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Home My WebLink About0390 OAKLAND ROAD - Health a4 390 OAKLAND RD. ,h-VANNIS A = 271 018 o { Commonwealth of Massachusetts Title 5 Official Inspection For r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ! Property Address CID 0 Cl Owner ✓� Owner's Name ae -.� information is required for every C7 I/j fs page. C �04 oa&� itylTown � h/'�7 State Zip Code Date of Ins ection FL 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, v` / [�[1 key to move your use only the tab I 1 Inspector: cursor-do notAM' use the return CAI. i,- key. Name of Inspector / �y�raa I t Company Name G/ = ! �O Company Address City/TowZ�v& ) Or-) 6 � 1 c�1 /�o 2,�,9 0 State Zlp Code c------ Telephone Number �Q � License Number B. Certification n 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 CNIR 15.000).The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 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 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 in and under the conditions of use - at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc•rev.6/16 Title 5 Cfficial Inspection romt Subsurface Sewage Disposal System•Page 1 of 17 r V 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner IQ-to I c Owners Name / information is required for every page. City/Town 6 U/ / State Zip Code Date of spe Ion Be Certification (Cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A1' System saes: I have not found any information which indicates that an of the failure in 310 CM Y e criteria described R 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are ed indicated below. I Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y ❑ N ❑ ND(Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection For a Subsurface Sewage Disposal System For/r'n!/-1 Not for Voluntary Assessments o rV1 Ci ~ Property Address 4/GN � Owner , Owners Name information is �� required for every page. CityTrown State Zip Code p Date of Inspecti B. Celrtification (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 [J 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303('I)(b)that the system is not functioning in a rra safety and.the environment: anner which will protect public health, ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address 2�0 Owner Owner's Name information is required for every G 4,41 601 page. Cityrrown State ZipCode / Date of Ins ctio B. Cerr ificatoon (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 ❑ L; ..,/clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ue 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title - r e ff�cisl Inspection p ns ect'® ®r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -' Property G� Address ---;Te Owner cy / Owners Name information is �� required for every �0✓1 i J �, • , page. City/Town State ZipCode Date of Insp ction Be Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or 1-<obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high round water ele vation. evation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 19 Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Lr y portion of a cesspool or privy is within 50 feet of a private water supply well. El 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 nd chain of custody merit be attached to this form.] ❑ he system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commo nwealth ®f Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments k Property Address Soo Owner information is Owners Name required for every G trI dtl page. City/I own State Zip Code U. UheCk�ast Date of I spec on Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes 1� ❑ ping information was provided by the owner, occupant, or Board of Health �❑ Were any of the system components pumped out in the previous two weeks? ❑ s the system received normal flo ws in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? y Were as built plans of the system obtained and examined? available note as N/A) (If they were not Was the facility or dwelling inspected for signs of sewage back up? p 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 Wormatoon Residential Flow Conditions: Number of bedrooms(design): — 2 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): --_ t5ins.doc•rev.6/16 Title 5 Officiai Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts v Title 5 Offidal Inspectoon For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is required for every / � � ��//(� / ( �� / page. CityRown State Zip Code Date of Inspection/ D. System Inffortmata®� 71 Description: 60,-5 (_J'174, Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes 'Co Laundry system inspected? ❑ Yes No Seasona►use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes No Last date of occupancy: C L4//J--e' Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts = Title 5 Official Inspect-on r a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �H Property Address 0 J_cs� Owner f (i Owners Name / information is required for every C;?,4 page. Citylrown State Zip Code Date of Insp cfo 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 Sy em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 'rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For a Subsurface Sewage Disposal System Foram -Not for Voluntary Assessments Owner Property Address Owners Name information is required for everyi)— page. Citylfown C State / Zip Code Date of I pecti n De SYStem Information (cont.) Approximate age of all components date installed (if known)and source of information: �29 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: /L2 feet Material of construction: ❑cast iron 40 PVC ❑other(explain): Distance from private water supply well or suction line: f � feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): / Depth below grade: feet �/ Materigl-6f construction: concrete Elmetal ❑fiberglass ❑ Polyethylene-�- l ❑other(explain) & If tank is metal, list age: years �] Is age confirmed by a Certificate of Compliance?(attach a copy o certificate �`--� f ) ❑ Yes ❑ No Dimensions.- Sludge depth: t5inns.:':;:c•rev.6/16 Title 5 official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is �� required for every ✓7 4!1 � `� 6 0/ page. Cityrrown State Zip Code Date of 1pfspeobn De System nforrmation (cont.) Septic Tank(cont.) 77 Distance from top of sludge to bottom of outlet tee or baffle 1 / Scum thickness / " o Distance from top of scum to top of outlet tee or baffle 'Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle --- Date of last pumping: _..— Date t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W `title 5 OfficialInspection r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Property Address Owner Owners Name information is �✓ �� required for every C7 y'l py i j r� page. City/Town State Zip Code Dat of nspe ion 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.): Fight or Molding'tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass 9 El 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��0 Property Address Owner / information is Owner's Name (/ required for every cam,14Ot 2=�S /W � ��/ page. City/Town State Zi Code P Date of spe on De System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): _ Depth of liquid level above outlet invert �Plij 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.): ,/ram 4&1 A-1 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 12 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection For a Subsurface Sewage Disposal Systems Form-Not for Voluntary Assessments 9 0 ' J Property Address G��``� Owner ^ Owner's Name ) information is required for every /f rJa 601 page. City/Town State ' / Zip Code Date of Ins ecti D. System Wormation (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ '"leaching galleries number: leaching / CL 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.): �r 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 t5ins.doc-rev.6/16 Indication of groundwater inflow ❑ Yes ❑ No Title 6 Official Inspection Form;Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal system Form -Not for Voluntary Assessments CJG % Property Address 20 Owner Owner's Name information is required for every q t'-/I page. Citylrown State Zi Code / P Date Insp ctio D. Syatem Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fors a _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ^l Owner (� OwnePs Name information is required for every A v) if page. Citylrown D. System Wormation (cont.) State ZipCode Date of In pectlo 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 pu 4crwater supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately I � C G� r�fci y -------------- f!J(jr — � a � /Leo c,11�0 t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal system-Page 15 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form a _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner f Owner's Name information is required for every t•7 W14/f 0'� (0Cl 1 page. Citylrown 2� State Zip Code Date of Insprection Do System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells J 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 QWard of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must dent a how you esta/dished the high ground water elevation: Lq G, H c!Gi vt ` -0 1 C) 0 C e / f L'/, // a v it- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17_ A o Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owners Name ; information is AU ,10�✓/ / required for every / f �` / page. Cityrrown State Zip Code Date of In ectio E. Report Completeness Checklist Inspection Summary:A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6116 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 JOHN W. KENNEY ATTORNEY AT LAW F'' '• F s., 12 CENTER PLACE 1550 FALMOUTH ROAD `+'�' FEB 6 1 t 1 CENTERVILLE, MASSACHUSETTS 02632 TELEPHONE 771-9300 FAX NO. 775-6029 AREA CODE SOB e-mail:john@jwkesq.com February 14, 2005 Town of Barnstable Board of Health 200 Main Street Hyannis, MA 02601 Re: Deed Restriction on 340 Oakland Road, Hyannis, MA 02601 Dear Sir/Madam: Enclosed herewith please find a time-stamped copy of the above-referenced deed restriction. Should you have any questions or wish to discuss this matter,please do not hesitate to contact me. Thank you. Very truly. rs.. Jaime I. Gillis, Esq. Enc. DEED RESTRICTION WHEREAS,Dawn M. Burt, of 338 Pleasant Pines Avenue, Centerville,MA 02632, is the owner of 340 Oakland Road,Hyannis,MA 02601 (hereinafter referred to as the"property"), and being shown as Lot 1 on a plan recorded with the Barnstable County Registry of Deeds in Plan Book 132,Page 85; WHEREAS,Dawn M. Burt, as the owner of said lot has agreed with the Town of Barnstable Board of Health to.a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS,the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit in compliance with 310 CMR 15.00 State Environmental Code,Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and authorizing the issuance of a building permit for the construction of a single family home on this property,is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document. NOW,THEREFORE,Dawn M.Burt, does hereby place the following restriction on their above- referenced land in accordance with their agreement with the Town of Barnstable Board of Health,which restriction shall run with.-the land and be binding upon all successors in title: - 1. Lot 1 as shown on a plan recorded with the Barnstable County Registry of Deeds in Plan Book 132, Page 85,having an address of 340 Oakland Road,Hyannis,MA may have constructed upon the lot a house containing no more than one(1)bedroom with a standard septic system; or a house containing no more than two(2)bedrooms with an alternative septic system with a 550 gallon per day or larger capacity.Dawn M.Burt agrees that this shall be a permanent deed restriction affecting the house located on 340 Oakland Road,Hyannis;MA 02601. For title,see Deed recorded with the Barnstable County Registry of Deeds in Book 8531,Page 69. Executed as a sealed instrument this 1 lo'day of February, 2005. �- Dabn M.Burt COMMONWEALTH OF MASSACHUSETTS J Barnstable, ss. On this 11ffi day of February, 2005,before me,the undersigned notary public,personally appeared Dawn M.Burt,proved to me through satisfactory evidence of identification,which was a license,to be the person whose names are signed on the preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose. J�Lut)a, Notary Public: My commission pires: Deed Restriction Burt/lb JOHN W. KENNEY �j) `r 1y 4 REE ATTORNEY AT LAW- a, 1' n 12 CENTER PLACE i:r„ FEDpR, i �1 . .. -. 11 1 550 FALMOUTH F2oAD. _ ... CENTERVILLE,MASSACHUSETTS 02632 �o a n4-f , /1�l oz& a/ ` � f±iiii iiii 3t ;i � iffi ii i f';��"#T t i: ii 3i(i rr ;r r i' ."J" e�. - r .. TOWN OF BARNSTABLE LOCATION �'94 Dl4K'll9I'rc/ ZV SEWAGE # Z9 '- SR/ VILLAGE 4Zy0 ibis ASSESSOR'S MAP& LOT. 7/- 0/S i INSTALLER'S NAME&PHONE NO. _e7'77—0 3 SEPTIC TANK CAPACITY /000 LEACHING FACILITY: (type) (size) 6,O X 'IX2 NO.OF BEDROOMS 3J µ BUILDER OR OWNER 4101 PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet 01 leachin facility) Feet Furnished by V, , .. s _i'S6-y�� , ��yc, � Y, . � 3�, "k�' _i y ; �. ��. � �� c ', 2 �a � k � �tL �� Fee(,5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS 0(pprication for Mgw5al.6p5tem Congtrurtion Permit Application for a Permit to Construct(z_,), epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 71 Installer's Name,Address,and Tel.No. �/°7`��/� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date -Title, Size_of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)_-Z y ZZ G.151415Z ziw l®X-/'k Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by 4s Boar of ealth. Signed Date Jq— 9-99 Application Approved by Date Application Disapproved for following reasons Permit-No. Date Issued a;�. ..l�f� •' ...._._ Fee T E THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 0[pprication for �Digpogal *pgtem Congtruction i3ertrYff Application for a Permit to Construct(4,o)lFepair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No.51749 0191<1" Owner's Name,Address and Tel.No. , Assessor's Map/Parcel ;7 glS 9 " e-'ve /V,/ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ✓os�P� 421c� 13.4i'rdS Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title.. Size of Septic Tank Type of S.A.S. Description of Soil S�s� Nature of Repairs or Alterations(Answer when applicable). Stlg& li;,.O GZ,Zlo Ti /.yi'CLi OXyA 2— Date last inspected: Agreement: - x The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo of Health. Signed Date- 8-�9 Application Approved by 017v f//./� Date Application Disapproved for h following reasons Permit No. i Date Issued ————————'——————————————————————————————THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( g, epaired ( )Upgraded( ) Abandoned( )by J s-e at 44,W1 5 has been constructed in accordance ' with the pro/visions of Title 5 and the for Disposal System Construction Permit No ,�� dated " Installer , s eo�% 17✓_ 4 I^,,o 5 Designer Jd S cp4 Vc s r•-o s The issuance of this permit shall not be construed as a guarantee that the ssys�e vill function as des' ed. Date Inspector--+""�, ,• / .�°9 fir, V NOW--^1-��) � ---------------- �7/ �/� -----Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS WDigpogar *pgtem Construction Vermit Permission is hereby granted to Construct(t..�-Repair( )Upgr de( )Abandon( ) System located at '�?0 ®t4k1,ia�W �ooz 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:Constrructi . u. be mpleted within three years of the date of Date: `/ Approved by r �x 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, )oj,-�4 Oti hereby certify that the application for disposal works construction permit signed by me dated concerning the property located at .T IO �4 K 4 1?yhw15' meets all of the following criteria: ,I'he failed 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. ere are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system t 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 not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surfac levation(using GIS information B) G.W. Elevation +the MAC. High G.W. Adjustment DIFFERENCE BETWEEN A and B SIGNED : �� DATE: [Sketch proposed plan of system on back]. q:health folder,cert r d � IWq M� Zo h7 000 , y TOWN OF BARNSTABLE LOCATION SEWAGE # 5,7�/ VILLAGE 194 ASSESSOR'S MAP & LOT?7/- 0/�' INSTALLER'S NAME&PHONE NO, SEPTIC TANK CAPACITY /6 4 j LEACHING FACILITY: (type) /fir ,�/ (size) NO.OF BEDROOMS BUILDER OR OWNER 1� ,/ PERMITDATE: —COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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 j ,\ 2l, / 31 �,