Loading...
HomeMy WebLinkAbout465A OLD STAGE ROAD - Health Ulm MU 1 465A Old Stage road Centerville A= 190 005 ,St'n'lle llll � UPC 12534 No.2153LOR wsn„os.�w Y 3 L k 33647 Ps208 --702 01-05-2021 a 03 = 30o 'GRANT OF NITROGEN LOADING RESTRICTION AND EASEMENT ON FACILITY LAND #457 OLD STAGE ROAD,(CENTERVILLE) BARNSTABLE, CHAPTER 360 ss. 360-45 This GRANT OF Nitrogen Loading Restriction AND EASEMENT on Facility Land made as of this 5 4,,, day of 2020, by Aliaksandr A. Kadolka recorded with the Barnstable County Registry of Deeds, Deed Book 31480 Page 350, of 465 Old Stage Road, Centerville, MA 02632 ("Grantor") hereby grants to the Town of Barnstable acting through its Board of Health (Grantee) a nitrogen loading restriction and perpetual easement to ensure maintenance of the facility. WITNESSETH WHEREAS, Aliaksandr A. Kadolka of #465 Old Stage Road, Centerville, MA 02632 recorded with the Barnstable County Registry of Deeds, a quitclaim deed being the owner in fee simple of that certain parcel of land located in Barnstable (Centerville), Barnstable County, Massachusetts, with the buildings and improvements thereon, pursuant to a deed from Michael J. Hayes, Personal Representative of the Estate of Carl F. Sherman to Grantee of the Benefited Property, recorded August 22, 2018 in Barnstable County Registry of Deeds as Deed Book 31480 Page 350, and being shown as Lot 2 on "Plan of Land on Old Stage Road in Barnstable (Centerville), Mass" a Plan of Land in Barnstable, Massachusetts, and recorded in the Barnstable County Registry of Deeds in Book 553 Page 65, referred to herein as ("Benefited Property"); and WHEREAS, Grantor desires to restrict the number of bedrooms as defined pursuant to 310 CMR 15.002 and/or the wastewater discharge design flow in any improvements located on the Property through the use of this Nitrogen Loading Restriction and Easement on Facility Land; and WHEREAS, the Facility Land has the benefit of a Nitrogen Loading Restriction and Easement over 11,000 square feet of land, being more particularly bounded and described in Grant of Nitrogen Loading Restriction and Easement on Nitrogen Credit Land, recorded with. the Barnstable County Registry of Deeds as document number and shown on a plan entitled Nitrogen Aggregation Plan prepared for Aliaksandr A. Kadolka at #465 Old Stage Road, Barnstable (Centerville), MA attached hereto as "Exhibit B"; and WHEREAS, the Nitrogen Loading Facility Aggregation Plan has been approved by the Barnstable Board of Health in accordance with the Board of Health Regulation Article XV Protection of Saltwater Estuaries, Chapter 360 On-Site Sewgae Dispposal Systems ss. 360-45 Interim Regulation;" and plan entitled Proposed Septic System Upgrade prepared for Aliaksandr A. Kadolka at #457 Old Stage Road, Barnstable (Centerville), MA attached hereto as "Exhibit A"; said approval being based upon the agreement by Grantor to incur certain obligations regarding the number of bedrooms, as defined in 310 CMR 15.002, and/or the wastewater discharge design flow in any improvements located on the Property and maintenance of the Facility Land Restriction and Easement to ensure protection of the nitrogen loading limitation of 5 mg/L nitrate nitrogen discharge standard pursuant to Chapter 360 ss. 36-45 in nitrogen-sensitive areas or in areas serving new construction where the residential use of both on-site systems and contribution to saltwater estuaries exist; and to grant to the municipality acting by and through the Barnstable Board of Health a perpetual easement to ensure maintenance of the Property including, but not limited to, removal of any prohibited uses and in connection herewith a perpetual easement to pass and repass over the Property for purposes of inspecting the Property to ensure compliance with and fulfillment of the terms of the Facility Land Restriction/Easement as hereafter set forth; NOW, THEREFORE, pursuant to the provisions of Chapter 360 ss. 360-45, Grantor does hereby GRANT to the Town of Barnstable, a Massachusetts municipal corporation situated in Barnstable County, having an address at 367 Main Street, Hyannis, Massachusetts, acting by and through its Board of Health ("Local Approving Authority") for nominal, non-monetary consideration, with QUITCLAIM COVENANTS, a NITROGEN LOADING RESTRICTION AND EASEMENT ON FACILITY LAND ("Facility Land Restriction/Easement") in, on, upon, through, over and under the Property, the terms and conditions of which are as follows: PURPOSE: The purpose of this restriction and easement is to protect and preserve the quality and quantity of ground water resources in the area of the saltwater estuaries in the Town of Barnstable, Massachusetts in order to ensure a safe and healthy saltwater estuary for the present and future inhabitants of the area. It shall also be for the specific purpose of limiting the introduction of nitrogen and other pollutants into, and maintaining the natural uptake of pollutants and the recharge of the ground water which takes place on the Property for the said saltwater estuary. OBLIGATIONS AND EASEMENT: 1. Prohibitions. Grantor agrees to restrict the number of bedrooms, as defined pursuant to 310 CMR 15.002, in any improvements on the Property to a total of four (4). 2. Easements. In creating this Facility Land Restriction and Easement, Grantor hereby grants to the Local Approving Authority, its agents, contractors, subcontractors and employees a perpetual EASEMENT to enter upon and the right to bring equipment onto the Property to do any and all acts deemed necessary to maintain the Property in a manner which ensures protection of the nitrogen loading limitation of 5 mg/L nitrate nitrogen discharge standard pursuant to Chapter 360 ss. 360-45, together with a right to pass and repass by foot and by vehicle over the Property for said purposes, and for purposes of inspecting the Property to ensure compliance with and fulfillment of the terms of this Facility Land Restriction/Easement. 3. Severabilitv_. If any court or other tribunal determines that any provision of this instrument is invalid or unenforceable, such provision shall be deemed to have been modified automatically to conform to the requirements for validity and enforceability as determined by such court or tribunal. In the event the provision invalidated is of such a nature that it cannot be so modified, the provision shall be deemed deleted from this instrument as though it had never been included herein. In either case, the remaining provisions of this instrument shall remain in full force and effect. 4. Enforcement. Grantor expressly acknowledges that a violation of the terms of this instrument could result in the following: f (i) upon determination by a court of competent jurisdiction, in the issuance of criminal and civil penalties,,and/or equitable remedies, including, but not limited to, injunctive relief, such injunctive relief could include the issuance of an order to modify or remove any improvements constructed upon the Property in violation of the terms of this Facility Land Restriction/Easement; and (ii) in the assessment of penalties and enforcement action by the Local Approving Authority to enforce the terms of this Facility Land Restriction/Easement, pursuant to Chapter 360 ss 360-45. 5. Provisions to Run with the Land. This Facility Land Restriction/Easement sets forth the rights, liabilities, agreements and obligations upon and subject to which the Property or any portion thereof, shall be left unimproved or according to which said Property may be improved, held, used, occupied, leased, sold, hypothecated, encumbered, or conveyed. The rights, liabilities, agreements and obligations herein set forth shall run with the Property, as applicable thereto, and any portion thereof and shall inure to the benefit of and be binding upon Grantor and all parties claiming by, through or under the Local Approving Authority or Grantor. The rights hereby granted to the Local Approving Authority and its successors and assigns constitute their perpetual right to enforce this Facility Land Restriction/Easement. Grantor hereby covenants for himself/herself/itself and his/her/its executors, administrators, heirs, successors and assigns, to stand seized and hold title to the Property, as applicable thereto, and any portion thereof, subject to this Facility Land Restriction/Easement, provided, however, that a violation of this Facility Land Restriction/Easement shall not result in a forfeiture or reversion of Grantor's title to the Property, as applicable thereto. 6. Concurrence Presumed. It being agreed that Grantor and all parties claiming by, through or under Grantor shall be deemed to be in accord with the provisions herein set forth and to agree for and among themselves and any party claiming by, through or under them, and their respective agents, contractors, sub- contractors and employees, that the Facility Land Restriction/Easement herein established shall be adhered to and not violated and that their respective interests in the Property and the Facility Land Restriction and Easement, as applicable thereto, shall be subject to the provisions herein set forth. 7. Incorporation into Deeds, Mortgages, leases and Instruments of Transfer. Grantor hereby agrees to incorporate this Facility Land Restriction/Easement, in full or by reference, into all deeds, easements, mortgages, leases, licenses, occupancy agreements or any other instrument of transfer by which an interest in and/or a right to use the Property, or any portion thereof, is conveyed. 8. Recordation. Grantor shall record and/or register this Facility Land Restriction/Easement with the appropriate Registry of Deeds and/or Land Registration Office within 30 days of the latter of: receipt from the Local Approving Authority of the approved Facility Land Restriction/Easement. Grantor shall file with the Local Approving Authority a certified Registry copy of this Facility Land Restriction/Easement as recorded and/or registered within 30 days of its date of recordation and/or registration. 9. Amendment and Release. This Facility Land Restriction/Easement may be amended or released only upon approval by the Local Approving Authority. Release of this Facility Land Restriction/Easement shall be granted by the Local Approving Authority in the event the Property is connected to a municipal sewer system and the septic system serving the Property is abandoned in accordance with 310 CMR 15.354 or the Property is no longer located within a nitrogen sensitive area pursuant to Chapter 360 ss. 360-45. Any such amendment or release shall be recorded and/or registered with the appropriate Registry of Deeds and/or Land Registration Office and a certified Registry copy of said amendment or release shall be filed with the Local Approving Authority within 30 days of its date of recordation and/or registration. 10. Term. This Facility Land Restriction/Easement shall run in perpetuity and is intended to conform to M.G.L. c.184, §26, as amended. 11. Rights Reserved. This Facility Land Restriction/Easement is granted to the Local Approving Authority in connection with the approval of a Nitrogen Loading Facility Aggregation Plan pursuant to Chapter 360 ss. 360-45 It is expressly agreed that acceptance of the Facility Land Restriction/Easement by the Local Approving Authority shall not operate to bar, diminish, or in any way affect any legal or equitable right of the Local Approving Authority to issue any future order with respect to the Property or in any way affect any other claim, action, suit, cause of action, or demand which the Local Approving Authority may have with respect thereto. Nor shall acceptance of the Facility Land Restriction/Easement serve to impose any obligations, liabilities, or any other duties upon the Local Approving Authority. 12. Effective Date. This Facility Land Restriction/Easement shall become effective upon its recordation and/or registration with the appropriate Registry of Deeds and/or Land Registration Office. WITNESS the execution hereof under seal this �-k day of 2020. ri B Y h; Aliaksandr A. Kadolka COMMONWEALTH OF MASSACHUSETTS BARNSTABLEM JCc.Gt w , 2020 Then personally appeared the above-named (Grantors) Y i'c K�a aap Kat&I k0. , and acknowledged the foregoing instrument to be their free act and deed before me. Notary Public: 6te00C (0C 8Q rZ K"- My commission expires: MIT ff)j VIKTORIIA BURKE (SEAL) Notary Public ' Massachusetts My Commission Expires May 10,2024 APPROVAL BY LOCAL BOARD OF HEALTH We, the Barnstable Board of Health, hereby approve and accept this Grant of Nitrogen Loading Restriction and Easement on Nitrogen Facility Land. OF BARNSTABLE BOARD OF HEALTH OF THE TOWN BY f1- ;AJ1 A^l ( Pagel of 4 Bk 3.3647 Ps 217 -NIF703 ` I ii-05-2021 a 03 = 3i is GRANT OF NITROGEN LOADING RESTRICTION AND EASEMENT ON NITROGEN CREDIT LANDS Chapter 360 ss. 360-45 Q� I This GRANT OF Nitrogen Loading Restriction AND EASEMENT on Nitrogen Credit Land made as of this )S}i, day of �')-A-%ux.yu , 2020, by Aliaksandr A. Kadolka, located in Barnstable, Barnstable County, Massachusetts ("Grantor") hereby grants to the Town of Barnstable acting by and through its Board of Health ("Grantee") a nitrogen loading restriction and perpetual easement to ensure maintenance of the facility. WITNESSETH WHEREAS, Grantor being the owner in fee simple of that certain parcel of land located in Barnstable, Barnstable County, Massachusetts, with the buildings and improvements thereon, pursuant to a deed from William E. Robinson, Jr., to Grantor, executed on December 6, 2017, and recorded with Barnstable County Registry of Deeds as Deed Book 30945 page 137, and being shown as Lot 1 containing an area of 71,536 square feet as shown on "Plan of Land on Old Stage Road in Barnstable (Centerville), Mass" a Plan of Land in Barnstable, Massachusetts, and recorded in the Barnstable County Registry of Deeds in Book 553 Page 65, referred to herein as ("the Property"); and WHEREAS, Aliaksandr A. Kadolka of #465 Old Stage Road, Centerville, MA 02632 recorded with the Barnstable County Registry of Deeds, a quitclaim deed being the owner in fee simple of that certain parcel of land located in Barnstable (Centerville), Barnstable County, Massachusetts, with the buildings and improvements thereon, pursuant to a deed from Michael J. Hayes, Personal Representative of the Estate of Carl F. Sherman to Grantee of the Benefited Property, recorded August 22, 2018 in Barnstable County Registry of Deeds as Deed Book 31480 Page 350, and being shown as Lot 2 on "Plan of Land on -Old Stage Road in Barnstable (Centerville), Mass" a Plan of Land in Barnstable, Massachusetts, and recorded in the Barnstable County Registry of Deeds in Book 553 Page 65, referred to herein as ("Benefited Property"); and I W t-1hXhAJ, the benefited Property has the benefit of a Nitrogen Loading Restriction and Easement, being more particularly bounded and described in, a Grant of Nitrogen Loading Restriction and Easement on Facility Land, recorded with the Barnstable County Registry of Deeds herewith, and shown on a plan entitled Proposed Septic System Upgrade, Sheet 1 of 3, prepared for Aliaksandr A. Kadolka at #457 Old Stage Road, Barnstable (Centerville), MA attached hereto as Exhibit A; and WHEREAS, the Nitrogen Loading Facility Aggregation Plan has been approved by the Barnstable Board of Health, Barnstable, Massachusetts in accordance with the Board of Health Regulation entitled Article XV Protection of Saltwater Estuaries, Chapter 36B0, On-site Sewage Disposal Systems subsection 360- 45 Interim Regulations;" said approval being based upon the agreement by Grantor to incur certain obligations regarding the number of bedrooms, as defined in 310 CMR 15.002, and/or the wastewater discharge design flow in any improvements located on the Property and maintenance of the Facility Land Restriction and Easement to ensure protection of the nitrogen loading limitation of 5 mg/L nitrate nitrogen discharge standard pursuant to Chapter 360, subsection 360-45 Interim Regulation in nitrogen-sensitive areas or in areas serving new construction where the residential use of both on-site systems and contribution to estuaries exist; and to grant to the Grantee of the Benefited Property and to the municipality acting by and through the Barnstable Board of Health, Barnstable, Massachusetts a perpetual easement to ensure maintenance of the Property as nitrogen credit land including, but not limited to, removal of any prohibited uses and in connection herewith a perpetual easement to pass and repass over the Property for purposes of inspection to ensure compliance with and fulfillment of the terms of this Nitrogen Credit Land Restriction/Easement as hereafter set forth; NOW, THEREFORE, pursuant to the provisions of Chapter 360 subsection 360-454, Grantor does hereby GRANT to the Grantee of the Benefited Property and to the Town of Barnstable, a Massachusetts municipal corporation situated in Barnstable County, having an , address at 367 Main Street, Hyannis, Massachusetts, acting by and through its Board of Health ("Local Approving Authority") for nominal, non-monetary consideration, with QUITCLAIM COVENANTS, a NITROGEN LOADING RESTRICTION AND EASEMENT on NITROGEN CREDIT LAND ("Nitrogen Credit Land Restriction/Easement") in, on, upon, through, over and under a portion of the Property as shown on a plan entitled Nitrogen Aggregation Plan prepared for Aliaksandr A. Kadolka at #465 Old Stage Road, Barnstable -Centerville), MA attached hereto as Exhibit B; the terms and conditions of which are as follows: PURPOSE: The purpose of this restriction and easement is to protect and preserve the quality and quantity of ground water resources in the area of the saltwater estuaries in the Town of Barnstable, Massachusetts in order to ensure a safe and healthy saltwater estuaries for the present and future inhabitants of the area It shall also be for the specific purpose of limiting the introduction of nitrogen and other pollutants into, and maintaining the natural uptake of pollutants and the recharge of the ground water which takes place on the Property for the said water supply and for the specific benefit of the above referenced Benefited Property. OBLIGATIONS AND EASEMENT: 1. Prohibitions. Grantor agrees to maintain the Property as nitrogen credit land by prohibiting activities which have .a detrimental effect on nitrogen loading on the Property, including but not limited to wastewater discharges, the use of nitrogen fertilizer, the introduction of artificial impervious surfaces, the raising, breeding or keeping of animals, livestock or poultry for commercial purposes, and the creation or introduction of land under water. 2. Easements. In creating this Nitrogen Credit Land Restriction and Easement, Grantor hereby grants to the Grantee of the Benefited Property and to the Local Approving Authority, its agents, contractors, subcontractors and employees a perpetual EASEMENT to enter upon and the right to bring equipment onto the Property to do any and all acts deemed necessary to maintain the Property as nitrogen credit land, together with a right to pass and repass by foot and by vehicle over Property for said purposes, and for purposes of inspecting the Property to ensure compliance with and fulfillment of the terms of this Nitrogen Credit Land Restriction/Easement. 3. Severability_. If any court or other tribunal determines that any provision of this instrument is invalid or unenforceable, such provision shall be deemed to have been modified automatically to conform to the requirements for validity and enforceability as determined by such court or tribunal. In the event the provision invalidated is of such a nature that it cannot be so modified, the provision shall be deemed deleted from this instrument as though it had never been included herein. In either case, the remaining provisions of this instrument shall remain in full force and effect. 4. Enforcement. Grantor expressly acknowledges that a violation of the terms of this instrument could result in the following: (i) upon determination by a court of competent jurisdiction, in the issuance of criminal and civil penalties, and/or equitable remedies, including, but not limited to, injunctive relief, such injunctive relief could include the issuance of an order to modify or remove any improvements constructed upon the Property in violation of the terms of this Nitrogen Credit Land Restriction/Easement; and (ii) in the assessment of penalties and enforcement action by the Local Approving Authority to enforce the terms of this Nitrogen Credit Land Restriction/Easement, pursuant to Chapter 360 subsection 360-45. 5. Provisions to Run with the Land. This Nitrogen Credit Land Restriction/Easement sets forth the rights, liabilities, agreements and obligations upon and subject to which the Property or any portion thereof, shall be left unimproved or according to which said Property may be improved, held, used, occupied, leased, sold, hypothecated, encumbered, or conveyed. The rights, liabilities, agreements and obligations herein set forth shall run with the Property and the Benefited Property, as applicable thereto, and any portion thereof and shall inure to the benefit of and be binding upon Grantor, Grantee of the Benefited Property, and all parties claiming by, through or under the Local Approving Authority or Grantor. The rights hereby granted to the Grantee of the Benefited Property, the Local Approving Authority, and their respective successors and assigns, constitute their perpetual right to enforce this Nitrogen Credit Land Restriction/Easement. Grantor hereby covenants for himself/herself/itself and his/her/its executors, administrators, heirs, successors and assigns, to stand seized and hold title to the Property, as applicable thereto, and any portion thereof, subject to this Nitrogen Credit Land Restriction/Easement, provided, however, that a violation of this Nitrogen Credit Land Restriction/Easement shall not result in a forfeiture or reversion of Grantor's title to the Property, as applicable thereto. 6. Concurrence Presumed. It being agreed that Grantor and all parties claiming by, through or under Grantor shall be deemed to be in accord with the provisions herein set forth and to agree for and among themselves and any party claiming by, through or under them, and their respective agents, contractors, sub- contractors and employees, that the Nitrogen Credit Land Restriction/Easement herein established shall be adhered to and not violated and that their respective interests in the Property and the Nitrogen Credit Land Restriction and Easement, as applicable thereto, shall be subject to the provisions herein set forth. 7. Incorporation into Deeds, Mortgages, leases and Instruments of Transfer. Grantor hereby agrees to incorporate this Nitrogen Credit Land Restriction/Easement, in full or by reference, into all deeds, easements, mortgages, leases, licenses, occupancy agreements or any other instrument of transfer by which an interest in and/or a right to use the Property, or any portion thereof, is conveyed. 8. Recordation. Grantor shall record and/or register this Nitrogen Credit Land Restriction/Easement with the appropriate Registry of Deeds and/or Land Registration Office within 30 days of the latter of. receipt from the Local Approving Authority of the approved Restriction/Easement. Grantor shall file with the Local Approving Authority a certified Registry copy of this Nitrogen Credit Land Restriction/Easement as recorded and/or registered within 30 days of its date of recordation and/or registration. 9. Amendment and Release. This Nitrogen Credit Land Restriction/Easement may be amended or released only upon approval by the Local Approving Authority. Release of this Nitrogen Credit Land Restriction/Easement shall be granted by the Local Approving Authority in the event the Benefited Property is connected to a municipal sewer system and the septic system serving the Benefited Property is abandoned in accordance with 310 CMR 15.354 or the Benefited Property is no longer located within a nitrogen sensitive area pursuant to 310 CMR 15.215. Any such amendment or release shall be recorded and/or registered with the appropriate Registry of Deeds and/or Land Registration Uttice and a certified Registry copy of said amendment or release shall be filed, with. the Local Approving Authority within 30 days of its date of recordation and/or registration. 10. Term. This Nitrogen Credit Land Restriction/Easement shall run in perpetuity and is intended to conform to M.G.L. c.184, §26, as amended. 11. Rights Reserved. This Nitrogen Credit Land Restriction/Easement is granted to the Grantee of the Benefited Property and the Local Approving Authority in connection with the approval of a Nitrogen Loading Facility Aggregation Plan pursuant to Chapter 360 subsection 360-45 It is expressly agreed that acceptance of the Nitrogen Credit Land Restriction/Easement by the Local Approving Authority shall not operate to bar, diminish, or in any way affect any legal or equitable right of the Local Approving Authority to issue any future order with respect to the Property and the Benefited Property, as applicable thereto, or in any way affect any other claim, action, suit, cause of action, or demand which the Local Approving Authority may have with respect thereto. Nor shall acceptance of Nitrogen Credit Land Restriction/Easement serve to impose any obligations, liabilities, or any other duties upon the Local Approving Authority. 12. Effective Date. This Nitrogen Credit Land Restriction/Easement shall become effective upon its recordation and/or registration with the appropriate Registry of Deeds and/or Land Registration Office. WITNESS the execution hereof under seal this day of k , 2020. By Print Name ,r_ Grantor: (Aliaksandr A. Kadolka) COMMONWEALTH OF MASSACHUSETTS ' 'BARNSTABLE,§§ '_'AA q4 - 04, 2020 0 Then personally appeared the above-named (Grantors) ka_ksaodk KqCdo& , and acknowledged the foregoing instrument to be their free act and deed before me. VIKTORIIA BURKE all Notary PublicMassachusetts Notary Public: �r!<�o�Zi �2 ��� ��e My Commission Expires `J May10,2024 My commission expires: la 2012. APPROVAL BY LOCAL BOARD OF HEALTH We, the Barnstable Board of Health, hereby approve and accept this Grant of Nitrogen Loading Restriction and Easement on Nitrogen Credit Land. BOARD OF HEALTH OF THE TOWN OF BARNSTABLE By a: sci o, t + �' Pagel of 4 t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address - — - William Robinson Jr. Owner Owner's Name information is required for every Centerville _ Ma 02632 10/31/2017 page. Cityfrown 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 forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Ins actor key. p S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. MAR Centerville _ Ma 02_632 Cityfrown State Zip Code 774-248-4850 smjonestitle5@9mail.com S14522 _ Telephone Number license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the I information reported below is true, accurate and complete as of the time of the inspection. The inspection i 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-t Local Approving Authority i I 10/31/2017 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. i ""This report only describes conditions at the time of inspection and under the conditions of use i at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i f Commonwealth of Massachusetts _ W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address - William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. Cityrrown state Zip Code Date of Inspection B. Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 465a Old i Stage R g d Centerville is ng of a 1500 gallon septic tank, distribution box and 2 precast leaching b chambers s septic ta 33 xt1 3 x2'trench. em ii The system was found to be in proper working condition at the time of inspection. 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): i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 ' I Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address -- William Robinson Jr. _ Owner Owner's Name —� isrequired for every Centerville Ma 02632 10/31/2017 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due ° to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): i 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i i Commonwealth of Massachusetts w Title 5 Official Inspection Form F Subsurface Sewage Disposal System Form Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name — information is required Centerville Ma 02632 10/31/2017 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: i ❑ 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. I ❑ 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•3113 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 465 A Old Stage Road Property.Address William Robinson Jr. Owner Owner's Name - information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection _ B. Certification (cost.) Yes No I . i ❑ ® 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. i i ❑ ® 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 i ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply f t ❑ ❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 { i i V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 — DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 448 gpd provided t5ins-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is Centerville Ma 02632 10/31/2017 required for every page. CitylTown State Zip Code Date of Inspection D. System Information Description: i 2 Number of current residents: i Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No. Water meter readings, if available(last 2 years usage (gpd)): —--— i Detail: I i ! I Sump pump? � El Yes ® No � Last date of occupancy: current Date Commercial/Industrial Flow Conditions: r Type of Establishment: I Design flow(based on 310 CMR 15.203): Gallons per day(gpd) 1 Basis of design flow(seats/person s/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No i Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r i Commonwealth of Massachusetts - _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road _ Property Address William Robinson Jr. _ Owner Owner's Name - �- information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date --T Other(describe below): i t i General Information Pumping Records: r ; Source of information: ---- Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons I How was quantity pumped determined? Reason for pumping: -- Type of System: ® Septic tank, distribution box,-soil absorption system ❑ Single cesspool ❑ Overflow cesspool 4 ❑ 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•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r { I f Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road _ -- Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 _ -- page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 2/9/2006 per town records i E Were sewage odors detected when arriving at the site? ❑ Yes ® No i 1 Building Sewer(locate on site plan): j 1.5 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet i— Comments (on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof I Septic Tank(locate on site plan): 1 Depth below grade: feet i. Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) I I I t If tank is metal, list age: years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No I 1500 gallons Dimensions: 6" Sludge depth: — 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i i i i I ' 1 Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 465 A Old Stage Road Property Address William Robinson Jr. Owner Owners Name information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) 3" Distance from top of sludge to bottom of outlet tee or baffle ---- Scum thickness 3 i Distance from top of scum to top of outlet tee or baffle 6 I Distance from bottom of scum to bottom of outlet tee or baffle 10" — How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done within 2 years and again every 2 years for proper maintenance. Inlet and outlet tee intact. Water level was even with outlet invert, tank was structurally sound and not leaking. 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 — j Date of last pumping: Dace 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 i i i Commonwealth of Massachusetts y Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is Centerville Ma 02632 10/31/2017 required for every __ I page. City/Town State Zip Code Date of Inspection D. System Information (cont.) l Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i i 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 t 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr._ Owner Owner's Name information is Centerville Ma 02632 10/31/2017 required for every � page. CityfTown 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 leve(and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc,): i D-box was located but not excavated, box is functioning as intended. i f i i i 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.): i *If pumps or alarms are not in working order, system is a conditional pass. I Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. _ Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: i ® leaching chambers number: 2 ❑ leaching galleries number: i ❑ 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.): s.a.s. consists of 2 precast leaching chambers in a 33'xl TxT trench with d-box in middle. Leaching facility was found to have 2"of standing water with no stain lines higher. I 4 l 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • I Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. _ Owner Owner's Name information is required for every Centerville Ma , 02632 10/31/2017 page. Citylrown 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.): I 2 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.): t f i I t5ins•M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 I I ' I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road i Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 -- page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to j at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I I i i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I t i { r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I r 465 A Old Stage Road -- Property Address William Robinson Jr. Owner Owners Name information is Centerville Ma 02632 10/31/2017 required for 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 ❑ drawing attached separately i I A a y-sr t t5ins-3113 Tine 5 Official inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f 1 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. — Owner Owner's Name information is Centerville Ma 02632 _ 10/31/2017 i required for every Cienter n State _ Zip Code Date of Inspection page. D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water i ❑ Check cellar t ❑ Shallow wells 12'+ Estimated depth to high ground water: 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: Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 (Sins•3/13 I I i I L,\, Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner owner's Name information is Ma 02632 1013112017 Centerville _ required for every State Zip Code Date of Inspection page. City/Town E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked i ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater i Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ® I j Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t5ins-3113 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 465 A Old Stage Road Property Address r� William Robinson Jr. Owner Owner's Name information is Centerville ✓ Ma 02632 10/31/2017 ��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 forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com S14522 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 10/31/2017 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1.0jvs I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M °y 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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: The dwelling located at 465a Old Stage Rd Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 precast leaching chambers in a 33'xl3'x2'trench. The system was found to be in proper working condition at the time of inspection. 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-3/13 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 .' 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is Centerville Ma 02632 10/31/2017 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rt 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 448 gpd provided t5ins•3/13 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 'y 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. Cityrrown 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? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 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-3/13 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 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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 co of the current operation and 9Y PY P 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed 2/9/2006 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 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.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): Depth below grade: 1 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: 1500 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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 3" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 61 Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done within 2 years and again every 2 years for proper maintenance. Inlet and outlet tee intact. Water level was even with outlet invert, tank was structurally sound and not leaking. 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 i Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address : William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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 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.): D-box was located but not excavated, box is functioning as intended. PumpChamber locate on site plan): ( P ) Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 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 ' 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 ❑ 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.): s.a.s. consists of 2 precast leaching chambers in a 33'x13'x2' trench with d-box in middle. Leaching facility was found to have 2"of standing water with no stain lines higher. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I� Title 5 Official Inspection Form` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner owner's Name information is Centerville Ma 02632 10/31/2017 required for every kiwi 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 'V6 3- A -5► 2,-3 6• y/' �,-sy' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is required for every Centerville Ma 02632 10/31/2017 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: Groundwater elevation was determined by accessing Town.of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 465 A Old Stage Road Property Address William Robinson Jr. Owner Owner's Name information is Centerville Ma 02632 10/31/2017 required for every 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. . oo —n I Fee U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:^ �� PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication for �Digozal fppztem Con5tructiou joermit Application for a Permit to Construct( Repair(A) Upgrade( Abandon( ) 1XrComplete System ❑Individual Components Location Address or Lot No. yG S A 1 -0 5 1 A E R U Owner's Name,Address,and Tel.No. Assessor's Map/Parcel .!go G T— C-Z-Q0 r� P�� y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. L)005 145 `Y00 �4 �c SU/tJf Ii4 3��i;313� Type of Building: Dwelling No.of Bedrooms q Lot Size ?15 X, } sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons O Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ILfA/() gpd Design flow provided IV_4Y 5 gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank /$Up Cqr/Ja,✓ Type of S.A.S. `� VO Gra� ClroM�p/5 / .R X33 Description of Soil Nature of Repairs or Alterations(Answer when applicable) ��/� N P�✓ ys—t�/sue T� P,p4ie Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of t g g he afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this and 9f Health. Signe Date �2— Z—G Application Approved by Date —dG Application Disapproved by: Date for the following reasons Permit No. a 0 U b^ 0 Date Issued a—7—�6 No. 2U0 t0 �� .»..*.,+� Fee THE COMMONWEALT IOF,� ASSACHUSETTS Entered in computer: �--•� ;PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes d'' � I• ..y ' 4' w Application for Mizponl *p5tem Con.5truction ,Permcit Application for a Permit to Construct( ) Repair(x) Upgrade( ) Abandon( ) I Y I Complete System ❑Individual Components Location Address or Lot No. 1 G S A Q' -0 5) A E R Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (�l� r v'�J f K Vd(� P Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. DOo5 A-5 •4 R/Ow'i ova-moo-'7/S� L_4 �� SU/vP l.� 5 3GD,-813z Type of Building: Dwelling No.of Bedrooms ',I Lot Size 71,5'IG t sq.ft. Garbage Grinder ( ) Other Type of Building /-/u No.of Persons O Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) yyU gpd Design flow provided y�/Q7 gpd Plan Date Number of sheets Revision Date lk ,.. Title. Size Iof Septic Tank /5-00 Gal)&'i Type of S.A.S. /a 8 X3'rj'` Description of Soil ,t Nature of Repairs or Alterations(Answer when applicable) -1 5e,D ie, Sv s/ e---( Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o Health. Signerd Date Appli(3ation Approved by �/ _(t' Date - '7"06 Application Disapproved by: `f Date ' t for the following reasons 1 Permit No. Q r)0 h- D yy Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (x ) Upgraded ( ) Abandoned( )by 1 r2.c3 c­) at #G5- 14 ok8146L Rd has been constructed in accordance with the pr-ovviisions of Title 5 and the for Disposal System Construction Permit No. 2 b n6- ()'r7/y dated .?" 7'UG Installer � 'G c 4 �/ g A / Designer ��T�� �,ir✓� f: .v� #bedrooms y Approved design flow t/yrJ. gpd The issuance of this permit shall not be construed as a guarantee that the system wi'llun{ct/io as d j&ned. Date Inspector ——————————U L I—————————————————————————--——————— No. 0 0 - Fee ( 0 U THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Bizpoml i§p9tem Construction Permit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at 1/65• ,4 O/Z) S TA G F— ZD 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 thisrpertnit. Date Approved by v _._ v Town of BArnstable �OFZHE Regulatory Services . Thomas F. Geiler,Director * BAEiNS1'�BLE, * ' MASS- � Public Health Division 4i ATED .P�A. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: STCp j}6t--D I+AA-S, PG Installer: Address: q 2 3 A&V71C-7 6A Address: o .1-3 ox, I L4 S 12 Ce, All On 7 00 A was issued a permit to install a (date) (installer) septic system at 16 -Ar o,_6 s rW4.c_- i� based on a design drawn by (address) 'S dated llz 45- (designer) ._ZI certify that-the septic'system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical.relocation of any component of the septic system)but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. y tallees Signa e) (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC TH*,ALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOT . THIS FORM AND AS- .� BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK'YOU. Q:Health/Septic/Designer Certification Form « � t Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST.AND SOIL EVALUATION EXEMPTION FORM I, `ram 14* 2 ,hereby certify that the engineered plan signed by me dated /I S__,concerning the property located at f 4t< 617- D s C- E¢?tD -meets all of the following criteria: • Two soil evaluations excavated for detailed examination(no hand augering)and two percolation tests shall be conducted. + This famed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. + The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There is no increase in flow and/or change in use proposed There are no variances requested or needed. + The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: �J 1 VP Vi ultjU"U'5U"UU0 LtUVUtt811(Ugtlif,lJlti utlutAlltttAV11) _& & -v B) G.W. Elevation +adjustment for high G_W, 3q.q DWRRLNCE BETWEEN A and B 1-7.& SIGNIBT� : DATE: /_ NOTICE Based upon the above information,,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system ply q:lSepgc�pmoaxemp.doc TOWN OF BARNSTABLE LOCATION �/� 5'/� r�/� S 54 f)-= —J?0 SEWAGE # VILLAGE C�emik&,ri ASSESSOR'S MAP & LOT�(� Cb INSTALLER'S NAME&PHONE NO. f SEPTIC TANK CAPACITY _/5en LEACHING FACILITY: (type) 2 SM 6411 Cbb^be4 (size) X NO. OF BEDROOMS BUILDER OR OWNER F PERMIT DATE: mll COMPLIANCE DATE: Iv Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ep P A 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 � � � .��� � �� �C I �� ® �f ® � y� ,�.-�S ... McKean, Thomas From: Connolly, Kathleen Sent: Friday, November 13, 2020 2:06 PM To: McKean, Thomas Cc: Nober, Karen; Fair, Marylou; Robbins, Susan Subject: Re:457 &465 Old Stage Road, Centerville Hi Tom, I have reviewed the attached grant of nitrogen loading restriction and easement and approve it as to form subject to the following comments. The first two paragraphs are a little bit confusing with respect to identification of the Grantor and Grantee. I recommend adding to the end of paragraph one after"(`Grantor')": " hereby grants to the Town of Barnstable acting by and through its Board of Health("Grantee") a nitrogen loading restriction and perpetual easement to ensure maintenance of the facility." Then in paragraph two after the words "quitclaim deed" remove the words "Grantee of the Benefited Property" in line two. Please say hello to Glen for me. I enjoyed working with him when I represented Mashpee. Kate Sent from my iPhone Begin forwarded message: From: "Nober, Karen" <Karen.Noberktown.bamstable.ma.us> Date: November 13, 2020 at 10:47:20 AM EST To: "Connolly, Kathleen" <Kathleen.Connollygtown.bamstable.ma.us> Cc: "McKean, Thomas" <Thomas.McKeangtown.bamstable.ma.us>, "Fair, Marylou" <Marylou.Fairgtown.barnstable.ma.us>, 'Robbins, Susan" <Susan.Robbins@town.bamstable.ma.us> Subject: FW: 457 & 465 Old Stage Road, Centerville Hi Tom, I am forwarding this to Kate for her review. Thanks. Karen Karen L. Nober 1 ACCESS COVERS MUST BE WI THIN 9- MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NOTES .. 6" OF FINISH GRADE 3 MAXIMUM COVER 'NVERT AT BUILDING: 96.25 DESIGN FLOW: _ 99, 33 \ F'RST 2 ' TO BE LEVEL MIN 2" OF PEASTONE 'NVERT IN SEPTIC TANK: 95.25 4 BEDROOMS AT ! 10 G.P.O. PER I . THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION •NVERT OUT SEPTIC TANK: 95. 0 BEDROOM EQUALS 440 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4- IUD .J' � AM - NVERT IN DIST. BOX: 94.3 r 3/4" - 1 112- DIA. NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS �B T DOUBLE WASHED STONE NVERT OUT DIST. BOX: 94. l3 9�� 25- o � ,S. 0 1- 94 /3 2 • � �,� 94. 0 SET. SEE SITE PLAN. ( ins 4. 3 0 $�92. 0 NVERT IN LEACH CHAMBER: 95.25 t BAFFLE- 94. SEPTIC TANK REQUIRED: C 3 OUTLET 2-500 GAL LEACHING , tOTTOM OF LEACH CHAMBER: 92. 0HAMBERS 440 G.P.D. X 200x - 880 GAL . J. ALL CONSTRUCTION METHODS AND MATERIALS AND DJUS TED GROUND WATER:: MAINTENANCE OF THE SEPTIC SYSTEM SHALL D-BOX W/4 " STONE AROUND. 12. 8 r x 33 ' 1 x 2 'd N/A SEPTIC TANK PROVIDED: 1500 GAL. MIN.1500 GAL �� ')BSERVED GROUND WATER: N/A CONFORM TO MASS. D.E. P. TITLE 5 AND LOCAL SEPTIC TANK 6' CRUSHED STONE OR 30TTOM OF TEST HOLE +►l : 86. 6 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS. COMPACTED BASE DESIGN PERC RATE l 5 M/N/I NCH PROF l L E : Nor TO SCALE i SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0. 74 GPO/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER THAN 3 ' BE 440 GPD / 0. 74 GPD/SF - 595 S.F. REQUIRED STANDINGIH-20PTH WHEELALL CAPABLE OF WITH- LOADS.PROVIDED: 2-500 GAL LEACHING CHAMBERS 0 2' W/4 ' STONE AROUND. A-606 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR 606 S.F. x 0. 74 - 448 G.P.D. APPROVED EQUAL . / 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED / SOIL TEST PI T DA TA s PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL ' BE WATER TESTED TO CHECK FOR LEVEL WHEN THERE LOT I INDICATES �_ INDICATES IS MORE THAN ONE OUTLET. PERCOLATION - OBSERVED TES T GROUNDWATER 71 , 536+ S. F. 7. BEFORE CONSTRUCTION CALL -DIG-SAFE-. o� TP +►I TP #2 1-888-DIG-SAFE AND THE LOCAL WATER DEPT. �aQ 0" NOR I ZON TEXTURE COLOR 97. 3 0' HORIZON TEXTURE COLOR 97. 3 FOR LOCATION OF UNDERGROUND UTILITIES. A LOAMY IOYR A LOAMY IOYR B. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE SAND 3/3 SAND 313 I O' 96. 5 /2' 96.3 DESIGN ENG/NEER TWO DAYS PRIOR TO CONSTRUCTION p p OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE SANDY 5O8R D SANDY SOBR CONSTRUCTION INSPECTIONS. \ ! ! ! 36 94. 3 34' 94.5 NOLL LLY I MED-COARSE IOYR MED-COARSE 10YR 9• EXISTING CESSPOOL TO BE PUMPED DRY AND SAND AND 5/4 I SAND AND 5/4 BACKFILLED. 9 GRAVEL GRAVEL SECOND FLOOR PLAN ry-94.9 + I , l0. EXISTING INVERT AT THE DWELLING TO BE RAISED r TO THE ELEVATION SHOWN. TP.1 50" 48- 2-500 GALLON BM. CORNER OF OUL414EAD LEACHING CHAMBERS / EL 98.63 r/4 STONE AROUND a \ CESSPOOL D-80x " / G G r / o '26" NO WA TER 86. 8 1261 NO WATER r 86.8 /Q �aQ rsoo GALLON G®4 00� DATE: OCTOBER 5. 2005 t i 0g•3 t. SEPTIC TANK p� TEST BY: STEPHEN HAAS 'f PERC RATE: l 2 MIN/I NCH ,. J .. 1 61 � 1 , r1 � � "d �' _ • j2 �l SEF' T / C SYSTEM DES / G/V 46 _5A OLD S TA GE ROAD MAP 190 . PARCEL 6.S ✓� I } l l j �i Lf ` J~ w�-'-- T ( CE/V T _R V / L L E > "A 1 \ A -W 6 I1 1 ►J =f / '\ 5 69�Ob 55 0 DR FEW AY TO OL. 1 STAGE. ROAD ---__7 -�•; PREP 56 by S g4.23 07 W Gopo oiv p Y Y ,LEGEND v B6 0/ 4;, w 4 �- j-(� CUS " ` .� ,/ ■ CB CONCRETE BOUND /v O V EMB E 3R O - 2 O O S `',? 4 ``^ -W- WATER LINE SCALE HYDRANT F A 0 L_ F_ S U FR V F I f I V G I NC C -G GAS LINE _ o u t es 6 A CHW- OVER HEAD WIRES 3 2 3 R LIGHT POST � �' zz� Ya �m© u t hhpo r t MA 02675 -E- UNDERGROUND ELECTRIC J C LINE V '�i'J/1!�`,��� 5 O 8 4 3 2-5 3 3 3 �- \� C 508 3 6 2-8 1 32 T- UNDERGROUND TELEPHONE LINE /1 I C \t CTV-- UNDERGROUND CABLEVISION LINE + 40 4 SPOT ELEVATION I t -40- __ EXISTING CONTOUR L O C U S MAP i0 PROPOSED CONTOUR 0 10 20 40 [ JOB NO : 05-084 F l EL D CFW/EEK CAL C: SAH/CFW CHECK: CFW DRN: SAN