESS ND VA7ER TIGHT�s L�3a 36' 21 62" 1T11F "
F.G EL- 5�1- 52 FG EL= 51- 52 R=Q1292' o N 89W15 E 4.3 4.7
y EOP Proposed Tight Tank
10 ---- ---- ---- POUR 1X1'LAVR OF LONG BEACH ROAD °y BAXTER, & HOLMGREN, INC.
r • OOt1CRElE ATOP TAW SEE "PLAN of PROPOSED BUILDING LINES ON LONG Registered Professional Of ss��
ter 'BE
BEACH ROAD," TOWN OF BARNSTABLE FEBRUARY 8, Engineers and Land Surveyors TEPHfN yG
20' WIDE PUBLIC WAY oy 1939 O PLAN BOOK 59 PAGES 125 do 127 812 Main Street,Osterville,MA 02ti55 i4LI'
• 4,7
N11C = 3.1 ALARM SIGNAL.SHALL BE ��4' • �
AUME/VISUALALERT 15 E 4.s Phone- (508)428-9131 Fax- (508)428-3750 9?soC
ts4 _ ��EST��
r EOP 4'S 10 0 10 20 °
T-4 UP �14-:�---�H 0 L�43.06 R�3 92' /Or�fAI.E `
FLOAT ALARM LEVEL , „ 52 22
-y~ OHi OH S 8 '50'15' W Ss
INLET FLOAT ALARM TBM: CB DH FND SCALE IN FEET G ®�
AVERT 5-7* 3'-3' a- 4.89' (NGVD)
LIQUO m HIGH SCALE. 1" = 10' DATE: 06-10-05
I LEVEL WATER ALARM
��TN or, s�q REV. DATE:
WALLS REMARKS
sr � o
a :--
6' WALLS T EP N.
6'CRUSHED STONE BASE
eo216 DRAWING NUMBER
°DETAIL Oils _TIGHT TANK �oNAL� 0: 2005 SURVEY WRKSHT 2005 039boh.dw
ZOO GALLONS-H2O LOADING
N.T.S. y�0s 2005-039