Loading...
HomeMy WebLinkAbout0064 NYES NECK ROAD EAST - Health 64 Dyes Neck Road East Centerville CP/R / A 233 021 i I ' y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Y Centerville MA 02632 Jul 2 2009 required for , every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the J computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 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 IL4 5 Jul 2, 2009 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. / (Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2, 2009 required for Y every 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: ® 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if the inspector cannot answer Yes to any of the failure criteria listed in Section D on pages 4-5 of this report. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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-09/08 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 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (corl ❑ 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•09/08 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 °wM 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2, 2009 every page. Cityrrown 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 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 l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 10 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2, 2009 required for y every 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: ❑ ® 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Y Centerville MA 02632 Jul 2 2009 required for , every page. Cityrrown 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd t5ins•09/08 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 wM 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Design flow indicated on previous Title 5 inpection form dated 11/13/2003. 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? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d n/a-well in use 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2, 2009 every page. City/Town 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: 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-09/08 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 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2 2009 required for Y every page. CityTrown State Zip Code Date of Inspection D. System Information (cont) Approximate age of all components, date installed (if known) and source of information: Age unknown. System is depicted on a plan entitled "As Built Conditions and Proposed Drainage Improvements"dated 12/15/1989 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 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.): Sewer not accessible for inspection. Septic Tank(locate on site plan): Depth below grade: 0.5 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: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 2 in t5ins-09/08 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 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2 2009 required for Y every 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 32 in Scum thickness none Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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•09/08 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 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2, 2009 every page. Cityfrown 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 fiberglasspolyethylene h r❑ ❑ ❑ g ❑ ❑ 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2, 2009 required for Y every 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 at 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.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. 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-09108 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 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2, 2009 required for Y every page. Cityrrown 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Leaching gallery was uncovered and found to be dry. No effluent contact staining was observed at cover interface 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-09/08 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 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is Centerville MA 02632 Jul 2 2009 required for Y every page. Cityrrown 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•09/08 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 °M 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is, required for Centerville MA 02632 July 2, 2009 every page. Cityrrown 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 El drawing attached separately °WELL 100 FL TO SAS PER BSC PLAN OF 12/I5/89 LOCATIONS A 1 16 Ft 35.5 ft 2 36 FL 44 5 ft 58.5 3 38 f t ft EXISTING DWELLING NOT TO SCALE A # 64 a SEPTIC TANK IE 0 90 LEACHING 20 D-BOX GALLERY NYES NECK ROAD EAST t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 J i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2 2009 every 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: 6+ 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: A survey instrument was used to determine that the bottom of the SAS is 6.8 feet above elevation of nearby Bearse Pond, which is part of Wequaguet Lake, a controlled elevation lake. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Nyes Neck Road East Property Address Diane Bradshaw and Ronald Wiggins Owner Owner's Name information is required for Centerville MA 02632 July 2 2009 every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.— Z «o Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppYication for Migpogaf *pgtem Cottgtruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. L��I.y�'f ova4lr' 10 Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 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 Nature of Repairs or Alterations(Answer when applicable) lZe-u7S 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 b s ed by oar of health. Sig d Date Application Approved by Date �® Application Disapproved for the following reasons Permit No. aG:=� 3 0 Date Issued o o L/ !ev .5 YNo. FeeTHE COMMONWEALTH OF MASSACHUSETTS Entered in compu Yes t. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 2pplication for Miopooaf 6potem Conotruction Permit Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) O Complete System El Individual Components- Location Address or Lot No. PC/r /70 Owner's Name,Address and Tel.No. Assessor'sMap/Parcel ail �. 11 �3 3 a. y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G� Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'Type of Building 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, Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been-iss ed by oard of ealth. SighedG` Date Application Approved by Date �b c' Application Disapproved for the following reasons t Permit No. 04:n `✓ 3 0 Date Issued 3 o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( Upgraded( ) Abandoned( )by 1,US-- at k has been constructed in accordance with the provisions f Title 5 and the for Disposal System Construction Permit No.f' 00`l' 'Q dated —AA-1 . Installer Designer The issuances o this pe t shall not be construed as a guarantee thatkeyst l fu ctio as designed. Date L Inspector - --————————————---————— yy Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ZiZpotar *p5tem Cott.5tructton Permit Permission is hereby grant d to Cons t( )Repair( Upgrade( )Ab`andon( ) System located at PC, C I 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:Constructio/n- st be completed within three years of the darof this pe Date: .3/�`1�7,V Approved by i TOWN OF BARNSTABLE LOCATION (44 N�t�S MCI< M40 LAST SEWAGE # VUiAGE C E NT E 1� 191 L L- ASSESSOR'S MAP & LOT 2-3 3 - 2( INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY (0 00 112 1 f()N LEACHING FACII.ITY: (type) �LOw D l F>=u 5 s 07L 5 (size) NO. OF BEDROOMS Z' BUILDER OR OWNER gR�OS H A h/ �I C�GI IJ s PERMITDATE: 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 100 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist pU -�- within 300 feet of leaching facility) Feet Furnished by EM—TECH Ct%-JPEeT i0 tg AWELL" 100 Ft TO SAS PER BSC PLAN OF 12/15/89 LOCATIONS # A B 1 16 Ft 35.5. f t 2 36 f t 44.5 f•t 3 36 FL 58.5 f t EXISTING DWELLING # 64 t NOT TO SCALE a SEPTIC TANK �o 0 J o 30 2 0 0-80X LEACHING GALLERY NYES NECK ROAD EAST I �-L 1 I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS kill DEPARTMENT'OF ENVIRONMENTAL.PROTECTION MAP :, Z33 RECEIVE PARCEL LOT NO <42 3 TITLE EALTH D T. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSIPSSME�T — -- SUBSURFACE-SEWAGE DISPOSAL.SYSTEM FORMt�� l���,3 PART. A CERTIFICATION DEC 8 2003 Property Address: 64 Nyes Neck Road East TQ1/UH Q f BA,TH Q aTA6LE e, Owner's Name: Bradshaw Owner's Address: Encore Construction Co.,Inc. 103 Main Stet Denmsport,MA 02639 Date of Inspection:11-13-03 Name of Inspector:(please print)John Ni ORcilly,P.E.and Linda J.Cronin,EIT Company Name: Bemrett&Otte ,Inc. Mailing Address: P.O:Box 1667 Brewster,MA 02631 Telephone Number: 509496-6630 CERTIFICATION STATEMENT I certify that I have:personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection The inspection was performed based on my training and experience m the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.34o of rwe 5(ne CMR 15.o00).The system: Passes X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: // Z - 0 3 The system inspector shall submit a copy of this inspection report to the Ap 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 DER The original should be.sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments The hole in the crd of the septic tank nerds to be repaired. The inlet at the-outlet end of.the tank needs-to be rerouted to:the other end. ****This report only descrihes 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 faturje under the same or different conditions of.use. Page 2 of I I OFFICIAL INSPECTION FOR-M - NOT FOR VOLUNTARY ASSESSMENTS SUB SURFACE_-SEWA-GE DISPDSAL_SYSTBMJW_ECTION F9RM PART A CERTIFICATION (continued) Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 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 3 1 0 CMR 15.303 or in 3 10 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: X One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the ie_placement or repair as approved by the Board of HQalth,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. No 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. ND explain: No 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 b _..System will.pass inspection-if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: No 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 obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW-AGEDISPDSAL SYSTEM INSPECTION._FORM PART A CERTIFICATION (continued) Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 C.Further Evaluation is Required by the Board of Health: Conditio exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect ublic health,safety or.the environment 1. System will pass nless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not fun ioning in a manner which willprotectpublic health,safety and the environment; Cesspool or pri s within 50 feet of a surface water _ Cesspool orprivy i within.50 feet of a bordering ve�elaled wetland or a salt marsh 2. System will fail unless the Board of ealth(and Public Water Supplier,if any)determines that the system is functioning m a manner thatp tects the public health,safety and environment; _ The system has a septic tank and soil a orption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface ater supply The system has a septic tank and SAS and th SAS is within a Zone I of a public water supply. The system has a septic tank and SAS and the SA is within 50 feet of aprivate water supply well, The system has a septic tank and SAS and the SAS is ss than 100 feet but 5 0 feet or more from a private water supply well'.Method used to determine di s e "This system passes if the well water analysis,performed at a P certified laboratory,for coliform bacteria and volatile organic coiWounds indicates that the well is a from pollution from that faciliy and the presence of ammonia nitrogen and nitrate nitrogen is equal to or s than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to is form.. 3. Other: r r Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 D. System Failure Criteria applicable to all systems: You must indicate yes or no to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or.ponding of effluent to the surface of the ground or surface-waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last-year NOT due to_clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Arry-portion of cesspool or-privy is within 100 feet of a surface water supply or tributary to a.surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of aprivate water supply we-U. X 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and thepresence 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;) No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 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. rge Systems: To be nsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must in ' ate either"yes"or"no"to each of the following: (The following c ' eria apply to large systems in addition to the criteria above) yes no the system is wi ' 400 feet of a surface drinking water supply the system is within.20 et of a tributary to a surface drinking water supply the system is located in a nitro n sensitive area(Interim Well head Protection Area-IWPA)or a mapped Zone II of a public watersupply. If you have answered"yes"to any question in Sec E the system is considered a significant threat,or answered yes in Section D above the large system has failed. a owner or operator of any large system considered a significant threat under Section E or failed under Section shall upgrade the system in accordance with 3 10 CMR 15.304.The system owner should contact the appropriate re ' nal office of the Department, I Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE .SEWAGE.DISP_OSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 Check if the following have been done.You must indicate"Yes or no as.to each-of the following: Yes No X _ Pumping in-formation was provided by the owner,occupant,or Board of Health X Were any of the system componentspumped out in the.previous two weeks'? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? na _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,materials of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X _ 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: Yes no X Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CUR 15.302(3))(b)] i Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSRECTIONF.ORM PART C SYSTEMJTFORMATION Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 2 Number of bedrooms(actual): 2 Design flow based on 3 10..CMR 15.203 Ifor example, I I0 ad x#9f bedrooms: 220 Number of current residents: Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use: (yes or no): No Water meter readings,if available(last 2 years usage(gpd)): No Water Information at Water Dept. Sump pump(yes or no): Last date of occupancy: August 2003 COMMERCIAUUNDUSTRIAL Type of establishmc Design flow(based on 3 0 CMTR 15.203): gpd Basis of design flow(seats rsons/sqft,etc.)- Grease trap present(yes or no . Industrial waste holding tank pre t(yes or no): _ Non-sanitary waste discharged to th Title 5 system-(yes or no): _ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Rec9rds Source of information: No information at BOH Was system pumped as part of the inspection(yes or 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) Tight tank _Attach a copy of the DEP approval X Other(describe): Septic tank,leach chambers Approximate age of all components,date installed(if known)and source of information: Were sewage odors deLtecredwhen-ariying.atthe site,&s or-nod_No Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUB SURFACE_SEWAGE-DISP.O-SAL SYSTEM INSPECSIONF.O—I PART C SYSTEM INFORMATION.(continued Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC_other(explain): Distance from private water.supply well or-suction line-. Comments(on condition of joints,venting,evidence of leakage.,etc.)- SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1000 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 34" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Tape Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Length of tee 10". Liquid level 5"below out invert. Hole in end of ST with root intrusion-needs to be patched. Inlet at same end as outlet needs to be rerouted to other end. GREASE 'Cate on site plan) Depth below grade: _ Material of construction: concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to topXbottomo baffle: Distance from bottom of scum tot tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): e Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 TIGHT or HOL ING 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: allons Design Flow: ons/day Alarm present(yes or no): Alarm level: Alarm in workin rder(yes or no): Date of last pumping: Comments(condition of alarm and float switbhes,etc.)- 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.)- Not found. PUMP CHAMBER: (locate on s%conditi Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump cha pumps and appurtenances,etc.). i Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUB SURFACE.-SEWA-GE-DISP_OSAL_-SYSTEM.IN,SPE-CTION.-'9BM PART C SYSTEM INFORMATION_ oominned) Property Address.•64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 SOIL ABSORPTION SYSTEMJSAS)�; .1locate on siteplan,excavation not_required) If SAS not located explain why: Type leaching pits,number: X leaching chambers.,number: At least 1. leaching galleries,number: leachinglrenches,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 ofponding,damp soil,condition of v getation, etc.). Dry 1 ft deep. CESSPOOLS:_ (cesspool must be pumped as-Tart of inspection)(locate on site plan) Number and configur 'on: Depth-top of liquid to etinvert: Depth of solids layer: Depth of scum layer, Dimensions of cesspool: Materials of construction: Indication of ground water inflow(yes no): Comments(note condition of soil,signs Nydraulic failure,level of ponding,condition of vegetation,etc.)- PRIVY: (locate on siteplan) Materials of construction: Dimensions: Depth of solids: Page 10 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUB SURFA E—SEWAGEDISPOSAL.-SYS-TEM-INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 SKETCH OF.:SEWA E OISPOSAL.:SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate:all.wells within I 00.feet-Locate where public water-supply enters the building.- ExiST a Bzem e A .3 © 1613�� 62 ;n' it 3 I Page 11 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Nyes Neck Road East Centerville,MA Owner: Bradshaw Date of Inspection: 11-13-03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 5 feet Please indicate(check)all methods,used to determine the high-ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: Comparison of USGS information with Town of Barnstable Groundwater Map. SENT BY: DALE R. NIKULA CO. , INC; 508 760 0002; OCT-27-03 2:48PM; PAGE 1 `103 Main Street Dennisport,MA 02639 ;Voice(508)780-6900 `TTY(508)760-1001 :Fax(508)760-0002 COMPANY, INC. ftx 7FAx. Donna Mioran Barnstable Health Dept From: Kathy DeMeyer 508-790-6304 Pages: 3 wlcover Date: 10/27/2003 'Rec CC: ❑UMent ❑ For ew ❑Please Comment ❑Please Reply ❑Please Recycle Comments: As per our conversation,i'� am faxing you a copy of the DEP letter for property at 64 Nyes Neck Road East in Centerville. please advise if this will ough information for us to permit this kitchen remodel and window replacement. Thanks, Kathy 1 / D U" DI i ISENT BY: DALE R. NIKULA CO. , INC; 508 760 0002; OCT-27-03 2:49PM; PAGE 2/3 310 CMA 10.99 Form a DEP File No. S E 3-13 3 5 ... `(To be proviaed by DEP) CnrTown BARNSTABLE Common aith of Massac.;; sects Aool1cwt Ronald Wiggins Certificate of Compliance Massac , setts Wetlands Protection Act, G.L. C. 1319 §40 From De art nt of Environmental Protection ssuing Authority TO: Ronald w' ns a Ha 2 3 W 4hin ton Str rouN orwe °rWe( dfess p41e of Issuance M ': c h 2 1990 This Certificate is issued r work regulated by an Order of Conditions issued to Jame H. Crocker dated 5/_13/8 6 _end issued by the De a rtmPr,+•_ -_ 1 ❑ It is hereby lified that the work regulated by the above•reterenced Order of Conditions has been satist 3rily completed. 2. ® It is hereby Itified that only the following portions of the work regulated by the abcve•refer- enced Orde ;_f Conditions have been satisfactorily completed:(If the Certificate of Compliance does odric ` e t entire oject,sp® what portions are Ind tied.) Installation o f septic s em awdr well nave been col �eted. Construction of reta ing walls , replacement of he foundation and constru : ion of dry wells are no longer proposed nor permitted by the perseding Order of Conditions issued for SE 3-1335 . Any fut .�' e work proposed in an Area Subject to Protection unyder t' Act shall require the filing of a new Notice of Intent a, p It is hereby lified that the work regulated by the above-referenced Order of Conditions was never Comm Ceti.The Order of Conditions has lapsed and is therefore no longer valid. No future work subjec D regulation under the Act may be Commenced without filing a new Notice of Intent and recelvin a new Order of Conditions. , .................................... .........eaW SoaCO....nkl.... ..... i ..... ..... f 8-1 l ffective 11/10/89 SENT BY: DALE R. NIKULA CO. , INC; 508 760 0002; OCT-27-03 2:49PM; PAGE 3/3 4. This certificate 3 of be recorded in the Registry of Deeds or the Land Court for the district In which the land i '' rated. The Order was originally recorded on 6/24/86 (date) at the Registry o Barnstable Book 2792 -.page 2_ 88 S. C The following cc 1 Mons of the Order shall continue:(Set forth any conditions contained in the Final Order, suc as maintenance or monitoring,which are to continue tar a longer period.) Issutld by Departing t of FnvironmPntal. Protectign Signgture(s) IJli A be ` A. 1{oulo eras, Chief, wetlands Section When issued by the Cons vation Commision this Certificate must be signed by as majority of is members. On(his day of before me per onafly aopeared i bet A. K h s tome known to be the per3on described in and w `i executed the foregoing instrument and acknowledged that he/She executed the Same as hislher free a ;&nd deed. r c2 6y Pub lic y M commission Pexpires TJD/jt. Ovicft on dotted tine and stab r to the lssuwV AutnonlY To Please oe aaetsad that(ne Care a of corriclienee lot tilt pvtoct all. File tilurtlow be"recarded at the 14"OVY of art0 I1s3 Oeen n01ed to the cnwn F one of the stf eat ad area"on it raGQraea land.the insmiment new wntU 1CeMtliea this(rsflSSCaOn is It re4131erea laic,In*document mate wrncn Idanoiies ous oansacuon t8 �►o0ltrant Signature 8-2