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HomeMy WebLinkAbout0019 DANIELE STREET - Health Da`niele Street t Otlllt S vy � 1 rY �3k`' �i t A = `027.078'' I` f • Commonwealth of Massachusetts Title 5 Officizl Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A,•`' 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name r" information is required for every Cotuit MA 02635 7/24/14 page. Cityrrown State Zip Code Date of Inspection t r F � Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: I key to move your cursor-do not lames Ford use the return key. Name of Inspector U18Company Name P.O. Box 49 6 Company Address refam Osterville MA 02655 City/Town State t Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,`accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails V • ❑ Needs Furt er valuation by the Local Approving Authority t 7/29/14 Insp rs Signature Date The tem 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. 15ins•3l13 I Title 5 Official Inspect! n F m Subsurface Sewage Disposal ;ystem • age 1 of 17 • Commonwealth of Massachusetts W Title 5 Officia at, Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 19 Daniele Street k Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit page. City/Town MA 02635 7/24/14 �' State Zip Code Date of Inspection B. Certification (cont j, Inspection Summary: Check. "Q,B,C,D or E/always complete all of Section D ii A) System Passes: I ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or ih:310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. ` Comments: w . w4 r 11 B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. Tl e system, upon completion of the replacement or repair, as approved by the Board of Health, willpass. 1 , Check the box for"yes", "no":ofr"not determined" (Y, N, ND)for the followingstatements. If"not determined," please explain; I . 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): ti I r r . (Sins 1 3113 J Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 ,I �I 1� Commonwealth of Massachusetts w Title 5 Official) Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Daniele Street 1 Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. City/Town State ZipCode Date of Inspection B. Certification (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally.Passes (cont.): ❑ Observation of sewagel'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): i ❑ obstruction is removed El Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ;4 ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are'.replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I . C) Further Evaluation is Required by the Board of Health: 1. :. 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r - Commonwealth of Massiaohusetts H v Title 5 Officia'I`,°Inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments 19 Danielle Street c G„M SV 0 y`0. Property Address s Mimi Fowler Owner Owner's Name i information is t' required for every Cotuit MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) k f.' 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 s6p�ic tank and SAS and the SAS is within a Zone 1 of a public water supply. k; ❑ 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 septi'44nk 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: s_ **This system passes if the-well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: it i u ). If a ' 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 1/2 day flow l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 a Commonwealth of Massachusetts w Title 5 Official)nspection Form Subsurface Sewage Disposals,System Form - Not for Voluntary Assessments 19 Danielle Street Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. City/Town r State Zip Code Date of Inspection B. Certification (cont.)I..:: Yes No 4 . r' ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:1. ., ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any por.,tion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any pgftion 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 atrmgnia 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- 10,000`gpd. El ® The s,,ystem 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 neces'96ry to correct the failure. E) Large Systems: To be coln'sidered a large system the system must serve a facility with a design flow of 10,000 gpd16 15,000 gpd. u ; 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 L''� ❑ El the system is within 400 feet of a surface drinking water supply r ❑ ❑ 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"jtoany 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 3:10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 15ins•3/13 `I „ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i I Commonwealth of Massachusetts v Title 5 Official ; Inspection Form Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments 19 Daniele Street r Property Address a Mimi Fowler Owner Owner's Name information is required for every Cotult page. City/Town MA 02 635 5 7/24/14 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 f, z, ® ❑ 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? ® El 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 a's 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 al:l 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. k ® ❑ 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)) f+ D. System Information Residential Flow Conditions`, Number of bedrooms 4 4 (design):i; , Number of bedrooms (actual): DESIGN flow based on 310'CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 h' 1 y p I: r ii !Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 li `i F';1 � Commonwealth of Massfachusetts i . ; Title 5 Official, ; Form Subsurface Sewage Disposal°System Form -Not for Voluntary Assessments fl 19 D ni a ele Street Property Address Mimi Fowler p ' Owner Owner's Name information is (i t required for every Cotuit MA 02635 7/24/14 page. City/Town " State Zip Code Date of Inspection D. System Informatio:t1 Description: r ° ii. i� E: Number of current residents1 2 Does residence have a garbage grinder? ❑ Yes ® No •, t . Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) ;y . i Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No j: Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable 4 t Sump pump? ❑ Yes ® No currentl Last date of occupancy: :i y Date � r i Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310`GMR 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? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.•3/13 I� Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 r— 1. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposall!System Form - Not for Voluntary Assessments r A, 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date a Other(describe below): 1: i General Information i, Pumping Records: i Source of information: couple of years Was system pumped as paol`-t of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gal. gallons ' P How was quantity pumped determined? Reason for pumping: maintenance Type of System: ;i ® Septic tanki distribution box, soil absorption system t3 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 ofathe I/A system by system operator under contract ❑ Tight tank.''Attach a copy of the DEP approval. ❑ Other(des'aribe): 4` i . i INns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments e 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is COtUIt required for every 1' MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all cornoonents, date installed (if known) and source of information: installed on 2/20/90 Were sewage odors detected'when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: I. feet Material of construction: ❑ cast iron ® 40'Pk ❑ other(explain): Distance from private waters:supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): r ji Septic Tank (locate on site;plan): Depth below grade: 20" 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: 1000 gal. Sludge depth: 3 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts N v Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is required for every COtuit MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection D. System Information. (cont.) Septic Tank(cont.) ` Distance from top of sludge tot.bottom of outlet tee or baffle 29 Scum thickness 4 'i Distance from top of scum tol top of outlet tee or baffle 6 t, Distance from bottom of scum;to bottom of outlet tee or baffle 15 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees were present. The inlet cover was 4" below. The tank was pumped after the inspection r Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal. ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i 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: E, Date I5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts H v Title 5 Officia'I Inspection Form Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments 19 Danielle Street Property Address i Mimi Fowler Owner Owner's Name information is required for every Cotuit J. MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection D. System Informatioin (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 ;� El other(explain): N/a t Dimensions:. (' Capacity: , gallons Design Flow: it 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 pum,p,ing contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 p.: 4' Commonwealth of Massachusetts Title 5 Official ,Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments• 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection D. System Informatidn (cont.) Distribution Box (if presl.must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was normal ;i is Pump Chamber(locate on tsite plan):. 9 ' Pumps in working order: ❑ Yes ❑ No' Alarms in working order: V ;. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): iI ` If pumps or alarms are not in.working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Dis osal'S stem P y Form Not for Vo luntary Assessments 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ` ® leaching pits"' number: 1- 1000 gal. f; ❑ leaching chambers number: ❑ leaching galleries number: . ❑ leaching trenghes 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.): The pit had 3' of liquid on the bottom. The stain line was at the same level. There was no sign of failure. The cover was 20" below grade. i, { 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 j. Dimensions of cesspool ; , ' Materials of construction i Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Ft. Commonwealth of Massachusetts • W Title 5 Official inspection Form Subsurface Sewage Disposal*System Form - Not for Voluntary Assessments 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. City/Town 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.): it II. ii Privy(locate on site plan): Materials of construction: Dimensions Depth of solids i Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a r;. f` ,t i� e, i5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r:' • Commonwealth of Massachusetts _ v Title 5 Officicl Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments . f 19 Daniele Street �Ai 9 Property Address Mimi Fowler ' Owner Owner's Name information is required for every Cotuit . - MA 02635 7/24/14 page. City/Town State Zi Code • P 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 f ; i, i; f � A 3 3 2S l a ,l • 15ins-3/13 e Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 15 of 17 i� F P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 19 Daniele Street Property Address Mimi Fowler Owner Owner's Name information is required for every Cotuit MA 02635 7/24/14 page. City/Town f State Zip Code Date of Inspection D. System Information (cont.) Site Exam: t, ❑ Check Slope ❑ Surface water ❑ Check cellar , ❑ Shallow wells Estimated depth to high ground water: 45' +/- r" feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record f' If checked, date,of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) : e ® Checked with local Board of Health - explain: Using topo and water contours maps ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: l You must describe howyou�established the high ground water elevation: see above : f i Before filing this Inspection Report, please see Report Completeness Checklist on next page.' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Y' i . Commonwealth of Massachusetts Title 5 Officia;i Tlnspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Af Af Af 19 Daniele Street f Property Address } Mimi Fowler f ' Owner Owner's Name information is required for every Cotuit I MA 02635 7/24/14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist (Z Inspection Summary: A, B,.C, D, or E checked ® Inspection Summary D j: ystem 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 i ,t .i i ti 1 ' 4� p jj7 1 {I t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 . _ Gk 20739 Ps339 -MorL9507 02-15-2006 a'1 10 =09a DISCHARGE AND RELEASE OF DEED RESTRICTION WHEREAS CHRISTOPHER J. OLSEN AND CAROL L. OLSEN of 19 Daniele Street, Cotuit,MA are the owners of 19 Daniele Street, Cotuit,Barnstable County, Massachusetts 02635 (hereinafter referred to as "the Property")and being shown as LOTS 25, 29 AND 31 on a plan of land entitled"Subdivision Plan of Land in Barnstable (Cotuit),Mass. for James and Muriel Downey Scale 1" = 100' October 2, 1973"which plan is recorded at the Barnstable County Registry of Deeds in Plan Book 280,Page 25 WHEREAS CHRISTOPHER J. OLSEN AND CAROL L. OLSEN as the owners of said land and the TOWN OF BARNSTABLE BOARD OF HEALTH have agreed to remove the restriction as to the number of bedrooms which can be included in any home built on the Property. The Property contains a four bedroom septic system which passed inspection on 1/10/2006 in compliance with 310 CMR 15.000 State Environmental Code, Title V,Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and the Town of Barnstable Code. Said Title V official inspection report is on file with the Town of Barnstable Board of Health. WHEREAS,the deed restriction referred to above was recorded with the Barnsatble County Registry of Deeds in Book 16663, Page 199 on 3/31/2003 @ 2:03 p.m; and WHEREAS by signing below,the Town of Barnstable Board of Health agrees with the Discharge and Release of Deed Restriction to be put on record with the Barnstable County Registry of Deeds;now THEREFORE, CHRISTOPHER J. OLSEN AND CAROL L. OLSEN& the BARNSTABLE BOARD OF HEALTH does hereby remove the deed restriction recorded at the Barnstable County Registry of Deeds in Book 16663,Page 199. PROPERTY ADDRESS: 19 Daniele Street, Cotuit,MA 02635 r+ t Bk 20739 Pg 340 #9507 EXECUTED as a sealed instrument this 67 day of February,2006. 7 4 CHRISTOPHER J. OLSEN a/k/a Christopher Olsen CA OL OLSEN a/k/a Carol Olsen COMMONWEALTH OF MASSACHUSETTS Barnstable, ss: February ,2006 Then personally appeared the above-named CHRISTOPHER J. OLSEN AND CAROL L. OLSEN who proved to me through satisfactory evidence of identification which was/were drivers license(s), to be the person(s)whose name is/are signed on the preceding document and acknowledged to me that THEY signed it voluntarily for its stated purpose. dAj Notary Public: My Commission Expires; •� .,•,•I,,rt e Bk 20739 Pg 341 #9507 EXECUTED as a sealed instrument this _TthL day of February, 2006. TOWN OF BARNSTABLE BOARD OF HEALTH r a By: Its: COMMONWEALTH OF MASSACHUSETTS Barnstable, ss: February ,2006 Then personally appeared the above-named fkl' 4 J r I I►� � , its who proved to me through satisfactory evidence of identification which was/were drivers license(s), to be the person(s)whose name is/are signed on the preceding document and acknowledged to me that HE/SHE/THEY signed it voluntarily for its stated purpose. 0 0 0 Notary Public: My Commission Expires: ,,,,$eal , S 10 •��� •'�"��rHNN��N BARNSTABLE REGISTRY OF DEEDS - _ tIQP"At c� O 4 LOT 24 LOT 28r i. tu 617 68645 SF (TOTAL) i J . CO Yal LOB' 3o tlsG � Q CEi?TIFIED TO: CAPE CAD FIVE CENTS SAVINGS BANK Rocs[ isa as t--aetatetnrred by ate a m (z not ncaauct:rs--h"y 1lntH dpr-i(jva Plana are om"ad by RLSO andtar a vmdicat ooartroi Y pelt m jd.p—h-eons canna be datesmkja L asgoa tasaO7e r N�i.��° t„ tdtasoe km . rnb x , 1 Via" m ey >L .atd oas - _JotsUnd an ca >A" �� he „ �z�resat 1Mbw alum 2ft Pm ma�tpt Lwo"rid r�K L CA mm of 40-A or dead- ���-bs sgb�eat x aut-ao(.ti saoNaeFa and siWtti _ asedh::of"Mad and PWMPNMs l�s to?aad or tras+raua aod� t 1�de>trtaed 093 Mum �. rsz ,m,ny� sod f` COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM FORM PART A r s �v ry CERTIFICATION s tT Property Address: 19 DANIELLE ST COTUIT SZ- Owners Name: OLSEN —« O9/JOwners Address: Date of Inspection: 1/10/06 Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:P•O Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Falls Inspector's Signature: Date: 1/10/06 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Revised on 10/31/2000 Page 2 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information winch indicates that any of the failure criteria described in 3 10 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: at this time system MEETS NfINIMUM PASSING REQUIRMENTS B. System Conditionally Passes: one or more system components as described in the"Conditional Pase' 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 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 distribution box is leveled or replaced The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 C.Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone I 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 19 DANIELLE ST COTUTT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 D.System Failure Criteria applicable to all systems: You must indicate"yes or no to each of the following for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped — X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 3 10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or no to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — 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 11 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''m 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 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 19 DANIELLE ST COTUIT Owner: OLSEN Date of Inspection: 1/10/06 Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant,or Board of Health — X Were any of the system components pumped out in the previous two weeks ? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X Were all system components,excluding,the SAS,located on site? X _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X Existing information. For example, a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3 ))(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection. 1/10/06 RESIDENTIAL FLOW CONDITIONS j Number of bedrooms(design): 3 �O�` ( gn): Number of bedrooms(actual):�y 2f�� �//'' DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms). ' �/ �0 Number of current residents- 0 1 d Does residence have a garbage grinder(yes or no): NO �IAO . a` f Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] AlJ�rQ Laundry system inspected(yes or no): NA � , Seasonal use: (yes or no): NO O q Water meter readings,if available(last 2 years usage(gpd)): OS'- 7'/,,Coo Sump pump(yes or no): NO Last date of occupancy: NA COMMERCIAL/INDUSTRIAL: Type of establishment: ° Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): 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/use: OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: 2 20 1990 JOHN A AALTO Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 BUILDING E S WER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: 12" Material of construction: X concrete_metal_fiberglass _polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: 1000 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 'TRACE 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: WOODEN POLE Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- TANK LOOKS STRUCTUALLY SOUND AT THIS TIME COULD USE PUMPING GREASE TRAP:_(locate on site plan) Depth below grade:_ 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): 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.): 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 pumps and appurtenances,etc.): r Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 SOIL ABSORPTION SYSTEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: Cr leaching chambers,number: 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.): P IT DRY AT THIS TIME STAIN LINE ABOUT 4'FROM BOTTOM 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 or 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.): f Page 10 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection: 1/10/06 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 sup ly enters the building. Sf8 �y Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM } INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN \ Owner's Address: Date of Inspection: 1/10/06 SITE EXAM Slope: Surface water: Check cellar: Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: II/24 BGOK-6987PAGE 061 6341-9 I, JOHN. J. Drm-AHW, Trustee of DELANEY REALTY TRUST, under Declaration of Trust dated May 3, 1984 and recorded with the Barnstable County Registry of Deeds in Book 4101, Page 47, of 38 Evelyn Circle, Barnstable (Centerville), Barnstable County, Massachusetts 02632 for consideration of FIFTY THOUSAND AND 00/100 ($50,000.00) DOLLARS paid, grant to j L. CHRISTOPEOP'OLSEN and CAROL OLSEN, husband and wife, as tenants by the entirety, both of Nine Surf Drive, Mashpee, Barnstable ; County, Massachusetts 02649 1 the land, together with the buildings thereon, situated in Barnstable (Santuit), Barnstable County, Massachusetts, more particularly described as follows: 4 Being LOTS 25. 29 and 31 as shown on a plan entitled "Subdivision Plan of Land in Barnstable (Cotuit), Mass. for James and Muriel ' Downey Scale 1" = 100' October 2, 1973" which plan is recorded at the Barnstable County Registry of Deeds in Plan Book 280, ' Page 25. i • t Subject to and with the benefit of all rights, rights of way, j reservations, restrictions and easements of record insofar as the same are in force and applicable. ' I, John J. Delaney, hereby certify a y, y that I am the sole Trustee Y s ee of Delaney Realty Trust and that I have been authorized and j directed by all of the beneficiaries of said Trust to execute !! the within instrument and that said Trust is still in full force s and effect and has not been amended. For title, see deed recorded with Barnstable County Registry g of Deeds in Book 4700, Page 203. 1 WITNESS my hand and seal this day of 157"16& 1989. ' DELANEY REALTY TRUST � VD EX� BY:- fires i 1 4 010 i J. ELANEY, TRUStEi es.�onzv COMMONWEALTH OF MASSACHUSETTS Barnstable, ss: 7C�r.s,r 1.1, 1989 Then personally appeared the above-named John J. Delaney and ' acknowledged the foregoing instrument to be his free act and deed as Trustee of Delaney Realty Trust, before me NOTARY PUBLIC My commission expires: �wn.d1� 14 a3 l I i I { t I i a J µ I 1 Y 1�( j i L t BOOK 6987pw 062 . I i r r. O LJ CORE DEC 13 89 I , 4 i i � s f I . ARPJS i"Af3L,k COUNTY REGISTRY OF DEEDS. A TRUE COPY,ATTEST JOHN F.MEADE,REGISTER j J 1 X 0 13-31-21 103 a .0.2 : a;3P DEE D RES TRICTION TRi CTION I WHEREAS, / ' n. � �r Cn GYM of (owner`s name) MA (address) .is the owner of P �'� C� - ' '[CA. located (address) MA (hereinafter referred to as and.being shown on a plan entitled "Subdivision of.Land in m r:w;ourrf� MA, Property of JcAu A RE).J9 , et al, duly recorded in Barnstable County Registry of Deeds in Plan Book Asa Page, 45 .SUB.,��V15t 01►� ��`3a8 Or on Land Court Plan Number WHEREAS, cNR►Z0262 t CA96-L 00N 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 included:in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Bamstable Board of Health, as a pre-condition to granting a disposal works construction permit 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 the lot be put on record with the Barnstable County Registry of Deeds by recording this document, deedr r Bk 16663 Ps 21 ii a NOW, THEREFORE, CPR;;-rM4-- 9 (44c�l. Bi.St~x' does hereby place the (owners name) 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: 1. 19 n.Q u-i�i r 7"i" Crt.tjrr- .� G may have constructed (address) upon the lot a house containing, no. more than riR (3) bedrooms. �N�1 fi� �►> �r,st, +�aQ�z o�sru agrees that this shall be permanent deed (owners name) restriction affecting '. q 2 located on+9 1�t LE-, c'a�-u�T MA, and being shown on the plan recorded in Plan Book and. , Paged 25 Or on Land Court Plan For title.of 19 9A> ~ 5-r seethe following deed: Book 69€�77 , Page r Lad ourt C 'ficate of Title Number Execute as a eaf d ' u nt day of l s'g ., re O n r Owner's s Hat :re ` ° >� Z �4 M Owner's signature o r r-t �Qm COMMONWEALTH OF MASSACHUSETTS >do C nCP M i ;IJ Then p s nally ap eared t;e ab ve-131M. known to me to bethcfperson who executed the foregoing instrument and acknowledrmd the saris be =5 free act and deed, be re me, Notary , I u I 4 My commission.expires: (date) NOTARYPUBL[C VVIMMMSSIONEXPEBS.13,M. , deedr BARNSTABLE REGISTRY OF DEEDS Stanton, David To: (Colsen@barnstablefire.org) Subject: Septic inspection Good Morning Chris, I met with Doug Brown this morning. We probed the stone surrounding the leaching pit, and it has the leaching capacity for 4+ bedrooms. Doug updated his inspection report to show this. I also signed the inspection report as I witnessed it. The property can't have more than 4 bedrooms because of local regulations. I stopped by the fire station, but they said you were at a meeting. I have a your copy of the inspection report with the update. If you are going to be at the fire station this afternoon, let me know, and I can drop it off while I'm out that way doing septic inspections. Or, if you want, you can stop by the Town offices between 3:30 and 4:30 today. Now all you need to do is get the deed restriction discharged, and you are all set with selling the home as a 4 bedroom home. Thanks, Dave 1 r: at op 41i r� •�. y. C �1 r Ln met '' ANY Y•� i �• ♦. ter^ �� IL lti� r n 1 r � t `�1 :b'�4�`���':.�p , , t '���,,.�. art• •' � .�,/! ` •y •!`}r��.`' kh ��� ,f�� .�:� °'. ���...jjj/// A� ice• � � Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 19 DANIELLE ST COTUIT Owner's Name: OLSEN Owner's Address: Date of Inspection. 1/10/06 FLOW OWN �N 197 •2 RESIDENTL,L � N : nS e �l Number of bedrooms(design): 3 Number of bed s(actual): DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): : Number of current residents: 0 Does residence have a garbage grinder(yes or no): NO (1 Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] 9 Laundry system inspected(yes or no): NA 1 -t2'O 6 Seasonal use: (yes or no): NO ®v- S-c"orpo l JA G Water meter readings,if NO available(last years usage(gpd)): Q, ' 7°// Sump pump (yes or no). ip Last date of occupancy: NA jr � . COMMERCIAL/INDUSTRIAL: Type of establishment: I ���,,' �r�. Design flow(based on 310 CMR 15.203): gpd tot 6 X 7 Basis of design flow(seats/persons/sgft,etc.): 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): _ V 3�p '76 Gt lwv C/4 Water meter readings,if available: ti Last date of occupancy/use. ,(� OTHER(describe): )I GENERAL INFORMATION //�1 I Pumping Records o� Source of information: Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: 2 20 1990 JOHN A AALTO Were sewage odors detected when arriving at the site (yes or no)? NO Leac�,t P%� c, jcu jA► 'o j 17 f k�YMd"Cl /1Jf7s �n V2r ' 0 c E �1n r 3 r?' p &v 0 !c IG0000 0 v0 C ®Gc 0 r' I x r x h X S P sa�P 78, S_ S 1 7 qq cP �xG C, x wf a SAU?e CAM . x y� 5-0 �.��� �6zXY _ _ T Y'Y 'f �2C3 ►y)x � x y X�.� 31Y 3 ?2-5 �,) `5 tl //-5, 2 ---111 w ter; - ��VVVF# 2 Mai "- `r 9 f z.}pry' ` �yF }' Pul - OR- �2w MOO ri E r a& MIMI R$zu'E,__a -� ,E � 3QU#0 O.�S 308�544 � " .., raiR -70y € 1 ..; 32 ,r a EE l �€ A%MN � �6 (� �6 ZI €HR�`ER €'�"... 'n �,.%slt�. -- ,e�/ �€� y � ram- 4� 3O80V8`'. E S #56 h � $ MM 3.08065 073 D�� 1 592" E N;• "` ' `� 08061 -'`� �.. �-3#600� ��``� .. EE . E - ZN � 308066 #606 F 1 � i rflG Rai . P� , �•••>k5Dp �WW fiA � U3 �i �-� r� � z�, �r� �� d- _ a �„� • � � � DOCK v/asw/+.TJ. -/ 38'•p.. lo:le' 26'-0" W.o" 38'-O" Wo.. �"' , , _ �[4uHnR �yTov�'I OW 0 a[u• [yur[I.F_ - !/ •^'+ eN JLV 34 sr• as w�,.i} wce;IN I 2�6 �/1. � � ��f�ll - . � - 1•urP a � ' wOkAGk w - L"YHLL P I0A17` •� a o' sxe ive5' `"'�[HEr.) .%.. _ .:O LIr�WG ROOM TL N L'AT71 1 r 11 Ws� 7/L V � .I GAM ... _ . OH.yf0. O 'AL - 1 _ aZ. l` 1 9 V co lIN oN fWAIL / S FFurve FUN[f - '{a/t." 12'•0•. CIO. ',k J!I ilAY4/ 1 � AteA .�. IL•.b" p . STUD/ .1 o BEDROOM o m IL HALL I MiN _ —� 1 -- C ' _ •Hr/u I I— -- BEDRooM q�(�p 'oa/1a:ADs LIVWGRDOM IR•!' IY•-O" d .I 33 u o ly'A IL IL O 0 2442 0 1 ^ t44Y fry 'AND.VFAe./ 6m 2E Mi M�_ IiYYI _ q 1 9HrF VO/.CH 6 c Ylua 6.B' 2 H1L eEAmS FAMILY UOOM CATVLUf.AL a." 1:_ O .l 13 I /u.ocf veNr O Cf I LING • h 4 1o'IL SECOND FLOOR 1/q"= 1'-O' - Arr—K.goo i4 FT - A.nIN TD CTCWa AFWf, -El R ST FLOOK V i 1 p ,. AvVA.. 12•.0�.A,Fr• ~ CUSTOM CfwC 'w/.PO(.'CN OL5EW CHRIS x CAROL . - v.Lnlu.'c:y �17v-G793 TOWN OF BARNSTABLE 1.0 TION S T SEWAGE # �� VILLAGE ASSESSORS MAP & LO Z-7 `716 INSTALLER'S NAME & PHONE NO. f SEPTIC TANK CAPACITY / 'O po C LEACHING FACILITY:(type)` �, f (size) z� X NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER �� ,c BUILDER OR OWNER ��1 j_S (`/ He Vl _ DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: A , VARIANCE GRANTED: Yes No a " - m No.--���1-_4i6 / Fps............................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........ .......... ................OF......................................---.--•-----............------...................... Appliration for Bispasal Works Tijustrnrtinn ramit Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal System at: Gp�v'_ ................_.... ...6r..---:.... .. --•• - ...f w...6K.26' Location-Address < or Lot No. .......a&0 Ql".61E4.......................... ...............aAN.t9 ....:2r..................................................... ` Owner Address a �►^' ..... ►5.0..9��t �z..51 MM...c2--U Instai'er Address UType of Building CAPE Size Lot...?$.V_6a!f5�......Sq. feet Dwelling—No. of Bedrooms............. ...........................Expansion Attic (✓) Pbo Garbage Grinder ( ) a Other—Type of Building V9oD1�1N61�FAth-No. of persons............I.............. Showers (2 ) — Cafeteria ( ) Other fixtures ....may`J°RY-------------------------•---- W Design Flow........_°ta!�..........................gallons per person per day. Total daily flow...............3 3.0............--......gallons. 1:4 Septic Tank—Liquid*capacity.)®Or O.gallons Length................ Width................ Diameter.---.....---.... Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. ¢` Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...►4..4.i5tl.!•!d_11A.a :i.1.C9At1,01J......................... Date..-.. ........... Test Pit No. I......Z.......Omutes per inch Depth of Test Pit......lk ..... Depth to ground water----------------_-.-.. Gza Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......-----........----. --••-------------------------------•------------------...........---•--•----................................-•------•-•-----...--------._.........---....--- 0 Description of Soil.......;-9D.---S4Mg.....( M.Vgl....................................................................................................................... ---------------------------------------------------------------------------------------•--•-•--....-----•-----------------------------...-----------.......-•------...-•----------------•---..:---•----- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... •------------------------------•--••---------------------------------------•-••--------•----•---•-•---•---.....-------------------------------•----------------------------------------............-•-- Agreement: The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with { the provisions of'-,T :�5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee • u by the board of kealth. ed........... --•-...... --------------------------------•-----•-•----.---•- ----•-......--------.._......... ate Application Approved By................._ .: r ���_. Date Application Disapproved for the following reasons-------------•-•---------------------------------•-----------.....--•--...-•-----------------•--••------•--••••- .._........................................................-........................................................................................................................................... �J Date Permit No.......... .......... 1647. Issued..................... ` L� _Q ............. ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................0 F.......................................................................................... ApplirFa#ion for Disposal Works Tonstrnrtiun rumit j Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...................... _st:...----•-------------.....•..-•-•-._..... ................ .._.. •- Location_Address or Lot No. ......................QN 1 o ER _.. oL_•o SE! ................:............... .................. .............................................. Owner Address W J©�1N..1tflLTQ..._._._.. -•--_..:. ! o..W,4�,�uT.sT:_..!L.VdF-)9.*TAfi�£..MA._..0266S-------- ,-� -----...----•••--••-•-•..._....--•- -...._U Installer -! Address Type of Building CAPE Size Lot..... .$..(oA5......Sq feet �-, Dwelling—No. of Bedrooms.............. ............................Expansion Attic ( V) go Garbage Grinder ( ) aOther Other—Type of BuildingWQo1?/S)Wj.C_.fAJb No. of persons_...._____`f_______________ Showers (2 ) — Cafeteria fixtures ....Lr4uA%Pf�Y ----------------- W Design Flow..................q.:5...............__gallons per person per day. Total daily flow..................3.Q_.................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed .......................... Date.... ............... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix .-------•--•---------------------------------------------•-••---...-•---...---••••-••----•-••-----•----------------- •------------------ •----- •---•------•---- 0 Description of Soil........................................................................................................................................................................ x U -------•---••••-••••---------•..............................••------------•-•--•---•••••-._....--•....-••--------••----•._.......--------•---•••-•••---•----••----------._....--------------------_.._.. w x U Nature of Repairs or Alterations—Answer when applicable............................................................................................... --•---------------------------------------------••-•----------------•-••------..._._._..---•----.......-•----•-•-----------------•---------...----••••-------._...__....----------•---••••--•--••---•-•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee s d by the b and o health. Si ned- .. 2 ---•--._.... -----•...............•--•- -•--- - -=---- -----Application A roved B - - rtS` ' PPPP Y ....................................................•- --- Date Application Disapproved for the following reasons_....................................................... ...................................................... ............................................... -•----------....-----•--....------................................................................................ --•- .............................No..............& -`•-----___-` -•=-- Issued.- 1113 —`> D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ar ....................OF'.................... N........... . ............. C�rr#ifirtt�r of (�um�rli�anrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) b ................. S � .�. b ---.......-•-•----•--•--•---•----••-•- Ins 1 er j has been installed in accordance with the provisions of TITLE 5 he State Sanitary Code s des ri the application for Disposal Works Construction Permit No.- .........................__________ dated__..__._...�. _ r �J'�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUAR NTEE THAT THE SYSTEM WILL FU TION SA SFACTORY. - RDATE. -- Inspect = THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH CN -1 ................. OF................ - �7 No......................... FEE........................ irrr �al rks,,, rnr##irrn rani# Permissionis hereby granted...........-----•---------^.............•-................................................................................................... to Construct_ for Repair ( f,)� n Indivtd� Sey 1 f�oj system ..Cii' �` Street ? as shown on the application for Disposal Works Construction Permit No_____________________ Dated.......... .......................... ---.....--•-•------------------•---•---------•-•--------•-------..------...---...----..............--•-- Board of Health DATE........................................................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS i . ''I��{r., i; /U 2ta ,p� �r. r; •ii /l`(,i%r %1 N.4GARZA&t .Ge:0DER_ C�i 4 FL; wi33`0 G. P. p. CNr��` T'. -i` _t ►-t f �EPTI� TANK." .336 '. 15o "4Q5 G.P.O. L ^� j' si=r S PA6-AL. -S l 0• �00 r- . 37 r C3-.P. 0. i.�..: go7T•o ly ':t AR.l�A � So S.•F. .. ' 6:1K1,. 4 Z.5' Q-.P• D. 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