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HomeMy WebLinkAbout0162 SKUNKNET ROAD - Health S Centerville k P A = IZI 006I t q t rv �r Commonwealth of Massachusetts `. S• Title 5 Official Inspection Form Q+, saga&� R Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. Cityrrown 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 Ron Burlingame use the return Name of Inspector key. Company Name 58 Oak Street Company Address West Barnstable MA 02668 W Cityrrown State Zip Code 508-776-8544 S14124 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 LU sewage disposal:systems. I am a DEP approved system inspector pursuant to Section 15.340 of •.1 Title 5(310 CMR 15.000).The system: i , - t -w ® Passes ❑ Conditionally Passes ❑ F,allco ILL- �` El Needs Further Evaluation by the Local Approving Authority rn Q 03/26/12 In pector's Signature Date - i 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 1 of 17 r - Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owners Name information is required for every Centerville MA 02632 3/26/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 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: ❑ 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 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.] ❑ Z 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•11/10 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 162 Skunknet Road Property Address Robert B. Our, III Owner Owners Name information is required for every Centerville MA 02632 3/26/2012 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 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 M , 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Septic tank, D-Box and infiltrators. Number of current residents: 5 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 Yes 9 ( Y 9 (gP ))� Detail: 2010- 115,000 2011 - 101,000 Sump pump? ❑ Yes ® No Last date of occupancy: 03/26/2012 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owners Name information is required for every Centerville MA 02632 3/26/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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-11/10 Title 5 Official Inspection Forth: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 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 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: All components installed on 11/12/96 from Certificate of Compliance 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.): Septic Tank(locate on site plan): 1' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) Inlet&outlet covers on septic tank brought to grade and D-Box cover brought to grade. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts L Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. Cityrrown 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 2" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 1 Distance from bottom of scum to bottom of outlet tee or baffle 1" How were dimensions determined? Tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. Citylrown 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 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 Normal 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.): Water flow was level. 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: Was located at time of inspection. No ponding water in hole dug beside infiltrator. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 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: 30'x 15' w/infiltrators. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. CityrFown 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.): l5ins-11/10 Title 5 Official Inspection Forth: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 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 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 REAR. QI^ Rpu5E i I t 1 1 t e l t p �uv r'l t✓T���-�a r�,5 � 9 '30")c PI/I Aj?:�-IL-T.,Z47—o R-S j:1�5L.,A t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. Citylrown 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: No H2O at 10 feet 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. 11/12/96 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 t , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �< 162 Skunknet Road Property Address Robert B. Our, III Owner Owner's Name information is required for every Centerville MA 02632 3/26/2012 page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 LOT 15 O� 7;�0.36, IN o LOT 16 ` 17,069 sq.ftt CONCRETE . 0.39 Acres FOUNDATION 85 T O O O N � 7�1,p4. LOT 47 I k JOB # 96-251 CER TIFIED PL 0 T PLA N 6 _ � ►o- 3 LOCATION : SKUNKNET ROAD CENTERVILLE, MA SCALE : 1" = 30' DATE NOVEMBER 7, 1996 PREPARED FOR: REFERENCE LOT 16 PB 224 PC 127 CHAMPION BUILDERS INC. I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE � 1N Of GROUND AS SHOWN HEREON. �o� ARNE �� off fi08�62—�541 H. fax'fi08 362—D88U OJALA .26348 0k own cape enginef ring, tnC. 7 / F C/ST[?N �UU Q� i CIVIL ENGINEERS ----- / ----- -- ----------- —��CHALLANa SJ LAND SURVEYORS 39 main sL yormouth, ma 02675 DATE REG. LAND SURVEYOR DEED RESTRICTION WHEREAS; Robert B. Our, III and Meredith R. Allen, as joint tenants, both of 162 Skunknet Road, Barnstable (Centerville), Barnstable County, Massachusetts, are the owners of the land, with the buildings thereon, situated at said 162 Skunknet Road, Barnstable (Centerville), Barnstable County, Massachusetts, and being shown as LOT 16 on Land Court Plan 35435-A (Sheet 2) filed in Land Court Confirmation Case No. 35435, drawn by Charles N. Savery, Inc., Surveyors, dated October 11, 1967, filed with the Barnstable County Registry of Deeds in Plan Book 224, Page 127, and more fully described in a deed recorded with said Deeds in Book 20021, Page 156 (hereinafter referred to as the "Premises"); and WHEREAS, the said Robert B. Our, III and Meredith R. Allen as the owners of said Premises have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in the single-family residence on said Premises as a pre-condition to maintaining an existing septic disposal system in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; and � I WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to approving the subsurface sewage disposal system in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum .Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing ,the issuance of a. building permit for renovations to the single-family residence located on said Premises, is requiring that the agreement for the restriction on the number of bedrooms in said residence be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE, we, Robert B. Our, III and Meredith R. Allen as the owners of said Premises, do hereby place the following restriction on their Premises in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and shall be binding upon all successors in title: There shall be.no more than three (3)'bedrooms as defined by 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for.the Subsurface Disposal of Sanitary Sewage located on the Premises, and we agree that this restriction shall be a permanent restriction affecting the Premises as described above. For title see deed recorded with said Deeds in Book 20021, Page 156. Property Address: 162 Skunknet Road Barnstable(Centerville), Mass. o Executed as a sealed instrument this v day of { 2007. Robert B Our, f �V Meredith R. Allen COMMONWEALTH OF MASSACHUSETTS Barnstable County,ss. On this _ day of 2007, before me, the undersigned Notar y ry Public, personally appeared the above-named Robert B. Our, III and Meredith R. Allen, proved to me by satisfactory evidence of identification, being (check whichever applies): [ ] or other state or federal governmental document bearing a photographic image, [ ] oath or affirmation of a credible witness known to me who knows the above signatory, or [ ] my own personal knowledge of the identity of the signatory, to be the person whose name is signed above, and acknowledged to me that they signed the foregoing instrument voluntarily as their free act and deed, and for its stated purpose. Notary Public :'�'`• r t.Y Print Name: w } - My Commission Expires: �,j a U E [�L,, 0-1 o U Qualified in the Commonwealth of Massachusetts y} 'A C) `-` R *R3e LINDA W. HOMER ..... [SEAL] NOTARY PUBLIC My Commission Expires June 12,2009 -2- BARNSTABLE REGISTRY OF DEEDS COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS A � DEPARTMENT OF ENVIRONMENTAL PROT Z EIIVFr) o^ W M d A MAP PARCEL FJUN 3 0 2004 ` ' ®��D C�.,M 6y9�o , OF bnr,Ja i:,oLt ;r0T TOWN . - ---�- HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 gdCl AM Owner's Name: MR. EMMA Owner's Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 LJ LOPY Date of Inspection: 6/14/04 Name of Inspector: (please print) JOHN GRACI,INC. Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA. 02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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 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: X Passes _ Conditionally P 'se _ Needs Further ation by the Local Approving Authority Fails Inspector's Signature: Date: 6/14/04 The system inspector shall submit a y of this in report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspectio f the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall bmit 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. Notes and Comments SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YERAS TO PROLONG THE SYSTEM'S USEFUL LIFE. i ****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. Titla S Tncna(-.tinn Fnrm f/i v,)nnn 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YERAS TO PROLONG THE SYSTEM'S USEFUL LIFE. I 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. n/a 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: n/a n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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: n/a Page 3 of I 1 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR. EMMA Date of Inspection: 6/14/04 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 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 n/a "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 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: n/a Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: 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 '/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 nLa. X Any,portion of the SAS,cesspool or privy is below high ground water elevation. _ X Any 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 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 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.] NO (Yes/No)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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 1I 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. d Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR. EMMA Date of Inspection: 6/14/04 Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health _ X Were any of the system components pumped 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? X _ 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,material 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) [310 CMR 15.302(3)(b)] I S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 Number of current residents: 1 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));_I a ?j Sump pump(yes or no):NO _ Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5'system(yes or no):NO Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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 Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1996 PER ASBUILT Were sewage odors detected when arriving at the site(yes or no): NO F Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR. EMMA Date of Inspection: 6/14/04 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 12" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no):NO(attach a copy of certificate) Dimensions:H 10' 6" H 5' 7" W 5' 8`1 Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: I j Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass—polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a I DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 IS STRUCTURALLY SOUND. PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): n/a R Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type n/a leaching pits, number: n/a n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a 0 leaching trenches, number, length: n/a 1 leaching fields, number: 15'X30' LEACH FIELD n/a overflow cesspool, number: W/INFULTRATO n/a innovative/alternative system n/a Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH FIELD IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SOIL PROBED DRY-BOTTOM IS AT 2'. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no):NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a U III Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1 OQ feet.Locate where public water supply enters the building. 1S 0C-) �� g III G5� in - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR T C SYSTEM INFORMATION(continued) Property Address: 162 SKUNKNET ROAD CENTERVILLE,MA 02632 Owner: MR.EMMA Date of Inspection: 6/14/04 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) NO Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: HAND AUGER- 10+FT. 11 _...:i AMSSORSMAM No. �V ..CEL ND` Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE' MASSACHUSETTS ZppYication for Migpool Opgtem Con5truction Permit Application is hereby made for a Permit to Construct(✓)or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. 14 G OwnersName,IAddress and Tel o Assessor's Map/Parcel G e-I9 �lO/a��� Inst er's Name,Address,and Tel.No. Designer's Name,Address and Tel.No/ , Type of Building: Dwelling No.of Bedrooms Garbage Grinder4v Other Type of Building ,No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow >0 gallons per day. Calculated daily flow gallons. Plan Date 31,010 Number of sheets Revision Date Title 54- 44y l Q �Z Description of Soil r e Nature of Repairs or Alterations(Answer when applicable) �/ txf 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 issue o of th Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. / _ 5�3 Date Issued No. Fee �j ,��� ;�,. .,, , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ; t 2pplicatiou for ;Migaal *pgtem Cottgtruction Permit Application is hereby made for a Permit to Construct(✓)or,Repair( )an On-site Sewage Disposal System at: ' Location Address or Lot No. L©�— l�ij Owner'sName,Address and Tel No L Assessor's Map/Parcel lie /111/ e e,h �'z°�vr"Ile Inst ler's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder4_p Other Type of Building�e�IA�iPifiF�No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 0 gallons per day. Calculated daily flow ��Cr gallons. Plan Date K4 310pl, Number of sheets Revision Date Title emu%��Lz; Description of Soil S P F' dfl!/J Nature of Repairs or Alterations(Answer when applicable) 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued y o of lth. Signed Date Application Approved by Date /0- Application Disapproved for the following reasons` `i Permit No. / S3- Date Issued I 0 —————————--—————————--————————————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Dispos#System installed-( or repaired/replaced( )on by Installer at�h7 l/lj` / „ `'//�/G.i�C ✓'G✓" Py 'f^.�/i/�t ° has been constru ed in accordance with the provisions of Title 5 and the for Disposal System Construction rmit No.q G ,r3-? dated -M - 9 4- Date Inspector THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TIL&THE SYS- TEM WILL FUNCTION SATISFACTORY. v -----33------------------------- a Feed No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migozal bpztem Construction Permit Permission is he y granted to to construct( repair( )an On-site Sewage System located at No.# AV/7- u Lv1 f" street and as described in the above Application for Disposal System Construction Permit. 96 S33 No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local rovisions or special conditions. All construction must be completed within ee years f the date below. Date: / -17 Z ' Approved by Board of 16alth + 1 { SCOPE OF WORK fo the best of my krowledge these plans were drawn to CAP 12651 r15 comply with owner's and/or builder's specifications and am charges made to them after prints ore madewil � 1) REMOVE RAFTERS / ROOF OVER GARAGE ad be dA a expense aid rest and il or builder's �SICJENfIAL fiOME DESIGN PN. C 508) J8 41- add bon d exper ze and responslbdfEy, The contractor 2) INSTALL NEW ROOF SYSTEM / ROOM OVER GARAGE shall verif4is all dimensions and enclosed druct4on. s K (Ay dE51CM FAX (508)398 4144 beslcyfs Is rot liable for ewers once carytructlon has Ef�IZlli'GV.G'S, E-MNL 3) DIVIDE EXISTING UPSTAIRS BEDROOM INTO NEW CLOSET beam. F7PMNG f'I.ANS W000 MAM MPIM5 Ja4cadde5415-b1z While even{effort has been made In the preparation of W WW5(INf.8 EXf) WEf39fe this plan to avoid mistakes,the maker can not cpnaarnfee acia!nzt human error, The contractor of the fob must check ANIMATED WALf:Ttt'OIl@'G www,Caddeslcpls,biz all dimensions and other details prior to construction aw 6e sdely responsible thereafter, A / KE�/{\5 FOOTAGE FIN15H FLOR AITA 5QM Ff. ® G,�N�t?AL N5 FINI5NFI713A5FMFNfAA N/A 15f FLOOD AITA �p 1, ALL WORK I5TO COMPLY NIH fFE LAS5f AVO V 2N7 FWOV AlU VEk51ON OF 11E MA DILDING CODE eV111 JN a 6 AM ANY casmORfowNompimmol>mm� r5. FIN151tP ATTIC AMA N/A �/ F-••f 2. f0%FIN15HFLOOkAITA - w _ OJER 5CALED DIMEWSION5. 120 NOT 5C&L TNT RMINGS MlSC,AAAkIN GAM.6AM. 5 N/A U U 5. DESIGN LOPDS: ` ®® RROOFF 2�psF. COV P FOVC!-IF5 N/A ®�®® ®®. H FLOOR 4o Ps,P. WOODEN MCK5 N/A ®®®® SfA1R5 100 P.SF. A//err IA\I rr\X/ DECKS 60 P.S.F. PA CZ V I I V�V/\ ®®®® 4. Rf FOR IWA1ON(MINIMUM REO9P.ENENfS-SEE MASLFEIX REPORT FOR IWSLLAfION WEDED) & FM, GG G r/J) ®®®® Fl00 - WALLS R-11 I ��L I'AGf� G O 4 FLOOR!" R-i 10 2, MOW MO �L. VA11ON5 ,hq+/1 CEILING R-5N� fV�AP 5. ALL UgFIOt WALI.OReNIW6 s DeMW WALL GFENW 6fOKAVE5alPItAMP,LIE550atRM5E 3 Lg�T& f;IGNf�I �VA110N5 -Ct?055 5�C110N r 11371CAfE7. G n u TITLE PAGE NOT TO SCALE 6 5/8"FIBCODE5FEe1ROCKINSGeGARAGE4 L} f OUNVA�ON PI AN HOPE FOR Flnm=m ma9 ww. 7. EAA10 ROOM TO HAVE A MNMLIM WINVON OPENNG OF ]L 5.5 50.ff.WtH A MIN.CLEPR OPeNNG OF 20"X 24"IN EWIFER f G tR n /A�� ® U SIMCTION NV A SILL FEICNf LE55 THAN 44"OFF 4e FLOOR. 151 n( �G IOOt��r Ly�I/V V - 1S.2 All N1N70GR WAN 18"OF THE FLOOR NV MAN 6, 2NV I LOOP\1�M 12"aF ANY DOOR SFW,L HAVE fEMPEF.ED aA➢NG. 9. ALL TLLD OR SHOWER ENCLO5 95 ARE f0 DE aA9V WITH � [L� SAFETMaA0%. 7, �X1511NCA FOR t'M5& OVMEW5 N 10. ALL EXTeAOR WNDOWS ARE f0 Pe vou%e aAZED ll^^ AND ALL UI MOR DOO125 ARE fO DE SOLID CORE NW WEATFER5TAPAN6. \F�/ I il. CLTPECf ALL SMOKE DETEC1Ob f0 NCti`f ELECiACAI SYSTEM AN71N!EA.00K EACH 50 THAf WrEN ANY OW 15 9, TAPPED ny ALL WLL 5a4JD. 12, PV4M COMDLL ON AIR eNr5(W/%KK N)FOR ANY 10 1 ^ n G 4 c c i APA-W a WITH AN OPEN FLAME. v \ V A OI I5. DATFROOM5 AND UnLIN ROOM5 ARE TO LIE VENTED fO TFE 1(, G 0Jr5IM WITH A MINMIIM OF A 90 C.P.M.PAN. - 155U(- O m, POOLING ARE fO DEAR ON IN7I5nM17 LEVEL 5Ol 12. DEVOID OF ANY CWMC MATERIALS MV 5SFFW i6 MOI9RE12 ro MAINTAIN 1FE ff'01MD mm DELOW 1Fe FI" 13/0-7 GRADE.SOIL DEA"PF.E551RE AAMP fO Pe 2000 P.5.1. 13, - 19. AL!-Cr`NOM fO DE ISED fO HAVE A MNM1M OF - v 2,500 P.5.1.COMPG.E%ION S1�N'.,A IN 28 DAYS. 1�' 16. ALL WOg71N C=ALf Wh11 CONCRETE f0 DE xsse Pff,9M 1T.AW. 15 i 17. WATERPROOF DA`WENr WPLl5 DMPOM DACKFILLING. 16 SCALD UNI.�55 15. OEAM POCXET5 IN CONCRETE fO HAVE 1/2"ARSPACa Af NO1 1 - I SIDES AND ENDSWfHAMNMLLMCFS"BEARING. 11, c OTHNZW15� I 19. DA".-`.h',eNfSA'D CEI-LABS NJf ICED AS FWiITPD1.E, C " I r OCOPU5'.2 SPACE SIVU DE PROVIDED WITH A MINMWI OF 18, FOR SLID DAS V�I ING fM,CR AWM%fYP'c eMENr �V90N5 FOR 1/4 evm 150i 5OJAm FEEf OF FLOOR AMA,OR MLfIPI.ES 119. TFEREOF.A;S7 SHy-L De LO✓S17.A5 tM A5 PRACTICAL.f0 I smc PROVIDE CR•J55 VENUf1%. 20. PR^i>TDE lWgLAnoN DA°FLe5 Af EAVE VENf5. 20 21. ALL At(ICS M6r DE VEN!ED.VENT VMH E(HR 5oFF1f G.R DAP eva VENr Af EAVE AN7 00Le 21. n LOfVF,ES GR ADC6 VENT Af TOP. � - 22, o i .. 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WrIIfR CEDPR 5H6 e5 R_3O ,A VJ8 X OVER 1/2"CVX PLWWOOD ADD 2 X 10 F100R J05Fi wxf f0 . . . . STEEL I-REAM EXM"2 X 6 CRLM J!J5f5 5CAL. UW55 NOTP OTlfm5E N 1/4 - I' LEFT ELEVATION p � e I • I � -� : I I � - - - - - - - - - - - - - - - - - - -- L - - - - - - - - - - - - - II II I O I ° I I _ I I I a �4511NG FOUNPA110N I I 0 M511NG GARA2 I .' FOUN7A110N ® � v Con I ,a z 19AS of I ; I FINAL 1551,11� V 15/O-7 - - - - - - - - - � I- - - - - - - - - - - -d - - - - - - - - - -� I P — — — — — — — — — — — - — — — — — — — — — — — SCAL� UNL1�55 NOSP 32'-0" 2'-4" OTHMN15� � � N \ N FOUNDATION PLAN n � MCK " 14'-1 3/4" H-11 / " 24' T-91/2" 00 -0" 4'-9" 1� �� f� u co A W 'T PATH -.--t-- I� O KITCWN 13PYAKFA5f AAA crr� 0 � - GAp.AG�- P4 — — — — — — 1666 2466 I - - _ P4 - - - - - - - - - - �r// 4 W8 X 215TEM I-Pf M u v Zee ,aw fyNOQ `� ® flL V] �T PINING BOOM LIVING t;00M i ( I Z DATE OF - - - - - FINAI, 155U� 5/15/0-7 e vs T-0 TO" - 2'-6' ,4'-O" 1P_6„ 2,4" 18,_2„ 5C&L UW55 46'-0" NOTf P, 0TWI W15� 1ST FLOOR PLAN N 5 O V e 2'-4" 1 T-13/4" 7-13/4" 5'-10 3/8" 3-81/8" 4'-id' 3'-6" 5'-81/8" 6-9 7/8" 24310 ULLION F joo o i FT � � O MASTI t;13�f7t;00M — — — BATH F PWFO0M # 5 VAIMP OILING-114" 0 0P4 u 2666 1666 2466 V c-F N N _ _ _ _ _ _ _ - _ _ _ -K�i T- - - - 2466 15/4"X R WL FM — — — — — — — — — — — — — — — — — — — — — — — — Si�d1LfIRAL IDT fiEM1 LVl'SFOP$AI7 i — — — — — — — - WALK IN C,05�1 C2) 15/4"�91/2" V n � Z PATS OF IfMOF 79"-+/- FINAI. 155U� 51151 O- N A21 A21 A21 ` 4 v � § 2,_g, � 4-4" 14'd" 4�4- 4`5, SCA�G UNLf.55 _ N01�f7 ,4 32- OTNM5� �-0 � VN 2ND F LOO]R P LA N tr-r — aa• n's I I OEDROOM#3 BEDROOM#2 O z.ee 4 4 ®® ' ®® - - - — — — — - - - co®® ®®®® a . a's a'-e• la•s a•-a• as sza I P4 EXISTING PLANS /Jl`\Ji00 �a Iza 0 4 1U DELK � V w'-13/a' _ 7-10/• 2a' P4 124 I/a' P-912' Tf4l'-0f/a• 0 DAfN f3MWA5f ARE ® c GAMr O I— KIfCNEN PAS OF FINAL 19%1� � l l 3/13/0-7 ® zese lase C fiM(b 0 DINING ROOM LIVIN 5c&L LJW55 — LIVING ROOM I_ q NIT12 4 F � N T-0' TO 9'A' �1-56' �2'6' 2'-r T� �56' 3'6• � ^ � PA6F # Y i i r... ., ...'.-..... ..: .... _i. .'."r:.. r. ... a .. ... ...... .:... 4... }.. .. • - ,. _ ..... .. ..r. _.. : , .. _ SEPTIC PROF11,E'_ TEST HOLE LOGS T.O.F. AT EL f w-•S (NOT TO SCALE) _ ._ t ._:_.__._...- -__,_ ---•-f.-- y"' " .,x ACCESS COVER TO-WITHIN G' OF FIN. GRADE ACCESS COVER (WATERTIGHT) To ENGINEER:._ WITHIN Ir OF FIN GRADE { c s+l INIMUM .76' OF COVER OVER PRECAST r 2% SLOPE REQUIRED OVER SYSTEM WITNESS: I RUN PIPE LEVEL. I 1 PROPOSED oo - FOR FIRST 2' �iWASHED PEASTONE �� ^ ' DATE: - - i / GALLON SEPTIC ORIFICES 10 8E: 3 To �►'9- �+ PEKC. RATE -- ---.___�+1'.j /�' s/19 - - TANK H- Ai Yam."Sl o� r v p I 0 o0 00 600 Ooo ano boo 400 0� __� �' 51% L . �j - ---'�_� J °oq�__Qaa.._..Qnr�_ 4ara_. 9at�___4np.._..Srao__S ix CLASS __ -'- SOILS P , I T------ - -- -- - 1 ___J w LONG W I!- WIDE j - -- - - y� fr CRUSHED STONE OR MECHANICAL. I i _COMPACTION. (15.221 [2p f `` - DEPTH OF FLOW m ___ 3/4' TO i-1 If DOUBLE WASHED STONE SLOPE) TEE SIZES: ( _C SLOPE) (ram SLOPE) hT INLET DEPTH � �0.__ _ r Crd - ----- - i LOCATION MAP OUTLET DEPTH o FOUNDATION- - p _ _ SEPTIC TANK ___. ..__-._ Z 1 - __ D' BOX -- - - LEACHING j ' ASSESSORS MAP �� \ PARCEL FAC1l.l1�i ( <j -Y_..10 5 4Z.i. o s!� , `' c. r FLOOD ZONE BUILDING ZONE: II ff i SETBACKS: FRONT - av SIDE - I c'' REAR - _ .._.) - i t o at� I PLAN REFERENCE: I I I 1 A f - - - 1-57 ! I i i �lj �' (GARBAGE DISPOSER IS )! �• N .�,t� <. SEPTIC (GAR --- _ / / . DESIGN �Ft_OW. _ BEDROOMS ` p GPD) DATUM (_ . ) - GPD 1 . D IS - - USE. A _ ?o GPD DESIGN FLOW 2. MUNICIPAL WATER IS SEPIIC TANK: r'aJ GPD ( ) _ _� GALLONS 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. / I ' 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO-H.J_0_._._._ �� I ( ' � '�� USE A �504 GALLON SEPTIC TANK z ep_ I , 5. PIPE JOINTS TO BE MADE WATERTIGHT. I E ACHING_ 0 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. ENVIRONMENTAL CODE TITLE V. " ' ! I € E 0T`TOM:__3o_n 1 t_ - - � ._ GPD 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE r L-- I USED FOR LOT LINE STAKING. - '0I'A... ` ` �? S,F. ?�3 GPD p p.... _ ,_z� ._- 8. PIPE FOR SEPTIC SYSTEM TO SCR, 40-4" PVC. _ r ! 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT ,- " ff fI_ + - *" __ + _, _.r��i __ � `�1 1,4- s ►) INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED " r 1 FROM BOARD OF HEALTH. LEGEND ► "' / F. 100.0 -1 PROPOSED SPOT ELEVATION } 100x0 EXISTING SPOT F '.E=VATION 1 001 PROPOSED CONTOUR +7I o4' I 1 ff SITE, AND SEWAGE PLAN OF @0 - EXISTING CONTOUR I , t BOARD OF HFA1.TH IN THE TOWN OF: -^I _- - ___ --- _. _ - '_ _ - ------ APPROVED DATE PREPARED FOR: 2O O Zu [,.v Feet SCALE: _ DATE: down cape engineering, Inc. CIVIL ENGINF;ERS LAND SURVEYORS PHONE 508--362-4541 H. FAX 508-362--9880 I� 930 main st. yarrroutl., ma o267fi JOB# 9� - z s � - �U �� 9IT . � o +jpr�, Da 77 p