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HomeMy WebLinkAbout0714 OLD STRAWBERRY HILL ROAD - Health 714 Old Strawberry Hill Rd 273-210 R Hyannis 4" I k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yy. 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is required for every Centerville Ma 02632 4/23/2010 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any ' way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection "Idl Company Name 74 Beldan Ln. Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonesbtle5@gmaii.com SI 4522 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.Th&inspection was performed based on my training and experience in the proper function and maintenanceof on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to/-Section 1540 ct; r'"nnh �t Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ' ❑ Needs Further Evaluation by the Local Approving Authority y � 4/23/2010 Inspector's Signature Date The system inspector shall submit a copy of.this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner, and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewa is of S stem-Page t of 17 (� ge f� Y I Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y�. 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owners Name information is Centerville Ma 02632 4/23/2010 required for every page. City1rown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is Centerville Ma 02632 4/23/2010 required for every page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is Centerville Ma 02632 4/23/2010 required for every — page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "l 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Flame information is required for every Centerville Ma 02632 4/23/2010 page. City/rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owners Name information is required for every Centerville Ma 02632 4/23/2010 page. Cityfrown State Zip Code Date of inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts . Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r< 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owners Flame information is required for every Centerville Ma 02632 4/23/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2008=61,500 total gallons= 169 gpd 2009=60,750 total gallons= 166 gpd Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's(dame information is Centerville Ma 02632 4/23/2010 required for every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is required for every Centerville Ma 02632 4/23/2010 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: new system installed 1999 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 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.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): Depth below grade: 5 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons Sludge depth: w t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is required for every Centerville Ma 02632 4/23/2010 page. Citylrown 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 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 How were dimensions determined? Opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): water level in septic tank was high due to the filter being clogged. Tank needs to be pumped/cleaned and the filter needs to be cleaned to allow water to flow through. This filter needs to be cleaned 2x per year to prevent clogging. Tank was structurally sound and not leaking. GreaseTrap(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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. lug - Property Address Susan Kemmling Owner Owner's Name information is required for every Centerville Ma 02632 4/23/2010 page. Cityrrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Flame information is required for every Centerville Ma 02632 4/23/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was level and in good condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins-09/08 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 J"f 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owners Name information is required for every Centerville Ma 02632 4/23/2010 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ® leaching chambers number: 5 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil and stone surrounding s.a.s.was probed in various locations with no sign of saturation. 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•09108 Title 5 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 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is Centerville Ma 02632 4/23/2010 required for every — page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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•09J08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °yl 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is required for every Centerville Ma 02632 4/23/2010 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 New Page 1 Page 1 of 1 TOWN OF,BARNSTABLE LOCATION R SEWAGE# r U VEU AGE !TJ -ry rf'�01 SESSOWS MAP dt LOT&Q'D�D 14STALLEWS NAME&PHONE NO. Ufa .r -o SEP'I IC TANK CAFAcrry f st a o LEACHING FACQdTY: (type) ZZ.4 7042 —(size) _ NO.OF BFSDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: S Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 fat of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 0 G j•7. •. a Y Mx.. , J4 2 13a- ` A 31L(33-� http://www.town.bamstable.ma.us/assessing/2010/f Mdisplay.asp?mappar=253010TO0&seq=1 5/3/2010 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is Centerville Ma 02632 4/23/2010 required for every page. Cityrrown 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: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: location of septic system is elevated compared to nearby lake. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 749 Old Strawberry Hill Rd. Property Address Susan Kemmling Owner Owner's Name information is required for every Centerville Ma 02632 4/23/2010 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 . F Bk 23048 P o256 �38423 -- 07-17--2008 -8 08 = 19C R; DEED RESTRICTION WHEREAS, I, Sug:anna R. Kemmlmg of 749 Old Strawberry Hill Road, Centerville, MA being_the-owner of real estate located at of 749 Old Strawberry Hill:Road, Centerville, MA shown on a plan recorded in Barnstable County Registry of Deeds in Plan Book 69, - Page 119 and described in deed recorded in Book 12123, Page 311_,have agreed with the Town-of Barnstable Board of Health to a restriction as to the riuniber-of bedrooms which can-be-included in any home built on said lot as a pre=condition_granting approval for a family; p a artment; and WHEREAS, the town of Barnstable Board of Health, as a pre-condition to granting a approval for a family apartment 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, Suzanna R. Kemmling does hereby place the following restriction on her above-referenced land in accordance with her 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. The dwelling located at 749 Old Strawberry Hill Road, Centerville, MA shall contain no more than four (4) bedrooms until such time as the septic system is upgraded to accommodate greater than four bedrooms, all in accordance with said Title 5 and local Board of Health Regulations. Suzanna R Kemmling agrees that this shall be permanent deed restriction affecting the real property located at 749 Old Strawberry Hill Road,_Centerville, MA and being_ shown on the plan recorded in Plan Book 69 Page 119. For title of Suzanna R. Kemmling, see the following deed: Book 12123 Page 3-11. Executed as a sealed instrument this t_&')� _day of e�� , 2008. f Suzanna R. Kemmling Town of Barnstable Health Inspector Office Hours Regulatory Services 8:00—9:30 Thomas F.Geiler,Director 3:30—4:30 » Only B wsTns[E « MAS& r Public Health Division i63q. 10 Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT QUESTIONNAIRE 1. General Information: 'hlI e J Address: 4 w� Map P,53 Parcel "() � t� I � 5� 1'1rU _� Name: 5 V S 1 Phone: 2. How many bedrooms exist on your property now? 2a. Please include a copy of your floor plans for the entire property. ✓ 3. Is the dwelling connected to public sewer? YES NO If the dwelling is connected to public sewer, skip ques io s -9 below. I 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a.If yes,how many bedrooms were approved according to this permit? i --A Bedrooms. n� 7. Were any building permits obtained for construction of additional bedrooms? YES,fV✓ojr NOJV 1�' 8. Is there an engineered septic system plan on file at the Health Divisi ? YE orO ' c 9. Has the septic syste spected by a DEP certified inspector within the last two ears? : YES or 1V0 FOR OFFICE USE ONLY TO BE SIGNED BY A HEALTH INS P CTOR/AGENT ONLY The Public Heal! vision has no objection to bedrooms at this property. Signed: Date: Z/ /01t5— Inspector(Print�)--�:772;-G-AA6: s Q;/healthlwpfiles/amnestyapp 4516* O© t r-%ISTING uYINO' RODH .. law ED ROPH N0:1 ._ ._ ... .. 0 v N E XisTIN:a H TH ExIcrINa.FrREP1.RLE u d EI+B N;O QOOK tRSES 000K CRSfS .. _—._ tb. 4 ...... ...... 711 777 1 , • •� - - i ��ftl BED goo %, exlcTlN�D�NIdG RDOF1 >; — i 0 f ..., .. _ _.... — wLI� - ' qfro nlD FLOOR D[N�EN&10 GUI ;'-:REALTY.:Tk U ST !WEST! :YARMAUTH MA.02673 508.-7.'71-6'S-40--....PA 6 E-NO: No. ` Fee —0' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for ;Digpoga1 *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade(''Abandon( ) %Complete System ❑Individual Components Location Address or Lot No. - 1 1kCl d to�TYri v trN�} �.k Owner's Name,Address and Tel.No. Y i Assessor's Map/Parcel i, "T----M t-` Installer's Name,Address,and Tel.No. Y Designer's Name,Address and Tel.No. :=>0 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures cc Design Flow ��' gallons per day. Calculated daily flow 4et 0 gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank i Type of S.A.S. i- P� Description of Soil Nature of Repaior Alterations Answer when applicable). Y � r'T roa� s C( ems. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has b _ i y s f a Signed Date 6 Application Approved by Date Z` 3" Application Disapproved for the following reasons � g Permit No. Date Issued Fee 50 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes T PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS ZIpplication for Zigool *pgtem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(Abandon( ) l,Complete System ❑Individual Components Location Address or Lot No. `1 qCj Q l0 Slot t.,( e !1,k Owner's Name,Address and Tel.No. Assessor's Map/Parcel i Installer's Name,Address,and Tel.No. Designer's Name,Address-Ad Tel.No. i Type of Building: D�elling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures` Design Flow "1 k 0 gallons per day. Calculated daily flow kACA 0 gallons. - ,,M-P1an. Date Number of sheets Revision Date r" ..Tim r/ f e` Size of Septic Tank 17 CTU _ T � Type of S.A.S. ATI,QV CZ.,06 Description of Soil Nature of Repai2 or Alterations)Answer when applicable) tl�S114�� v � v r t(Tr j G _ C L,, roIv S p Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has b y is f Signed Date .' Application Approved by t. _ Date Z - `Y Application Disapproved for the following reasons Permit No. Date Issued Z Z --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS 2 -7 Certificate of Compliance ,,�. THIS IS TO CERTIFY,that the Oa Sewage Disposal System Constructed( Repaired ( )Upgraded(✓) Abandoned( )by -G C--,,v- �C _ at Z) rkw -% rt.. - has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit .o�� dated Installer I Designer % /5 n r A t The issuance of this pe tt 'hall n6t be construed as a guarantee that the systeln will function as desiigneVI ® c Date Inspector — l ------------------------------Fee -i,..-.'." No. _ - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Zigogal *pgtem Cotwtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(Abandon( ) System located at ----� � O l(� S`(yli 1CY ,,,:,� L(,V ,e-7 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Q Date: Z - 2 3 -'/ / Approved by •/�. r i , 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. l B CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �-(� �C'["La* , hereby certify that the application for disposal works construction permit signed by me dated . p���`� , concerning the property located at -Mcl (v?!�7 meets all of the following criteria: The 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. � A /There are no wetlands within 100 feet of the proposed septic system B ' There are no private wells within 150 feet of the proposed septic system /- There is no increase in flow and/or change in use proposed ZI 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: 22 A) Top of Ground Surface Elevation(using GIS information). 7 J B) G.W. Elevation +the MAX. High G.W. Adjustment DIFFERENCE BETWEEN A and B A SIGNED : w DATE: ��`� [Sketch proposed an of system on back]. q:health folder:cert ��G�� � ���, .� � � �,o � �! ��To TOWN OF BARNSTABLE LOCATION 4 (zZ / LC SEWAGE # ! r J VILLAGE SESSOR'S MAP & LOT �DI0-IIv. INSTALLER'S NAME&PHONE NO. 94, SEPTIC TANK CAPACITY i d LEACHING FACILITY: (type) •v /_T �6.0 r (size) S NO.OF BEDROOMS BUILDER OR OWNER , PERMTTDATE: - COMPLIANCE DATE: p 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by TT h 9" t �j City F� L r = - C0:�1%f0\�NTALTH OF MASSACHUSETTS EhECUTIVE OFFICE OF ENVIRONMENTAL RS DEPARTMENT OF ENVIRONMENTAL PRO ON �f O r 01E RI\TER STREET. BOSTON AL9 02108 (617) 292•5i0 A E R r �oF S �999 N�,,,� TRU XE "n0 c et ARGEO PAUL CELLUCCI DA , RUHS Governor s:o;er SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM tl�kP aS3 PART A LaT O t A D CERTIFICATION Qb CyA �\\ Property Address: ptr.�wrS A,` Nand of Owner 2 k K,iL\e�,T Date of Inspection: a\ � Wad lIAS Addres/so/fOwner: N,.7e�ft4�S�b�.C _ t [ EL/�U Name of Inspector:(Please Print C(e Q e c J 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide'5(310 CMR 15.000) ! Company Name: r 2 �k ✓�; �— u a... r �.'f u F Mailing Address::?, dt. a 2- ?. • I-e d:5,-N� I7",Pt c=)2_45 4-cl Telephone Number: r pZ� 4j= 9-;z l Lr • Z_c 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails 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 thirty (30) days of completing this inspection. It 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 Department of Environmental Protection. The original should be sent to ttre system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS l S�sT�-w. w��l tv�-ecA �Q�vzu��w� S ►.� t-v�i�. revised 9/2/98 page iorll %j Pnnied on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) "rope rty Address: qycii O�&ST@,E1wbe��� 1nr- � "Jwner: Date of Inspection: INSPECTION�SUMMARY: Check A, B, C, or D: +4 A.` -oSYSTEM PASSES: I'have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: )Nf x1f 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 revised 9/2/98 Page 2of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 i the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 10 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AN SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a It marsh. 2► SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUB C WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption sy tern(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 soil absorptio ystem and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorpti system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorp ' n system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well wat r analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facilit and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine stance (approximation not valid). 3) OTHER revised , /2/98 Page 3of11 Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: have determined that one or more of the following failure conditions exist as describ�etl�in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. - Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. is _ 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 d to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or av lable volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year T due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cess ool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 1 0 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is withi a Zone 1 of a public well. _ Any portion of a cesspool or privy is w' hin 50 feet of a private water supply well. Any portion of a cesspool or privy i ess-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. f the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. III E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to eac of the following: The following criteria apply to large ystems in addition to the criteria above: The system serves a facility with design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the envir ment because one or more of the following conditions exist: Yes No the system is ithin 400 feet of a surface drinking water supply the syste s within 200 feet of a tributary to a surface drinking water supply the sy em is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public wate supply well) The owner or operat of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Depa ent for further information. revised 9/2/98 Page 4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: L% Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: �Ar Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)1 - _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintanan"-of Subsurface Disposal Systems. revised 9/2/98 page sorn Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION +roperty Address: Z4 okA $ ►�{WV3�evt,W� �l Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: !440_g•p•d./bedroom. Number of bedrooms (design):QL Number of bedrooms(actual):-Q�i Total DESIGN flow—%-\LkQ Number of current residents: Garbage grinder(yes or no):_ Laundry(separate system) (yes orQ:_: If yes, separate inspection required Laundry system inspected ee r no) Seasonal use (yes or no):'N Water meter readings, if available (last two year's usage(gpd): N Sump Pump(yes or no): N Last date of occupancy:�s .—v5&t COMMERCIAL/INDUSTRIAL: vV Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_. Non sanitary waste discharged to the Title 5 system: (yes or nol_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: VA P• . System pumped as part of inspection: (yes or no)_L-b If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) T-4ZI revised 9/2/98 Page 6(if II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction:_cast iron_40 PVC_ other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ ` (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(e lain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Y INo) Dimensions: Sludge depth: _ Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees o baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal F' erglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet ee or baffle: Distance from bottom of scum to botto f outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, c dition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) T9/2 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) )roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on.site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, vidence of leakage into or out of box, etc. PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,-condition of umps and appurtenances, etc.) revised 9/2/98 page 8oriI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: yC� -CAA Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): t.5 (locate on site plan, if possible; excavafion not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of ge ton, etc.) fZ� o 0 CESSPOOLS: (locate on site Number and configuration: Depth-top of liquid to inlet invert: Go Depth of solids layer: tt" )epth of scum layer: n1i Dimensions of cesspool: (o'V�,I Pt A`I Materials of construction: G Indication of groundwater: N c> ' inflow (cesspool must be pumped as part of inspection) NQ Comments: (note condition of soil signs of hydraulic failure, level of ponding, con on of vegetation, etc.) 0 PRIVY: 1� (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.) revised 9/2/96 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 7,191 O\d lwner: Dane of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ?y A L revised 9/2/98 Page 10of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM(INFORMATION (continued) roperty Address: c'4 rC Owner: Date of Inspection: NRCS Report name Soil Type_ - Typical depth to groundwater _, USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope L�Gs Surface water wmv-by Check Cellar'Vay Shallow wells INlp. Estimated Depth to Groundwater :�-30�eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers X Used USGS Data Describe how you esSablished the High Groundwater Elevation. (Must be completed) V,S. 1� C- 7 'S'u'R-v�ey5 ` e I revised 9/2/98 Page 11of11 - e t L � j V'A 053 6/0 , OO 9 y 0s3 ow .Noo BORTOLOTTI CONSTRUCTION, INC. 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,/ CERTIFICATION Property Address: �7 ,E Date of Inspection: / Inspector's Name• �wner's Name and Address: 70� CERTIFICATION STATEMENT, I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes onditiona11 P Needs Further v ad B e Local Aproving Authority Fails Inspector's Signature: Date: / Q The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTTON S IM>y ARV- A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined", explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced aced with a conf r 'P o rrung septic tank as approved by The'Board of Health. Sewage backkup or breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 WELL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) STEM FA L'S: li I have determined that the system violates one or more of the following failure criteria as defined in 3 1p CMR 15.303. The basis for this determination is identified below. The Board of Health sho d be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. , Discharge or ponding of efluent 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has .been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓As-built plans have been obtained and examined. Note if they are not available with N/A. EETThe facility or dwelling was inspected for signs of sewage back-up. he system does not receive non-sanitary or industrial waste flow. !/The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System, have been located on site. =The septic tank manholes were uncovered,opened, and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. ` V The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) C/I'he facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RFSA2ENTIAL: 1/ Design Flow:_ allons Number of Bedrooms: Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use:/0) Water Meter Readin , if available: Last Date of Occupancy: Cb MER ATAND ST TAI,:,A)d Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection: AJ U If yes,volum umped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy hared System(If yes,attach previous inspection records, if any) Other(explain)71.�9- p �A a lX�(Lp ZaL,4 07V �d OXIMA AGE of all components,date installed(if known)acid source of information: cZ: ` - Sewa a odors detected when arriving at a site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK:_ Depth below grade: Material of Constriction: concrete metal FRP Other (explain) — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP: /v y Depth Below Grade: Material of Constniction: concrete metal FRP Other lai(expn) — — — — Dimensions: Scum Thickness: ' Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage. etc.) TIGHT OR HOLDING TANK: A)d Depth Below Grade: Material of Construction:—co ncrete—metal—FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alarm and float swi(ches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) -5 - f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): 1--' (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods). If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number, dimensions: Overflow cesspool, number: / Comments: (note conditio of soil,signs of hydraulic f 'lure leve f ponding,condition of veg tation, etc.) 6z2 (a y 'g- CESSPOOLS: I/ Number and configuration:/- XS 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failu e, level of ponding,condition of vegetation, etc.) GL k ZZ `c�GGz PRIVY: kk Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. �I 1 i 5 DEPTH TO GROUNDWATER: Depth to groundwater: 2-0 Feet Method of Determination or Appro 'mation: -7- ,. � � � _V �� p Zl .. ►J � �� rR� a 8 � � i CO_IMON�NTALTH OF MASSACHtiSETTS _ Go EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS = DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE'WINTER STREET; BOSTON 12k 02108 (617) 292-5500 TRUDY C01E Secretare ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Cotmnissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: _1 kA� SV-p` \Namer of Owner SAddress of Owner: il.�c`�ftQaJS b�R_Tti`�A O��(o� Date of Inspection: A�\S� ` Name of Inspector:(Please Print C Q f EL/</C) I am a DEP approved system inspector pursuant to Section 15.[340 of Title 5(310 CMR 15.000) Company Name: 14#G i c Ek L-;'ram.L. "g, it in "I F - MarTing Address:jEd2 4, `EL- I.a Pl-S New J 1�9 '�)ZC4-(�7 Telephone Number: ���;� LLt -;z. 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails I 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 thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 as �� Pr.med on Recycled Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: kA� Q\& Jwner: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. 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. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or.tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 i the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 10 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AN SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a It marsh. I 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUB C WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption sy tem (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 soil absorptio system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorpti system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorp' n system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well wat r analysis 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. Method used to determine stance (approximation not valid). 3) OTHER revised .9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) property Address: Owner: Date of Inspection: D. SYSTEM FAILS: I You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. r Yes No Backup of sewage into facility-or system component due to an overloaded orclogged 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. / i Static liquid level in the distribution box above outlet invert d e to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or av lable volume is less than 1/2 day flow. Required pumping more than 4 times in the last year T due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cess ool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 1 0 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is withi a Zone I of a public well. Any portion of a cesspool or privy is w' hin 50 feet of a private water supply well. Any portion of a cesspool or privy i ess-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. f the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" to eac of the following: The following criteria apply to large ystems in addition to the criteria above: The system serves a facility with design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the envir ment because one or more of the following conditions exist: Yes No the system is ithin 400 feet of a surface drinking water supply the syste s within 200 feet of a tributary to a surface drinking water supply the sy em is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public wate supply well) The owner or operat of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Depa ent for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r"roperty Address: 1�� Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and-the system has been-receiving twrmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: F} Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)1 The facility owner (and occupants,if different from owner) were provided with information on the proper maintenan"-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION . 'roperty Address: CA-A STf2>�t►•i vt �,l Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: !Jkko g.p.d./bedroom. Number of bedrooms (design):O(A Number of bedrooms (actual):Qti Total DESIGN flow() Number of current residents:—a Garbage grinder(yes or no): Laundry(separate system) s or®:_; If yes, separate inspection required Laundry system inspected e_( eor no) Seasonal use (yes or no): N Water meter readings, if available (last two year's usage (gpd): 13 Sump Pump (yes or no): fv Last date of occupancy:— iZ— --VSA-yrl COMMERCIAL/INDUSTRIAL: U Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: v-A A . System pumped as part of inspection: (yes or no)_� If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool —41 Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed Nf known) and source of information: Sewage odors detected when arriving at the site: (yes or no) C�17 revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) +roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _cast iron_40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal _Fiberglass _Polyethylene_other(e lain) If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_ (Y INo) Dimensions: Sludge depth: _ Distance from top of sludge to bottom of outlet tee or baffle: 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: How dimensions were determined: 'omments: (recommendation for pumping, condition of inlet and outlet tees o baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal F' erglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet ee or baffle: Distance from bottom of scum to botto f outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, c dition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 7d9/2/98 edge 7arll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order: Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: _ idence of leakage into or out of box, etc.) (note if level and distribution is equal, evidence of solids carryover, v PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of umps and appurtenances, etc.) rev ' sed 9/2/98 Page 8ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address:—I`jC-\ C- S yu �l l Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS):— (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of ge lion, etcCA .) lZ� o S - o + CESSPOOLS: (locate on site an) Number and configuration: Depth-top of liquid to inlet invert: Co' Depth of solids layer: )epth of scum layer: Dimensions of cesspool: 62 i k4 A`1 Materials of construction: L Indication of groundwater: NC*.) inflow (cesspool must be pumped as part of inspection) i22+ 1 Comments: (note cqndition of soil signs of hydraulic failure, level of ponding, con ' ion of vegetation, etc.) �.o l — $YtV 4 0 PRIVY: l�. (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.) revised 9/2/98 Page 9ofII i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: -Tv( (2>4 Owner: Il Date of Inspection: NRCS Report name Soil Type_ — - Typical depth to groundwater _ USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope L�f-S Surface water t4eiWA-by Check Cellar>Cy Shallow wells fp1jo, Estimated Depth to Groundwater 130�eet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers X Used USGS Data Describe how you esSablished the High Groundwater Elevation. (Must be completed) V.S. yk oc� �� Sv���� 5 v,'s r�o ,y�9�� ►�T I \o .�d df Ir�wcl revised 9/2/98 Page 11of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 7 y� CAA lwner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 74 q 1 A �e�vL � i � L 'All revised revised 9/2/98 Page 10of11 BORTOLOTTI CONSTRUCTION INC. DRAINAGE LAND DEVELOPMENT SEPTIC SYSTEMS \ February 22;,1999. . Town Of Barnstable Jl®' Board.Of Health p 367 Main Street Hyannis,MA 02601 `" �levtsawe�o��nbi `— Telephone: 508-790-6265 6661 8 8dW RE: 749 Old.Strawberry Hill Road Centerville, MA To Whom It May Concern: :` `• Asper our phone conversation today with regards to the above stated Location and Pages 5& 6, I am sending along the Revised Pages with hopes that it meets your approval. If you have any further questions with regards to this matter,please do not hesitate calling- 508-771-9399: /n Since ire lyr,//// Robert J. Bort otti President Bortolotti Construction, Inc. / .4 MAR 8 1999 ` ah;>'ABLE L = ! /" e.d` R ,* _k -`t 1f f J..-`i• Le1 Z1 ! :. P.O. BOX 704 MARSTONS MILLS;MASSACHUSETTS 02648 a (508)428-8926„ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (coutinucd) SOIL ABSORPTION SYSTEM(SAS): Vf (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits, number: / Leaching chambers, number: Leaching galleries,number. Leaching trenches,number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil,signs of h dra lic failu a level of ponding,condition of vegetation, etc.)i� a 'b �' CESSPOOLS:_ , Number and configuration:�' �o�XS Depth-top of liquid to inlet invert: _ Depth of solids layer: Depth of scum layer: Dimensions of Cesspool:(o Materials of construction 'Xk" /xiIndication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note con ition of soilk, si ns of hydraulic f 'lure, level of ponding,condition of vegetation, etc. C �' (j"ye 7 PRIVY:_�(� Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYS'CEM INSPECTION FORM r, d PART C,.,j _... .." ' GENERAL INFORMA:7',ION,�.'(continued) SEPTIC TANK: A)0 Depth below grade: Material of Construction: concrete metal FRP Other (explain) — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) GREASE TRAP:_ Depth Below Grade: Material of Construction:(explain) —concrete—metal FRP Other — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for Puntping,,condition of inlet=and outlet,tees or baffles, depth of liquid level in relation to outlet invert, strnc(ural'integrity,evidence of leakage, etc.) TIGHT OR HOLDING TANK: A-b Depth Below Grade: Material of Construction:__concre-te_metal;FRP_Other(explain) Dimensions: Capacity:--,-gallons Design Flow,' gallons/day Alarm Level: = Comments: (condition of inlet tee, condition of alarm and float switches. etc.) DISTRIBUTION BOX: - Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box,etc.) PUMP CHAMBER: IJO Pump is in working order: ' Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) t' O5 3 (0/0 .i00 pig BORTOLOTTI CONSTRUCTION, INC.` . 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 `� 508-771-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO g A* PART A T ' CERTIFICATION Property Address: L� Date of Inspection: / Inspector's Name ner's Name and Address: 70-�;) CERTIFICATION STATEMENT* I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes onditionally Pa Needs Further v ati B e Local Aproving Authority Fails Inspector's Signature: Date: / The System Inspector shall submit a copy of this inspection report to rite Approving authority within this ty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUM ARYe A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system, upon comple- tion of the replacement or repair, passes inspection. Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The'Board of Health. Sewage backkup or breakout or high static water,level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): I { m * SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4 p'` Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 . 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 the public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT.THE'PUBLIC'HEALTH AND.SAFETY AND THE ENVIRONMENT: The system has a septic tankiAnd soil absorption systeni and is within 100.Feel to a surface water supply or tributary to a surface mater supply.' .The system has a septic tank.and soil absorption system and is With a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than.5- ppm D) YSTEM FAILS: M _ V I have determined that the system violates one or more of the following failure criteria as defined in 3 1P CMR 15.303. The basis for this determination is identified below. The Board of Health sho d be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS f or cesspool. ` Discharge or ponding of efiuent 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 clog- r t +. . ged•SAS or.cesspooi. ' ``.,• Liquid.depth.in cesspool,is.less than,6°below invert or available`volume is less than 1/2 ' day flow. b.. Required pumping more than 4.timcs in the-last'year.NO.T'due to clogged or obstructed pipe(s). Number of times pumped -2 f: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART A CERTIFICATION (continucd) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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.syste m is located in.a nitrogen sensitive area Interim Wellhead Protection Area ,, . . IWPA)or a mapped Zone.I of a,pubhc waferaupply well The owner or operator of any,such,system,shall bring the system' and facthty into full compliance with the groundwater treatment program requirements of 314 CMR 5.006nd 6.00: 'Please cbnsult the local regional office for further information.of the Department o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CII ECKLIST Check if the following have been done: ; Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period.. Large volumes of water have not been introduced into.the system recently or as part.of this inspection. ✓As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs'of breakout. All system components,excluding the Soil Absorption System';have been located on site. =The septic tank manholes were uncovered,opened;and"the interior of the septic tank was in .: ;�.. ._ "spected for condition of baffles or tees,material of,construction,dimensions,depth of liquid,. depth of sludge,depth of scum. I/ The size and location of the Soil Absorption System'on'the site has been determined based on existing information or approximated by non-intrusive methods. -3- =»Z4�,a f` ti SUBSURFACE SEWAGE DISPOSAC SYSTEM INSPECTION FORM PART B ' CIIECKLIST(continued) [/fhe facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - -. SYSTEM INFORMATION FLOW CONDITIONS RFSIDENTLAi:_ l/ Design Flow: lions Number of Bedrooms: Number of Current Residents: !/ -►� Garbage Grinder. Laundry Connected To Systemi4a Seasonal Use Water Meter Readin s,if v 'lable: Last Date of Occupancy: - (OMM .RCIAIJINDUSTRIALe/Qd Type of Establishment Design Flow- aallohdday°`Grease Trap Present: (yes'or _ Industrial.Waste Holdin Tank Present: .—Non-SamititryWiste Discharged-To The Title V System:- -_ .__-__�..... .. - Water Meter Readings,-If Available: -Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: pccut"T��&* P�as P System Pumped art of inspection: AJ 6 .,If yes,volum umped: gallons y Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,at h previous inspection records,if any) Other(explain):. OIdMA E AGE of all components,date installed(if known)aiid source of information:. +Sewa a odors detected when arriving at a site:�,r ?,�1 ° ` Z. SUBSURFACE SEWAGE DISPOSAL SYSTEM,I,NSPECTION FORM PART C .... ,GENERAL INFORMATION (continued) SEPTIC TANK:___ Depth below grade: Material of Construction: concrete metal FRP Other (explain) — Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,evidence of leakage. etc.) GREASE TRAP:_ l� Depth Below Grade: Material of Constnuction: concrete metal 'FRP Other (explain) — — — — Dimensions: Scum Thickness: ' Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baflles,depth of liquid level in relation to outlet invert,structuralittegrity,-evidenceof leakage etc) TIGHT OR HOLDING TANK: A)d Depth Below Grade: Material of Construction:—concrete metal FRP Other(explain) Dimensions: Capacity: gallons Design Floc: gallons/day Alarm Level: Comments: (condition of inlet.tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBERi Pump is in working order: Comments: (note condition of,pump chamber; condition of )iinps anr(aiipur<enances, -5- r . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits; number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields, number,dimensions: Overflow cesspool, number: / , Comments: (note conditiog of soil, signs of hydraulic f 'lure leve f ponding,condition of veg talon, etc.) Q. w ' '' ' CESSPOOLS: l/ , Number and configuration:/'(o XS Depth-top of liquid to inlet invert: Depth of solids layer: �' Depth of scum layer: ,-'Dimensions of Cesspool: W Materials of construction: " Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) 1 Comments: (note condition of soilk,signs of hydraulic failu e, level of ponding,condition of vegetation, etc.) 2;2GL. x PRIVY: Ak Materials of construction: Dimensions: Depth of Solids:. _ Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) s, r..... -n-w.,-.•.. _.. _ '.'—`__..._..—. _.. ....tee.. ��. ...r .- ., .t-w.._......-�.._. .......�......._......._....._ .....� ,. ._.. ...,..+r,. ���. -6- _ er. . I SUBSURFACE SEWAGE'DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. �I , DEPTH TO GROUNDWATER: Depth to groundwater: zo Feet M. Method of Determination or Approx'mation: r y -7- t , t i • TOW/NOFB RNSTyBy �E LOCATION TI� r��fX .S�l'Gcr✓✓pe/�/� / �l �( SEWAGE #, VILLAGE AlY 4Qi ASSESSOR'S MAP & LOTZ73 Z,oo'6 - INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= A-r d 6 LEACHING FACILITY: (type) 'C.P`, (size)k 03 + �d NO.OF BEDROOMS ,l / BUILDER OR OWNERI Y PERMITDATE: 'S I(A COMPLIANCE DATE: tt r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Al,rij-7v 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 f' within 300 feet of leaching facility) ' x +z Feet Furnished by_ o1!"k✓ Q�L r �� YJ�ycJ �' y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Miqozal 6pelem Construction Permit Application for a Permit to ConstructKRepair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components v V Location Address or Lot No. 400(-1V 6 4e Owner's Name,Address and Tel.No. 1a i-/,/i OZeW Wy, ,-may /)/'c 4<� l Assessor's Map/Parcel d cri2 Installer's Name,Address,and Tel.No. Designer's Name Address and Tel.No. jr Type of Building: Dwelling No.of Bedrooms Lot Size-3 Q/P5- ft. Garbage Grinder( ) Other Type of Building .5/ No.of Persons Z_Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow —3 7 gallons. Plan Date / / / rj F Number of sheets / Revision Date Title / Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bprd of Hea Signe Date r Application Approved by Date Application Disapproved for the following reaso Permit No. Date Issued 63 . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Vs Application for 0i5pogar bpgtem Con.5truction Permit (�M Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) El Complete System ,O Individual Components �}\ Location Address or Lot No. L U 11P-` 7/1 Owner's Name,Address and Tel.No. 0/v Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name Address and Tel.No. / Type of Building: _7-- Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) -Other Type of Building ,5/ No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow - kk gallons per day. Calculated daily flow —3 7 1;�s gallons. Plan Dater Number of sheets l' Revision Date Title Size of Septic Tank f << Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of'tle Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d of Health: Signe A Date ,Application Approved by �� /`�� ?, Date Application Disapproved for the following reaso �- A r Permit No. Date Issued —————— ———————————-———————————————————THE COMMONWEALTH OF MASSACHUSETTS , BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TOICERTIFY, that the On-site Sewage D' posal System Constructed( / ?)Repaired ( )Upgraded( ) Abandoned( )by t ` C c at ` lr Irt C /5L irlo" has en constructed in accordance with the provisions of Title 5 and the for Disp sal System Construction Permit No. dated Installer � Tom't i n / G �� Designer 4 ,1 A G The issuance of this permtt 1 not blef�ns ed as a guarantee that the sy e 1 I�fyuynction as des�ried% Date "! Inspector I��{ �, �. 1TT 0Z..- w f �e-V€/ v / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 33igog r pgtem Construction Permit Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m st be c o m leted within three years_of the date of s e t. l� G Date: I Approved by TOWN OF BARNST LE LOCATION Z/Z 5,141, „6 ''��`� SEWAGE # IS-9 VILLAGE ASSESSOR'S MAP & LOT Z73 Z/,; INSTALLER'S NAME&PHONE NO. J SEPTIC TANK CAPACITY _ r' d O LEACHING FACILITY: l" �'� -''I(h'pe) a E (size) , NO.OF-BEDROOMS ..BIDER OR OWNERC .c, ° i PERMITDATE: COMPLIANCE DATE: ? f j Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If.any wells exist on site or within 200 feet of leaching facility) r Edge of Wetland and Leaching Facility(If any wetlands exist Feet f within 300 feet of leaching facility) Feet Furnished by ('t!��\i i 1 n c� M o IV i s � '-.ems., A a4-cam 2 3 Z 'y�Op'THE� DATE: / 9 FEE • BARNSfABLE. "� tb;q. Town of Barnstable 9 `0� REC. B �prED MA'S A Board of Health c 367 Main Street, Hyannis MA 02601 �V Office: 508-790-6265 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Ralph A.Murphy,M.D. VARIANCE REQUEST FORM LOCATION Property Address: /, 6 y 1 Assessor's Map and Parcel Number: 2 Z/ % Size of Lot: Wetlands Within 300 Ft. Yes Subdivision Name: No Business Name: APPLICANT /�� -: CONTACT PERSON Nam — -G//'�i==/�/�1�� CC ;Name: Address: !�J V� Address: Phone: ' Phone: FAX: ? — G Z 9 3�— FAX: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) Checklist(to be completed by office staff-person receiving variance request application) —Four(4)copies of plan submitted(including septic system plans and/or restaurant floor plans) ✓ Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense(for Title V and/or local sewage regulation variances only) Full menu submitted(for grease trap variances only) Variance request application fee collected(no fee for lifeguard modification renewals,grease trap variance renewals[same owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems[only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Ralph A.Murphy,M.D. Q:/WP/VARIREQ 4 • l RARNWAUA l t639.h� MIS Town of Barnstable Zoning Board of Appeals Decision and Notice Appeal Number 1998-112-Ahern Variance to Section 3-1.4(5)-Bulk Regulations-Minimum Lot Size Summary: Granted With Conditions Petitioner: Barbara Ahern Property Address: 702 and 714 Old Strawberry Hill Road,Hyannis Assessor's Map/Parcel: Map 273,Parcels 209 8 210 Area: 1.44 acres Zoning: RC-1 Residential C-1 Zoning District Groundwater Overlay: GP Groundwater Protection District Background: The property that is the subject of this appeal consists of two vacant lots commonly addressed as 702 (Parcel 209) and 714(Parcel 210)Old Strawberry Hill Road in Hyannis. The subject lots are located in a RC-1 -Residential CA Zoning District-which has a minimum lot area requirement of one acre. The subject lots together are 1.44 acres in area; Parcel 209 being 0.75 of an acre and Parcel 210 being 0.69 of an acre. The applicant has owned both lots for 18 years, according to the application. In 1982, the property was zoned RC-1 and had a minimum area requirement of 15,000 sq. ft. In February of 1985, a minimum lot size of one acre was established for all residential districts, except for the RG district which was already 65,000 sq. ft. (STM 2/28/85,Art. 1). Section 4-4.2(2), Nonconforming Lots-Common Lot Protection, provides for a protection of development rights for a period of 5 years from the effective date of any increase in the area, frontage,width, yard or depth requirement of the Zoning Ordinance. For the subject property, the protection afforded by this section ended February 28 of 1990. The applicant is, therefore, seeking a Variance from the minimum lot size requirement in order to re- establish the development rights of each lot under the Zoning Ordinance. Procedural Summary: This appeal was filed at the Town Clerk's Office and at the Office of the Zoning Board of Appeals on July 15, 1998. A 60 day extension of time for holding the hearing and for filing of the decision was executed between the applicant and the Board Chairman. A public hearing before the Zoning Board of Appeals was duly advertised and notices sent to all abutters in accordance with MGL Chapter 40A. The hearing was opened October 7, 1998, at which time the Board granted the Variance with conditions. Hearing Summary: Board Members hearing this appeal were Gail Nightingale, Richard Boy, Ron Jansson, Elizabeth Nilsson, and Chairman Emmett Glynn. Attorney Kate Mitchell represented Barbara Ahern, who was present. Ms. Mitchell submitted a memorandum to the file in support of this appeal. Ms. Mitchell described the locus and its surrounding area. These lots are within a small subdivision located close to two condominium complexes and close to the business area. All the other lots in the area are built upon. As background, Ms. Mitchell explained that Barbara Ahern and Virginia Linquist bought Town of Barnstable-Zoning Board of Appeals-Decision and Notice Appeal No.1998-112-Ahern Variance to Section 3-1.4(5)-Bulk Regulations-Minimum Lot Size two lots together in 1982 with the intention that they each own one lot separately. They(mistakenly) thought that which ever name was written first on the deed was the true owner. They did not realize the lots merged under zoning. Ms. Linquist passed away, and under her will, Ms.Ahem inherited both lots. Ms.Ahern only learned of the merger when she tried to sell one of the lots and the[potential]buyer was told the two lots had merged under zoning. I As to variance conditions,Attorney Mitchell explained the shape of the lot is aberrant and unique to this area. If the two lots are combined the result is one oversized oddly shaped lot, and not like any other lots in the area. A literal enforcement of the ordinance would be a substantial financial hardship to the Petitioner because this would only allow one lot when two separate lots were purchased. To grant the relief would not be a determent to the neighborhood as these are the last two lots in the area and no use is sought other than that of a single family residence. The lots have always been taxed separately on two separate tax bills and both lots were bought at fair market value. Attorney Mitchell indicated the Petitioner will comply with the GP Groundwater Protection Overlay District requirements and will limit each lot to a three bedroom single family structure. Public Comment: No one spoke in favor or in opposition to this appeal. The Petitioner(Ms. Ahem)addressed the Board and reported that she was approached by a neighbor who would like to buy one of the lots. At this time, she is unsure about her plans for the other lot. Findings of Fact: At the Hearing of October 7, 1998,the Board unanimously found the following findings of fact as related to Appeal No. 1998-112: 1. The Petitioner is Barbara Ahem. The property in issue is located at 702 and 714 Old Strawberry Hill Road, Hyannis, as shown on Assessor's Map 273, Parcels 209&210. 2. The subject lots together are 1.44 acres in area; Parcel 209 being 0.75 of an acre and Parcel 210 being 0.69 of an acre. 3. These lots are undeveloped lots located along Old Strawberry Hill Road in the RC-1 Residential C-1 Zoning District which requires one acre of contiguous upland. 4. The remaining residential neighborhood is developed with lots of similar size or smaller than the locus. 5. There is no additional land to be acquired to add to these lots to make the lots conforming to the current Zoning Ordinance. 6. The town has taxed both lots separately as buildable lots. 7. These two lots are the only remaining undeveloped residential lots in the immediate area and to require the Petitioner to have a full one acre as is required in the current Zoning Ordinance would be an aberration to this particular area. 8. The relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of the Zoning Ordinance nor would it be detrimental to the neighborhood in view of the fact that all of the remaining lots are basically the same size. 9. The lots are located in the.GP Groundwater Protection Overlay District. 10. Pursuant to MGL Chapter 40A, Section 10, no Variance Conditions specifically relating to soil, shape or topography have been demonstrated. 11. The lots were purchased separately in 1982 and 1983 at full market value. Decision: Based upon the findings a motion was duly made and seconded to grant the Applicant the relief being sought in Appeal No. 1998-112 with the following terms and conditions: 1. The zoning relief being granted must be exercised within one year. 2 Town of Barnstable-Zoning Board of Appeals-Decision and Notice Appeal No.1998-112-Ahem " Variance to Section 3-1.4(5)-Bulk Regulations 2. Both of the lots that exist, as now individual lots, may be constructed upon with a house having no more than three bedrooms each. 3. All other portions of the Zoning Ordinance' Mackrequiremen as we use mus e lied with. The Vote was as follows: AYE: Gail Nightingale, Ron Jansson, Richard Boy, Elizabeth Nilsson, and Chairman Emmett Glynn NAY: None Order: Variance Number 1998-112 has been granted with conditions. This decision must be recorded at the Registry of Deeds for it to be in effect. The relief authorized by this decision must be exercised in one year. Appeals of this decision, if any, shall be made pursuant to MGL Chapter 40A, Section 17,within twenty (20)days after the date of the filing of this decision. A copy of which must be filed in the office of the To Clerk. �O ''V •, 1998 Emmett Glynn, Chairman Date Signed I Linda Hutchenrider, Clerk of the Town of Barnstable, Barnstable County, Massachusetts, hereby certify that twenty (20)days have elapsed since the Zoning Board of Appeals filed this decision and that no appeal of the decision has been filed in the office of the Town Clerk. Signed and sealed this ay of rider the pal and penalties of perjury. 1. Linda Hutchenrider, Town Clerk 3 THE TOWN OF BARNSTABLE �pf raw OFFICE OF 11eaa9TesL BOARD OF HEALTH HAS& o°ems 1639' \gym 367 MAIN STREET f0 MPY tr' HYANNIS, MASS. 02601 March 26, 1999 Larry Nickulas P. O. Box 507 West Barnstable,MA 02668 RE: Lot 6 Old Strawberry Hill Road,Hyannis A=273 -210 Dear Mr.Nickulas: You are granted a variance from the Board of Health "330" Regulation, to construct an onsite sewage disposal system at Lot 6 Old Strawberry Hill Road, Hyannis. This variance is granted with the following conditions: (1) No more than three(3) bedrooms are authorized. Dens, study rooms, finished attics, sleeping lofts, and similar type rooms are considered bedrooms according to the MA Department of Environmental Protection. (2) The applicant shall record a deed restriction at the Barnstable County Registry of Deeds in regards to the maximum number of bedrooms allowed at this property(three). These variances are granted because it is the Board's policy to grant variances for the construction of three (3) bedroom dwellings on lots of 18,000 square feet or greater. This lot is 30,182 square feet. Also, the proposed septic system meets all of the provisions of the State Environmental Code, Title V. It is the opinion of this Board that the construction of one septic system which meets all of the provisions of the State Environmental Code, should not significantly alter the quality of the groundwater in this area. Sincerely yours, Susan G: , R.S. Chairperson Board of Health Town of Barnstable SGR/bcs I lury ���H a N D a-, � I 3567 r X j a xw 1,-2-. C1 0 a,iv I rn bdl�9dl�tlnl o _ N you v �.11un hI M _ cLu • � POO lei a 0 I 9�,� }� k � w N b tA AL ON -11 LLI i 1 b fthNo r f • A , p i { ! IMF �1#9 /d1rn1 f AU a � I r , () Iy0ou 711t/ 11 f ♦ f ! it i q H I am l I - 1 Tl ^4 � i � .� � r } - - � ! -, '* �.,:t f Ti-+ i � { { � i I { j I •a �j � 1 , } 1 i � �_ •! 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