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Home My WebLink About0416 PITCHER'S WAY - Health Pi#G'lier's'a Way'} Hyannis A.='�291. 018 -Z - a ^1i i S i i { I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 I every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any Impodant: way. When fillip out /s A. General Information When er/ / forms on the �Jr U�� computer,use 1. Inspector: only the tab key to move your MICHAEL DEDECKO cursor-do not use the return Name of Inspector key. COMPASS REALTY DEV CORP Company Name P.O. BOX 2384 Company Address MASHPEE MA 02649 /M City/Town State Zip Code 508-221-5003 Telephone Number License Number B. Certification I certify that l have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: d"Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority t , b DQ1/26/07 v' n pecto?s Signature Date The system inspector shall submit a copy of this inspection report to the App owing Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system isla sharedsystern or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit tde report to the appropriate regional office of the DEP. The original should be sent to the systems owner and copies sent to the buyer, if applicable, and the approving authority. k.0 rr, ****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. 281OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is HYANNIS required for MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 ❑ N/ 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 ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ M/ 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. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ [� Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ET Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 19 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GM '' 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ LVI' Pumping information was provided by the owner, occupant, or Board of Health ❑ [3 Were any of the system components pumped out in the previous two weeks? ❑ LR Has the system received normal flows in the previous two week period? ❑ 1911" 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? 10 ❑ Was the site inspected for signs of break out? Lod ❑ 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? ❑ cs�/ 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: L�_}'/ ❑ 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)] 281 OLD MEETINGHOUSE•08/06 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): �� Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes Ef No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes NANo Laundry system inspected? ❑ Yes ErNo Seasonal use? ❑ Yes ER/N'o Water meter readings, if available last 2 ears usage d V4,� 9 ( Y 9 (gpd)): i Sump pump? ❑ Yes B�N o Last date of occupancy: I ` 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: Last date of occupancy/use: Date Other(describe): 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes V'/No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: �� —lS .�� Were sewage odors detected when arriving at the site? ❑ Yes O✓No 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owners Name information is HYANNIS required for MA 02601 1/26/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: a feet Material of construction: ❑ cast iron FQ(4 0 11 PVC ❑ other :ex lain ( P ) Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): —T-t- Septic Tank(locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is ag —e confirmed by a Certificate of Compliance? (attach a co of certificate) El Yes Yes No -------- ---------------- ------------------------ -------- ------------copy -------------- ---------- Dimensions: k Soo �fc Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle �� fr Scum thickness Distance from top of scum to top of outlet tee or baffle LA Distance from bottom of scum to bottom of outlet tee or baffle ��4I How were dimensions determined? y 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owners Name information is HYANNIS reg uired for MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): evDe r- k&—Vu ub �e 0 Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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): 281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address information is required for HYANNIS MA 02601 1/26/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): tom` x ( �t�, lovRa,J �z� u�.Se a? S Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type.- El leaching pits number: [� leaching chambers number: ❑ leaching galleries number: �l i.r— El 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.): 1 -- iz� 281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.): 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 418 PITCHERS WAY Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 7- e 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'F4o 418 PITCHERS WAY sa` Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for HYANNIS MA 02601 1/26/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: F1 Check Slope Vsuace water ck cellar LVJ Shallow wells Estimated depth to groundwater: 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) L� Accessed USGS database-explain: t L -,clwltiV.eS 47 a.�7a rub You must describe how you established the high ground water elevation: VS 281OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 TOWN OF BARNSTABLE LOCATION er SEWAGE # VILLAGE ASSESSOR'S MAP Bt 1,0172a - / INSTALLER'S N &PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 3 )qVAQVV� (size) NO. OF BEDROOMS BUILDER OR OWNER + C s PERMITDATE:_J 1-) fI- CO LIANCE DATE: Y / 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by (JJ � �c �� . � �. �_ � � � �:.�t � � �1 � � � No. Feed' / • A/ THE COMMONWEALTH OF MASSACHIJSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprtcatton for �Dtgpooal 6potem Construction Vermtt Application for a Permit to Constru )Repair(J)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. WPLA0-?5 al"g�. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 2q' ' J O -450 Installer's Name,Address,and Tel.No, 164 CS- Designer's Name,Address and Tel.No. 0 y6-zoo v l9� _41-wlGk � Mvt az.�Ys /S SvrJ Sele PZ S, 2723 Type of Building: Dwelling No.of Bedrooms Lot Size / sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 3 eueit�e 330% 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 th fore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ ental Code and to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of He Signed Date /2-/7- 6z Application Approved by Date 12-/?-D- Application Disapproved for the following reasons Permit No. 7- 0 2 5-9'7 Date Issued a1210 '� 01 Fee'yNG-W 2 ✓O V y' ''HE COMMONWEALTH OF MASSACHUSETTS. Entered in computer: j Yes -,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ,- application for �Digpogal *p5tem Construction-permit Application for a Permit to Consttu )Repair Upgrade( )Abandon( ); ElComplete System El individual Components Location Address or Lot No. rj Q/L$ "I F. Owner's Name,Address and Tel.No. 0Irri141) 14- o2C00 P i S Assessor's Map/Parcel2q'-� �'d � 1 Installer's Name,Address,and Tel.No. h Designer's Name,Address 7and Tel.No. ` %-17k vk?11 fi 'in S� l Li9 2!//L2 S.' a y6-z�ov g '/ 1-(&d.w i'c k M.4 a &,f Type of Building: Dwelling No.of Bedrooms Lot Size / /00 sq.ft. Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures . J Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title - Size of Septic Tank 5-00 6: '(_ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected:1 Agreement: The undersigned agrees to ensure the construction and maintenance of the�fore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ ental Code and rfot to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Hea(1 . Signed Date Application Approved by Date J 2-/'7-6 2 Application Disapproved for the following reasons Permit No. 7-L02- 5_2r7 Date Issued z 117 a Z THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Con pliAce THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed'( )Repaired ( )Upgraded( ) Abandoned( )by at t F'i t r S G,/a has been constructe in cordance with the provisions of Title 5 and the for D sposal System Construction Permit No. 2402_ffi'Sr1 dated l z t 17 0�- Installer Q aj s o.n ,,'tL Designer The issuance this permit shall not be construed as a guarantee that the s��ste wil1Nuncti esigned. Date A °I �) Inspector- ------------- `7 S No. �� ---------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Oiopozal *pgtem (Construction permit Permission is hereby granted o Construct( )Repair(� pgrade( )Abandon( ) System located at t+c , J S 41 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:Cons must be completed within three years of the date of this pe Date:_ 1217,170 '? C)2 Approved by TOWN OF BARNSTABLE SE LOCATION ! / WAGE # 24'0x-S9 VILLAGE nd ASSESSOR'S 8� LOT 9 - / � i INSTALLER'S NAL&PHONE NO. SEPTIC TANS{ CAPACITY LEACHING FACILITY: (type) .3 (size) j NO. OF BEDROOMS I BUILDER OR OWNER + f S PERMIT DATE:_Ir1=� -I-0 CO LIANCE DATE: I -d 9'0 2 Separation Distance Between the:. Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i � . ��.._. 59 I tJ 'Notice kis Form is To Be Used far thg kopLir Of Fviilgd Septic srysteaae galy PERCOLATION T%S T An 80IL EVALUATION EUWTLON FOIai 1, ti;�c- ; _ ,hereby o 'y tlut taus ovjiuvW plea oiprd by me dated Z to lo, ooaamlap dto gropity baited et I�Lm LLmavi muu ju of*v l�oll�av;e$ca3tui� • TW failed system it ooAtseeted to a mideAtial dwiMM ooiy, T! N AN W e0Metoial or baeltuu arise usooiatd wflls the dwow", '4 1 • The soil to aLmifid m CLASS I"A 11i W44144411It"G lorle WA of i,,qW t0 I MiAutu pes IA4'. rat oppiiaoo:air wr ltiotorlool dot*e6106"ho or mil+onduot yealiataituty uiti#t�i sitr wll�oaat�brilth�t p*+/1�At, • Shvo it to iaurem#In Sow ad/or 4stalo in Us$propmed Then ate no vuiusss lipsited or needed, • Tbs hftm of to f"Uty wlt;be IOWA U loot t"SVe fort 9bove the mexian=4uKod proUAWMv table elevetiosa.MUM the 1mU4a+MV%bW u Wj tbi FrbnDsar Osethod wkeA e�ZloA611) Pl•u•complete Ike femwbi► A) 'Tea otA and awful Yitvptto4lupin`C"idormatiea) D 8) GNBievttion �egftumaonulbrhig�ao.w, • Z___,_ D '�E&8N'CB�B A sad WOMO �— SICN>t� MOM �Ras�upaa he l�wa�fotofoat � mwcaawas, I�'o AtditioaJ bodroo�t�e �r,�,,,,_bodeoar:u I Pilo, tared is 61 AM W at ee�d soppy syetam 4�Serld�lbldu,�aro►4my f! ' •. Bk 16100 Os111 a11�331 1.2--17-2002 a'1 03 - 52n DEED .RESTRICTION j WHEREAS, -- -`I �r C0.,f ►1QX1 S of lJ 1 (owns name) 1. lJ l AOr))� a H O6 �1 MA (addres ) is the owner of L4 l4Ck k located II (address) at -ky)n1 s MA (hereinafter referred to as LL4- 3 i and b ing shown on a plan entitled "Subdivi ig� of Land in 1n s MA, Property of --K to WNIpS et al, duly recorded in Barnstable County Registry of Deeds in Plan Book <S�7 , Page ; Or on Land Court Plan Number WHEREAS, Q as the owner of said lot has (owner's name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be in .tuded in any home built on said lot as a pre-condition to obtaining a disposal works�construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board lof Health, as a pre-condition to granting a disposal works construction.iperrhiit for a septic system in compiance with 310 CMR 15,200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal ;of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on thellot be put on record with the Barnstable County Registry of Deedsby recording this document, deedr ! Bk 161.00 P:9 112 . 01 15331 NOW, THEREFORE, doW hereby place the (owner's WnW following restriction on his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 141 may have constructed (address) u�io.n the lota hous containing no more than ( )'bedrooms. < agrees that this shall be permanent deed a e p (o restriction affecting _ located on 41 Qc 2s '-J MA; and being shown on the plan recorded in Plan. Book 7 , Paged Or on Land Court Plan For title of � see the following deed: Book SOa6 Pa e M� . Or Land Court Certificate:of Title Number �— g Execute as aA-e'siled instrument day of 2M 2 Owner' sign ture 1 law"C-�, Owner's signature Owner's signature COMMONWEALTH OFF MASSACHUSETTS , ss �� C�mO- t l , 20�2 .Then pers nal y T&C-7-S peared the a owe-named 0 � �EN D AGES known to me to be the person who executed the foregoing instrument and acknowleoged the same to be , free act and dee before me, I � eJcy Notary BARNSTABLE CUb l Y - REGISTRYOFDEEDS M: commiSSl n X Tres: ATRUE COPY,ATTEST y 2�V EAM i�E�isTER &OSTABLE REGISTRY.% DEEDS (date) w r Town of Barnstable P# Department of Regulatory Services oFtttE►q� Public Health Division Date /2- 5"a 200 Main Street,Hyannis MA 02601 � BArINSTABtE. ` 9 MASS. - �'"rec �•�� Date Scheduled Time Fee Pd. Soil Suitability Assessment for Sewage Disposal Performed By: 4�/q� ,�1 �� Witnessed By: f TIQNNQA Location Address " G � Owner's Name4GS 2l�� 9�1/Q/fS Address ` G'lr2ll S G.r Assessor'sMap/Parcel: /r �Zl V;r�2 g Engineer's Name ./y,� ' �r NEW CONSTRUCTION CONSTRRU�UjjCTION REPAIR a ep one Land Use Slopes M �3 Surface Stones 7�vw Distances from: Open Water Body IJ �� ft Possible Wet Area ft Drinking Water Well A ft �',r}000r�7T*s pn.vo � Drainage Way !14 ft Property Line �.r ft Other U?S°1,& r*e�-r ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) ` Pdd i i its �a Parent material(geologic) f MW Depth to Bedrock _ / Depth to Groundwater: Standing Water in Hole- > 2 A'7* r Weepin from Pit Face /✓ 0 AI--- /9ri9'ro Estimated Seasonal High Groundwater .. ... ............r...............r......::o:�..,..r.r..:.,.:..:..._r..r�.......r.....r._r.......�.r...:....rrr.....r.. r rr:r......._,r:.r...:.... ��- !::xs::!!!!::i:!:::':�:.,. :!Ll.,r .{!.n.�:..::1l.4r:::.1:'.rvLr.r.rr.rr.urr...�.r.r r..r....__......_.............._..._.._...._..r........:.._.....:..............I.r...........u..v...n:m.:A.n...r....:...............r.......r.:l...r..r.ra rr.... .::i:.._.......i..,,;......:.:-�::::...v..:.v_n_...-::;,�.::..ol�i.!_ri..':-��:::. ....i............. .�.�,. i'Y .rr I .1: 11 .1 R. hla I+'CR 5 +. 4itCur r:,� Bt, .._ .:..1 r.:.r..... ......._.r.. .: .v.. ._.....:. .. .....r.: ...a..:..__ ..._ ....::.. .... Met o se Depth Observed standing in obs.hole: o soil mottles: in. Depth to weeping from side of obs.ho in. Groun t ft.' Index Well# Rea ' Index 1 level Adj.factor Adj.Groun wa er ... .....:_..:.. r�!'iiir 11 ;:I!;1jl;� :!iEd: .;u[Li:f:a!�� ,.r...., ,ERr.r!�DIA '. CN r: Observation Hole# ��/� /'n — Time / C J I/ Depth of Perc Time at 6" Start Pre-soak Time Q ��= 0 \ Time(9"-V) End Pre-soak l 1 Rate Min./Inch �� 21 C Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) O.(.4 Original: Public Health Division Observation Hole Data To Be Completed on Back--------- Q:HEALTH/WP/PERCFORM k 158 :.:::k'► - QI Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency+%Gravel) ®- S'' d� Ve Z "WILo�i�trsM' .'>` >`>> Depth from Soil Horizon Soil Texture_ Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. i i t� <:: <' ;i r3i - D P LR TIOL�T. :........ le# ............ ......QRS............A .....QN...................:....Q........................ .Q.. .........:...............:.......:......:...:........... ................................................................................ ... . .....................................................................:........ . Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottli (Structure,Stones,Boulderes. % Gravel) - i i ::,:...> a...�..... r''i`;`:�i!'2 iii'iii 2 .:. <:i ii:•i??<` `: as Ez2 Eli!i'`i?is>i; 2'?i >t'%iii'i ``�i, - ::..,:::,P{0:::.:.:.:. AT .SOLE G Depth from Soil Horizon Soil Texture Soil Color . Soil:.::..,. Other Surface(in.) (USDA) (Munsell) Mottling (Structu tones,Boulderes. % i FloodJusuranee Rate Mao: ..0 e. Above 500 year hood boundary No— Yes Within MO year boundary No_ Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring perviou material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification 4 y I certify that on 4V`� �J (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed b} me consistent with the required tr ' x ertise an per+ sctibed in 310 CMR 15.017. � 6,2 Signature Date `2� � FORM 30 CAW Hossss WnaaeN " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN DEPARTMENT 7 r�1 f►- , GAS ` ADDRESS �M 50y`0 TELEPHONE m Address I& 1 p � Floor Apartment No. No. of Occupants 3 Z 0-Y d _r vq No.of Habitable Rooms 6 No.Sleeping Rooms .� No.dwelling or rooming units No.Stories _ Name and address of owner � 9_j T�4_e_ `►zc>,®, 73 Remarks Reg. Vio. YARD Out Bld s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: a wl m— Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: fit/o (a✓ olw - c—Ce s, �A-. t-e&P—, I Dampness: Stairs: _r'ae.k 0 o.e,,. IF Li htin : o k STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: tf A Stacks, Flues,Vents: PLUMBING: Supply Line: 7av-- .(,v-R,44— ❑ MS LIST ❑ P Waste Line: i oc H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: %G c ,& rry,.,r -c r-cf 14 le ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom / Pantry Den N Living Room Bedroom 1 \ Bedroom 2 0 0 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: ® /(ice /®° ' Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: QQ 01,, (4A S ¢ Ce- ( Wash Basin, Shower or Tub: )S ,,,%.4ctff &-Odc Infestation Rats, Mice, Roaches or Other: o Egress Dual and Obst'n: VL - General Building Posted v& — dt-", Locks on Doors. ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) �I^ "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND4z) PENALTIES F PERJURY (, JS� INSPECTOR TITLE Cm _/VA DATE ` TIME l C y v P.M. C A.M. �11717 THE NEXT SCHEDULED REINSPECTION / P.M. R ^b. .t�� {A4w-MTV i#_� ,^V 9 410.750: Conditions Deemed to Endanger or-Impair Health or Safety The following conditions, when found to exist in residential premises, shali,be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listingis composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall.within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to'iriclud'e shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect Ve duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold,to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure.to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring-standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected fora period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as-required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. , i (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting„or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). '(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. A Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. "A g," M -v 41"'�5 "j, W m ........... V, jg,�;,g to Kgp I ",�,,,"E -mq, t g 1,04 k�)4 Q R 'kAi I�il �Y, l;. g v 0"', AM N h�A "k T, IC X v,',k"XA IT," W 0,, # o"O �41 Ir" i': o�P,�I,lo.7 o A,Aoty' It A Pgg.� M 't: -7 r '4, & P' �0, ,it "A 1� TOP OF Z� ]ON ,OUX -4 T N, 01,13 B "I"N 0/ C"l ,N 5 :�M ......... q VU �GRb W, A XI 01111"tzilllflj, F �itj!' ,I k D StIREACE,EZ___t_ GROUN -- I Z V, EL TES W k, W, '�s)AF,4," I I, Qh- N, ........... 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