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HomeMy WebLinkAbout0079 LONGFELLOW DRIVE - Health 79 LONGFELLOW DR., CENTERVILLE A=188-010 �� `r 0 I/II �gEGVClFO� � ��r►zeatrQ® 2° UPC 12534 No.2. 3 OR HASTINGS, MN r "� TOWN OF BAI2NSTABLE LOCAIRON ( CJn -4fe—I l,J r SEWAGE # -- VJLLAGE e4 Ae d' ,- e. ASSESSOR'S &LOT INSTALLER'S NAME&PHONE NO. SEPnC TANK-CAPACITY LEACHING FACILITY: (type) elf-5 (size) NO.OFBEDROOMS BUILDER OR OWNER PERMITDATE: COWL1ANCE DATE. • i 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 Edgeof Wetland and Leaclung Facility(If any wetlands exist within 300 feet of leaching facility) Feet_ Furnished by f6 { a-D- an' I o wo^ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 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. A. General Information 1. inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Service Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 5-12-11 r; Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be 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. Ln 5/11 t5ins-11/10 Title 6 Official Inspection Form:Subsurface Sewage Disp al System•Page 1 of 17 n Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town 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: El 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 than '/ day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town 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: r` 1` ❑" ®' '` Any porti'on`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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts EEMUENJ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 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: r ® ❑ 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 CM 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 79 Longfellow Dr Property Address Gail Mcaleer "Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry,system inspected? El Yes ® No Seasonal use? El Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump?, ❑ Yes ® No Last date of occupancy: 5-2011 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present?. } ❑ Yes ❑ No C ; Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): r I General Information Pumping Records: Source of information: Owner--pumped 3yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 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: 1999 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 48" Depth below grade: 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.): Good condition. Septic Tank (locate on site plan): Depth below grade: 40" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age, a `years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 10" t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts EUREMI W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 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 22 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? ' Tape Comments on pumping recommendations inlet and outlet tee or baffle condition structural integrity,( P P 9 g ty, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 f' Commonwealth of Massachusetts }#F W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 7M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town 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 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.): Good condition with water at workin g level and no sign of back-up. 9 9i Pump Chamber(locate on site plan): Pumps in working order:. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ Teaching chambers nu 4-Infiltrators mber: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leach°ing 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.): Infiltrator leach field in good condition with no sign of back-up into d-box or surrounding stone. i 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 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 V . � D t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town 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: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts 4-2 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 79 Longfellow Dr Property Address Gail Mcaleer Owner Owner's Name information is required for every Centerville MA 02632 5-12-11 page. City/Town 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 t t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r0 79 Longfellow Drive, Centerville, MA 02632 1 p — UPPER LEVEL (Total Sq. Ft.= 1104) 46 9.5 13.5 8.5 13.5 Dining 10 10 Kitchen Bath Bedroom 1 Room 10.5 10 3.5 ' 17.5 Hall 3 10 24 Closet 11 c Living o Room 7.5 Bedroom 3 Bedroom 2 13 9.5 Front Foyer 14 7 t"w 79 Longfellow Drive, Centerville, MA 02632 PROPOSED LOWER LEVEL (Total Sq. Ft.= 1300) 14.5 8 10 13 Utility Room Electronics Room 8 Bath 8 Heat/Hot Water g AlU el' Storage 11 Office 17 14 ►,�,, ���Y - J Hall 3.5 '" 3.5 4 Ft Folding Foyer Counter Fridge 13.5 13.5 Home Theater/Playroom 3.5 Laundry Room9.5 6 14.5 O Electric Gas Washing Sink Dryer Machine 23 SunRoom . 13.5 � 4 i V� j ' 5 Town of Barnstable Health Inspector t►+e t Office Hours �oF oiti Regulatory Services 8:30-9:30 Thomas F. Geiler,Director 3:30—4:30 BARNSTABLE, MASS. Public Health Division j°rEp .t A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE Date: September 29,2009 �V bA yr Address: 79 LONGFELLOW DR CENTERVILLE MA 02632 Map.188 Parcel 010 � Name: GAIL FITZBACK and JOSEPH A HEVENEX Phone#: 5.08-240-5900 Ext 212 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes,how many? 2c.. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the pr oposed amnesty apartment. Provide de width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO Private Septic If the:.dwelling is connected to:public sewer,skip.questions:#4 through#9 below:. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? i 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to a PUBLIC WATER 3 0 L< 7. Is a disposal works construction permit on file? YE of NO ;- Q 8. If yes,how many bedrooms were approved according to this permit? Bedrooms i~ 9. Were any building permits obtained for construction of additional bedrooms? YES or NO �.,.) W? 7 10. Is there an engineered septic system plan on file at the Health Division? YES r NO—"' 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES for NO,,) m FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: /% Date: Q:\GMD-Housing\\AAc�cesso�ry Affordable Apartment Progrgraam\ADDMIN\F(ORRMS&LElTT^ERS\Bla(nk Forms aLeestyappl.DOC McKean, Thomas From: McKean, Thomas Sent: Tuesday, April 13, 2010 8:42 AM To: Dabkowski, Cindy Cc: Perry, Tom Subject: Fitzpack Amnesty Apartment/79 Longfellow Drive Centerville The second owner of this dwelling, Joseph Hevener, came into the Office yesterday and informed me that he needs to remove the recorded three bedroom deed restriction immediately. He said according to the bank, Cape Cod Five, he cannot obtain a mortgage for this property. I informed him that this could require a new application to start the septic questionnaire process over again. He later called back and stated that he will agree to remove the door to the office and provide a minimum four feet wide opening. Should he be communicating with your Office about all these changes? Does this affect the amnesty apartment approval by the ZBA? i F Dabkowski, Cindy From: Dabkowski, Cindy Sent: Monday, November 30, 2009 10:01 AM To: McKean, Thomas Subject: 79 Longfellow Dr CV Good Morning Mr. McKean I received your message regarding Ms. Fitzback at 79 Longfellow Dr CV MA 02632 1 will fax the Amnesty Program Septic,Questionnaire for you to approve. Please clarify again - The main level of the house has 2 bedrooms and an office also note that the homeowners are retaining the work room and family room with closet in the lower level o f the home. Am I to understand that these rooms will be allowed because of the recording of a deed restriction. In the lower level bathroom laundry room bedroom dining room and living room/sun room and kitchen for the apartment will be permitted with and amnesty restriction. Please advise Cindy Dabkowski Affordable Accessory Apartment Coordinator Growth Management Department 367 Main St Hyannis, MA 02601 508-862-4743 1 Doc:." 1P1267336 10-22-2009 10ZS2 BA,RNSTABLE LAND COURT REGISTRY DEED RESTRICTION 'kHEREAS, Joseph M. Hevener and Gail Fitzback of 79 Longfellow Drive, Centerville, MA 02362 Is the owner of 79 Longfellow Drive located at Centerville, MA (hereinafter referred to as Owner) and being Lot 26 on Land Court Plan Number 24614-E (Slieet 3) and duly recorded in Barnstable Land Court Registry Certificate No. 154984 on October 1, 1999. WHEREAS, Joseph M. Hevener and Gail Fitzback- as th e owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction is to the number of bedrooms that may be used for sleeping purposes as a pre-condition to obtaining approval for an Accessory Affordable Apartment at 79 Longfellow Drive,Centerville,M.A. NOW, THEREFORE, Joseph M. Hevetter- and Gail Fitzback do hereby place the following restriction on their above-referenced land in accordance with their agreement with the Town of Barnstable Board (-,)f Health, which restriction shall run with the land and be binding upon all successors in title: 1. .79 Longfellow Drive, Centerville, MA may contain no more than three (3) bedrooms to be used for sleeping purposes. Joseph rvi. Hevener and Gail Fitzback agree that this shall be a pennanent deed restriction affecting 79 Longfellow Drive located in Ceritetville MA, and being shown as Lot 26 on Land Court Plan Number 24614-E(Sheet 3). For title of Joseph M. Hevencr and Gail Fitzback see the following deed: Land Court Certificate of Title Number 154984, Executed as a scaled Instrument this 2 1h day of October,2009. OwneLsAignature 0 "s signature J/ COMMONWEALTH OF NIASSACHUSETTS —----- ss October 21, 2009 Then personally appeared the above-named Joseph N1, Hevener rind Gail Fitz*back known to me to be the persons who executed the foregoing instrument and acknowledged the same to be their free act and deed,before me, U/ Notary Public N-ly Commission expires: K-BARKER Notary PUIAG cola��'OF vbryaty my comrr�tww tl*es 1-*1- 5,2013 " 4., Q IL 0 peGISTRY OF DEED$ A TRUE GOPY,A7TEST 4 BA NSTABLE REGISTRY OF DEEDS y UPPER LEVEL (Total Sq. Ft.= 1104) 46 9.5 13.5 8•5 13.5 Dining Kitchen 10 Bath 10 Bedroom 1 10 Room 10.5 23.5 17.5 Hall X 3 10 24 Living �O .Room 7.5 Office Bedroom 2 13 9.5 14 7 X Smoke Detector _ LOWER LEVEL (Total,Sq. Ft.= 1300) 1.4.5 8 10 13 Work Room 8 Bath 8 Laundry/Heat/Water Guest Room 11 s 17 14 X Hall X 3.5 1�ectrbc� rr� t5 1 p � 13.5 Foyer Family Room =-t 13.5 3.5 Kitchen 9.5 . Dining Room 10 �Q 6 Closet G' 14.5 � X Room � S SunRoom 13 X = Smoke Detector 13.5 O y tr -7 1 . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certifi-cate of (Compliance THIS IS TO CERTTYthat t e On-s• a Sewage Disposal System Constructed ( ) Repaired ( ✓)Upgraded( ) Abandoned( )by at 60 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �q—WSJ dated ` —9 7 Installer Designer The issu ce this p,�,�iX shill not cowtrued as a guarantee that the i 1 function s �e�np . Date- %Gi Inspector TOWN OF BARNSTABLE LOCATION 7° �v<�yI c< � �%��, SE WAGE # VILLAGE G erir v; C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �o//�L� 1 Ce-'I l SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �`/�`/ Q7 / (size) 9.f�3ZX Z NO. OF BEDROOMS 3 BUILDER OR OWNER ,-/ %r4 PERMIT DATE: 7-"Z IJ/ 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 well$exist on site or within 200 feet of lcaching facility) Feet . Edge of Wetland and Leaching Facility (If any wetlands.exist within 300 feet of leaching facility) Feet Furnished by TOWN OF BAMSTABLE LOCATION 7F , / SEWAGE # l l '" ZC- VILLAGE C P611l'�/`l�' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 3�2,.t' NO. OF BEDROOMS /� // BUILDER OR OWNER e'r1171` i4 PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) j7J�j 1 Edge of Wetland and Leaching Facility (Ifany wetlands exist within 300 feet of leaching facility) Furnished by J\C CVe�er 7� t2 Doc: IP126s336 10-22-2009 10:52 ��� , ei�Y� On� 6 � � BARNSTABLE LAND COURT REGISTRY DEED RESTRICTION 'we V1/�-MAS, Joseph M. Hevener and Gail Fitzback of 79 Longfellow Drive, Centerville, MA 02362 is the owner of 79 Longfellow Drive located at Centerville, MA (hereinafter referred to as Owner) and being Lot 26 on Land Court Plan Number 24614-E (Sheet 3) and duly recorded in Barnstable Land Court Registry Certificate No. 154984 on October 1, 1999. WHEREAS, Joseph M. Hevener and Gail Fitzback as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms that may be used for sleeping purposes as a pre-condition---to obtaining approval for an Accessory Affordable Apartment at 79 Longfellow Drive, Centerville, MA. NOW, THEREFORE, Joseph M. Hevener and Gail Fitzback do hereby place the following restriction on their above-referenced land 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: 1. 79 Longfellow Drive, Centerville, MA may contain no more than three (3) bedrooms to be used for sleeping purposes. Joseph M. Hevener and Gail Fitzback agree that this shall be a permanent deed restriction affecting 79 Longfellow Drive located in Centerville MA, and being shown as Lot 26 on Land Court Plan Number 24614-E(Sheet 3). For title of Joseph M. Hevener and Gail Fitzback see the following deed: Land Court Certificate of Title Number 154984. Executed as a sealed instrument this 2 Vh day of October,2009. 1 /_ Owne 's ignature 071, s signature 61 COMMONWEALTH OF MASSACHUSETTS ss October 21, 2009 Then personally appeared the above-named Joseph M. Hevener and Gail Fitzback known to me to be the persons who executed the foregoing instrument and acknowledged the same to be their free act and deed,before me, J_ Llaa,_�&.L� Notary Public My commission expiresA.WPM Notary Punic COMMo�rwn+of my commission Ex es Fdxuwy15.201502 i rrp•,0•�o,;.J �. �, yASN 1ABLE COUPT�`! �'• ,� p ` �EQISTRYOFDEEDS ;.y� ' +r►v SJ� , A TRUE COPY,ATTEST .,�,. •�.., e --�~ BARNSTABLE REGISTRY OF DEEDS I Town of Barnstable Health Inspector pF'THE tOy� Regulatory Services Office Hours 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30 ' 4 4 Public Health Division Thomas McKean,Director �ArEO MA'S 200 Main Street,Hyannis,MA 0260.1 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT- SEPTIC QUESTIONNAIRE Date: September 29,2009 Address: 79 LONGFELLOW DR CENTERVILLE MA 02632 Map 188 Parcel 010 Name: GAIL FITZBACK and JOSEPH M..HEVENER Phone#: 508-240-5900 Ext 212 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please.include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO Private Septic If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to a PUBLIC WATER 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO --------------------------- --------------------------------------------------------------------------------------- FOR OFFICE USE ONLY t`j/l3/D9 The Public Health Division has no objection to bedrooms at this property. l Special Conditions: Signed: Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyapp 1.DOC UPPER LEVEL (Total Sq. Ft.= 1104) 46 9.5 13.5 8.5 13.5 Dining Kitchen 10 Bath 10 Bedroom 1 10 Room 10.5 17.5 10 24 23.5 � Hall X 3 11 Living Bedroom 2 Room 7.5 Office 13 9.5 i 14 7 j I X = Smoke Detector LOWER LEVEL (Total Sq. Ft.= 1300) 14.5 8 10 13 Work Room. 8 Bath 8 Laundry/Heat/Water o Guest Room 11 s 14 17 X Hall X 3.5 3.5 10 13.5 4 Foyer Family Room 13.5 3.5 Kitchen 9.5 Dining Room 10 6 0 Closet f� �Q 14.5 X A � m � SunRoom 13 X = Smoke Detector 13.5 APARTMENT (Total Sq. Ft.= 743) 8 10 13 Bath 8 Laundry/Heat/Water 8 Bedoom 11 14 Hall X 3.5 10 13.5 Kitchen 9.5 Dining Room 10 X Livingroom 13 X = Smoke Detector 13.5 i ` O i tiX —,�i'7� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CER ,.that t e On-s' a Sewage Disposal System Constructed( )Repaired ( ✓Upgraded . ( ) Abandoned( )by d!- , �y 72 at BGrJ eh 7`enl e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. CN—�S' dated Y'"Z/—9 7 Installer Designer The issua ce this p h 11 not c strued as a guarantee that the i 1 function s de ' no . Date Inspector TOWN OF BARNSTABLE LOCATION 1 (/�%%�Y Iz<%U�/ ��% SEWAGE # VILLAGE G e 7 v;%�e ASSESSOR'S MAP& LOT /:�-ir—OW INSTALLER'S NAME&PHONE NO. ��li�� 1�G:51` 771 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �� ����`"/�f�QJ`�/ (size) 9X 3L X Z NO. OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: q_Z I J�COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �r Feet Private Water Supply Well and Leaching Facility (If any well$.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 TOWN OF BAMSTABLE � LOCATION 7F "��I /G"�� �//�, SEWAGE # eql `" 2d5 VILLAGE P617�LlIle ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: �( —Zl��' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �� 3 Feet Edge of Wetland and Leaching Facility(If,any wetlands exist within 300 feet of leaching facility) s !� Feet Furnished by 1 IN �. �_ ^ � -'�\ fit• \ h' L� C Town of Barnstable Health Inspector oF'I"E te Regulatory Services Office Hours o .8:30-9:30 Thomas F.Geiler,Director 3:30—4:30 • snxNsznsie Public Health Division ATF 039. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 A NESTY'PRO.'GRAM APPEICANT — SEPTIC QUESTIONNAIRE Date: September 29,2009 Address: 79 LONGFELLOW DR CENTERVILLE MA 02632 Map 188 Parcel 010 `® 1d� Name: GAIL FITZBACK and JOSEPH M. HEVENER Phone#: 508-240-5900 Ext 212 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? NO Private Septic If the dwelling is connected to public:sewer,skip questions#4 through#9 below: 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to a PUBLIC WATER 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ' -------------------------------------------------------- -------------------------------------------------------- Z FOR OFFICE USE ONLY I I OThe Public Health Division has no objection to bedrooms at this property. V — Spec' Conditions:, 3 e4rv0ro- Qz k,c {,' � ( -c- ,���, S li'7 Signed _- Date: )/ > Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms. amnestyapp 1.DOC D,0,,=Z- I,r1267336 jL b-22--zae4 10--!52 BAR hit STABLE LAHD COURT RE,G:ISTRY DEED RJESTRICTION W,17TEREAS, Joseph M_Hevener and. Gail Fitzback of 79 Longfellow Drive., Centerville, MA 02362 is the owner of 79 Longfellow Drive, locatred.at Centerville, MA (hereinafter rerferred to as Owner) and being Lot 26 on Land. Court Plan Number 24614-F, (,Sheet 3) and duly recorded in. Barnstable Larid Court Registry Certificate No. 154984 on October 1, 1999. ., WHEREAS, J I Sel) I. Reveller and Gail Fitzback as the. oNvaer of said, lot has agreed wit.11 the Town of Barnstable Board of Health to arestriction as to the number of bedrooms that may be used for sleeping, purposes as a pre-condition to obtaining; approval for an Accessory Affordable Apartment at 79-Longfellow Drive,Centerville,M.A. NOW', THLEREFORE, Joseph M. Hevener and Gai.1 Fitzback do hereby place the Following restriction on their above-re.ferenced land in accordance with 'their agreement with the Town of Barnstable Board of Health, which restriction shall rule with the land and be: binding upon all successors in title: 1. 79 Longfellow Drive, Centerville, MA may contain no more than three (3) bedrooms to be 'used for sleeping purposes. Joseph r M. Hevener and Gail Fitiback agree that this shall be a ermanent deed restriction affecting '79 Longfellow Drive located in C I ' p critervill OMA, and being shown as Lot 26 an Land Court Plan NLirnber 24614.-L(Sheet 3). For title of Joseph M. Hevener and,Galt Fitzback see the following deed: Land Court Certificate of Title'Number 154984, 'EXeC Uted as a sealed 1 ristrurnen t this 2 11.h day of October, 2009. �z Owne s ignature ON, 's signature COMMONWEALTH OF MASSACI-fUSETTS ss October 21, 2009 'Then personal lye appeared the above-named Joseph NT. He.-vener and Gait Fitzback known to me to be the persons who executed the foregoing ins(rumerit and acknovdedged the same to be their free act and deed, before me, Q� Notary Public ic l,.,.Ycomrrlissionexpires: -A. Vi NOWY PG' A. 49 to. dry OF Al COMLONMAM ".L-Lon LY0" c COU doukff 0 0601ST14Y OF-()F-ED-9 k TRU E 00 LLpIY,,ATS-ST SAASTABLE REGISTRY OF DEEDS 1 THE COMMONWEALTH OF MASSACHUSETTS `Crq 'Y��� BARNSTABLE, MASSACHUSETTS Certificate of Comptiance THIS IS TO CERTTfYthat the On-s' a Sewage Dis osal System Constructed( )Repaired ( ✓)Upgraded( ) Abandoned b D/` . at 4LOl. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 21—Z-OS— dated 9 Installer Designer The issua ce this p al not construed as a guarantee that the i 1 function s de ' ne . Date ;�j ' Ins ector � P TOWN OF BARNSTABLE LOCATION 7t SEWAGE VILLAGE e e•1 12fr v, C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Ayice/e07fV SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �— ,���r`-/'�/ /07�'/ (size). :3LX Z NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: q--Z 1—fZ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �r Feet Private Water Supply Well and Leaching Facility (If any well;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 TOWN OF BARNSTABLE LOCATION 7F (�'��9 ��G9� �/�, SEWAGE # VILLAGE �P617� 11Ile ASSESSOR'S MAP & LOT INSTALLER'S NAME 8z PHONE NO. -7 71 p399 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS / BUILDER OR OWNER 0/i' PERMITDATE: —COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S 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 i. UPPER LEVEL (Total Sq. Ft.= 1104) 46 9.5 13.5 8.5 13.5 Dining Kitchen 10 Bath 10 Bedroom 1 10 Room 10:5 23.5 17.5 Hall X 3 10 24 11 Living Bedroom 2 Room 7.5 Office 13 9.5 14 7 X Smoke Detector LOWER LEVEL (Total Sq. Ft.= 1300) 14.5 8 10 13 Work Room 8 Bath 8 Laundry/Heat/Water Guest Roomwe 11 17 X 14 Hall X 3.5 3.5 10 13.5 4 Foyer Family Room 13.5 3.5 Kitchen 9.5 Dining Room 10 0 F �Q'r 6 Closet 14.5 X m SunRoom 13 X = Smoke Detector 13.5 APARTMENT (Total Sq. Ft.= 743) 8 10 13 Bath 8 Laundry/Heat/Water 8 Bedoom 11 14 Hall X 3.5 .10 13.5 Kitchen 9.5 Dining Room 10 . X Livingroom 13 X = Smoke Detector 13.5 " TOWN OF BARNSTABLE SEWAGE # l ` — Z�✓� VII.,LAGE �( ?�f%!�!//�`C� ASSESSOR'S MAP & LOT lg'✓� —�lZ� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /5-3v LEACHING FACILITY: (type) � yr1;1&QVeP6; (size) NO.OF BEDROOMS /'3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: _ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching,faclity) d9 Feet Edge of Wetland and Leaching Facility(If�ny wetlands exist within 300 feet of leaching facility) r� Feet Furnished by `' o O Fro'd V wart. AL F J l `>- TOWN OF BARNSTABLE 120CATION 2,9 LOP5 _k1lal-11 141- SEWAGE # VIQ,AG ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY % a LEACHING FACILITY: (type) ��"7` (size) NO.OF BEDROOMS —3 e BUILDER O)�� PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le�ehing facili ) Feet Furnished b� r ��� � � � �� j'� I �� �- ,� .� if �� � f �� `� �V�-__ ,� -__`__..__ - -i ._______-------� x ' � _Z�S� f� �l No. Fee G G THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ., Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYitation for Migpogaf *pgtem Congtruttion Permit 'Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) MComplete System ❑Individual Components Location Address or Lot No. j _� � Owner's Name,Address and Tel.No. G Assessor's Map/Parcel (� �i' �� r" d f'' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7l Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ' Other Type of Building fSG �No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil �t�'�f�'� �'S ��t'3ZX ZJ Nature of Repairs or Alterations(Answer when applicable) '70 t,Z � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b�is&,,ard of alth. J Signed Date Application Approved by _ Date Application Disapproved for the following reasons Permit No. nI`Z Date Issued No. Fee go t �' THE COMMONWEA TH'OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION - TOVN OF BARNSTABLE} MASSACHUSETTS Yes Application for Migpooar *pztem Con6truction Permit Application for a Permit to Construct(, )Repair(✓)Upgrade( )Abandon( VComplete System ❑Individual Components Location Address or Lot No. �e,e� /Ie�� Owner's Name,Address and Tel.No. Assessor's Map/Parcel f �� �f! Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �Dr/p,/0 i L'4s95T Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(40 Other Type of Building A 5J0PeAr&_ No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3�D gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f�`DD Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) i Date last inspected: Agreement: The undersigned agrees to ensure the construction and`maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by is B ar of/ alth. l Signed !r/ Date �(,� Application Approved byE!YADate Application Disapproved for the following reasons Permit No. �Q -7,o5- Date Issued I -------------------�=----------------- THE COMMONWEALTH OF MASSACHUSETTS fO BARNSTABLE, MASSACHUSETTS Certif irate of Compliance THIS IS TO CER r, that t e On-siAe Sewage Disposal System Constructed( )Repaired ( ✓Upgraded( ) Abandoned( )by at G4 DGcJ �/j� y17`�I�U/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 'z or dated 4/—t l—9 Installer Designer The issua ce f this ptll not b construed as a guarantee that the s3� wi 1 function as de 'gned. Date j 2 Inspecto� l_ No. C Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS =i5pogar *pftem w6truction Permit Permission is hereby granted to onstruct H�e epair(✓)Upgrade( )Abandon( ) System located at h eneo .�✓r 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 must be completed within three years of the date of this a it. Date: y ?�l—� Approved by fn a•-YS i.2'x,q.�t -a... F. ,r� �. �..kr-;••+ _ v.,::.,. ......d:. 7`.+•..�.'u^ xg - .Wr U6/99 rT �t NOTICE: Thi �s Form Is To Be Used For the Repair Of Failed _ t x Septic Systems Only. t 1r CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WrrHOUT DESIGNED PLANS) x � I, o i4?1'r cr ®h �� /, hereby certify that the application for disposal works #a J construction permit signed by me dated y1i1/ Qr , concerning the ? �3. property located at meets all of the following criteria: ' J/The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system ' /There are no private wells within 150 feet of the proposed septic system p �' There is is no increase in flow and/or change in use proposed �� ere are no variances requested or needed. ; The bottom of the proposed leaching facility will not be located less than five feet above they x maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leachingfacility will not be located less than fourteen 14 feet above the maximum adjusted ty ( ) r> groundwater table elevation, ci Please complete the following: x A) Top of Ground Surface Elevation(using GIS information) B) Groundwater Table Elevation I max. adjusted g.w. z/q _ . ' / ry DIFFERENCE SIGNED : DATE: [Sketch proposed plan of system on back]. +� kliN M; _ 9 R n��yy,, xY�1T '( � � � �. �:�..���eE��h.h.���...-"� .R.. ..ia i t+"1'14x��h�m'.�1��.:�yN .l•.-,k.:w'. ��� �-G�,we�.,..{ul..i..LLLM_ Y�� ':i.�s� ,��� '•t I di - � ( D ,`j 0 TOWN OF BARNSTABLE q LOCATION 7F Z-ell //&i�/ f%/,, SEWAGE # l ! `" 205� VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO._ D/�D�'fl�©<1�J' 77/—P34:y SEPTIC TANK CAPACITY LEACHING FACILITY: (type) '�-'ar� //l`�Q�`G�/a (size) �X 3Z•�Z, NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: L—�� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility j Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �� �`9 Feet Edge of Wetland and Leaching Facility(If any wetlands exist y within 300 feet of leaching facility) rl Feet Furnished by TOWN OF BARNSTABLE LOCATION 7F 6/2, SEWAGE #V / VILLAGE ASSESSOR'S MAP & LOT l24' —C9/,r INSTALLER'S NAME&PHONE NO._6d� � l�P6�rJ` 7 7/-pi�9 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS ,,. BUILDER OR OWNERTr' I` PERMITDATE: 79�1 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility j Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /l� Feet Edge of Wetland and Leaching Facility(If A-J ny wetlands exist within 300 feet of leaching facility) Feet Furnished by l E u� I hrp�kJ ,Y-1q �;� a 3 J 'E n 0 'f t J i!