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Home My WebLink About0038 HIGH STREET - Health CO-LIlt -- - --- - -- - - - A= 035 -047 - - - - - . - `� i I AsBuilt 'Page 1 of 1 �1. !k9)Sdt -'TOWN OF BARNSTABLE LOCATION SEWAGE # °56 0 j: VILLAGE �2, 11�� ASSESSOR'S MAP G LOT INSTALLER'S NAME 6T PHONE SEPTIC TANK CAPACITY �� LEACHING FACILITY:(type)�o� �0} NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: , / D DATE COMPLIANCE ISSUED: r VARIANCE GRANTED: Yes N y i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=035047&seq=1 2/8/2018 Property Address: 38,High Street, Cotuit, Barnstable County, Massachusetts DEED RESTRICTION WHEREAS, Eric J. Cederholm and Sara Mycock Cederholm of 44 Chadderton Way, Middleboro, Massachusetts, are the owners of 38 High Street, Cotuit, Barnstable County,'Massachusetts, hereinafter referred to as "the Property", being shown on a Quitclaim Deed recorded in the Barnstable County Registry of Deeds in Book'30995,Page 313; WHEREAS, Eric J. Cederholm and Sara Mycock Cederholm as the owners of the Property have agreed with the Town of Barnstable Board of Health to a restriction as to the 'number of bedrooms which can be included in the accessory dwelling on the Property as a pre-condition to obtaining a building permit for the renovation of the existing accessory dwelling; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition of granting a building permit for the renovation of the existing accessory dwelling is requiring . that the agreement for the restriction on the number of bedrooms in the existing accessory 1 dwelling be put on the record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE, Eric J. Cederholm and Sara Mycock Cederholm do hereby place the following restriction on the existing accessory dwelling on the Property in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon on all successors in title: 38 High Street, g Cotuit, Barnstable County, Massachusetts may have constructed upon the property an accessory dwelling unit containing no more than two(2)bedrooms. Eric J. Cederholm and Sara Mycock Cederholm agree that this shall be a permanent deed restriction affecting the accessory dwelling unit located on 38 High Street, Cotuit, Barnstable .County, Massachusetts and being described in Barnstable County Registry of Deeds in Book 30995, Page 313. For title of Eric J. Cederholm and Sara Mycock Cederholm see Barnstable County Registry of Deeds Book, 30995, Page 313. 1 Executed as a sealed instrument L_L� day of June 2018. Eric J. Cederholm Sara Mycock Cederholm 2 f COMMONWEALTH OF MASSACHUSETTS BARNSTABLE;ss On this ;-9 'of June 2018, before me, the undersigned notary public, personally appeared Eric J. Cederholm and Sara Mycock Cederholm, proved to me through satisfactory evidence of identification, which were Lj Q-- ,VA-X.S , to be the person whose names are signed on the preceding or attached document and acknowledged to me that they signed it voluntarily for its stated purpose. JENNIFER DALTON ¢ Notary Public COMMONWEALTH OF MASSACHUSETTS My Commission Expires March 23, 2023 BARNSTAB F REGISTRY OF DEEDS John F, Meade, Register 3 i RECEIPT Printed:, July 13, 2018 @ 9:48:58 RY OF BARNSTABLEOHN F UMEADEEGIST REGISTER DEEDS Trans#: 178782 Oper:JUSTIN JENN Book: 31400 Page: 261 Inst# 33866 Ctl#: 227 Rec:7-13-2018 @ 9:47:52a BARN 38 HIGH ST DOC DESCRIPTION TRANS-AMT 1 CEDERHOLM, ERIC J RESTRICTION 10.00 County Fee $ 1$ 0- 20.00 Surcharge CPA $20.00 40.00 State Fee $40.00 5.00 Surcharge Tech $5.00 -- -- Total fees: 75.00 � * Total charges: 75.00 CHECK PM 119 75.00 AsBuilt - Page 1 of 1 TOWN OF BARNSTABLE LOCATION ' /` SEWAGE # �1U— 3l�O VILLAGE (> ASSESSOR'S MAP LOT INSTALLER'S NAMEA PHONE NO. SEPTIC TANK CAPACITY /�2 Q 0 0/"c r LEACHING FACILITY:(type)( U ;pa (size) / NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER / BUILDER OR OWNER Cn v e. '` 1d� C` DATE PERMIT ISSUED: Q DATE COMPLIANCE ISSUED_ f✓f •��xLq-a VARIANCE GRANTED: Yes No r q t • /�.��.TSB i. I i http://issgl2/intranet/propdata/prebuilt.aspx?mappar=035047&seq=2 2/8/2018 • ,.. - ;� C®¢•nononwealth of MassilIchdsi etts t Q35_ D om' M k u Title 5 Official Inspection Form K. o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 High st Property Address William Crocker Owner Owner's Na e information is d7 required for every Cotuit M'a 02635 1/22/16 page. City/Town State Zip Code Date of Inspection 110+ 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 A. General Information filling out forms on the computer, use only the tab Ins, cnt key to move your p • ect-�•.- cursor-do not Michael DiBuono use the return key. Name of Inspector _ _ DiBuono Sewer and Drain Company Name — 8 Johns path Company Address — �� S Yarmouth. Mpg,. ...._ .: 02664•,.. City/Town State Zip Code 508-364-9587 SI13522 " __ Te lephone hone Num ber'tuber 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 [j Needs Further Evaluation by the Local Approving Authority 1/25/16 "Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 r t Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form- Not for Voluntary Assessments. 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 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: Z i have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated,are indicated below. Comments: The system contains three cesspools and a 1000 gallon leach pit in series. There is more than addaquit leaching available throughout the entire system. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 . Commonwealth of Massachusetts W Tithe .5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotult Ma"'"' 02535' 1722/16 page. Cltyrrown State Zip Code 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-(cunt.): ❑ -Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑` distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of.Massachusetts W Title 5 Official Inspection a _ Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit va-, 02635 ""' 1/22/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, _.safety and.environment: . ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance:.., — **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® 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 '/z day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts mTitle _5 Official Inspection ®gym Subsurface Sewage Disposal System Form -Not for Vol u nta ry.Assessments °M 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Nf2" 02635 1/22/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping,more than 4 times in.the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: `® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. Er ® Any portion of a cesspool o 1.r 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 DEED certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of- Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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 Y ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 f Commonwealth of Massachusetts Title 5 'Offlcial 'In ' spection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 38 High st Property Address William Crocker Owner Owner's Name informat ion is re uiredfor e ve ryCotult Ma 02635- page. City/Town 1/22/16 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 -E ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ 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? El ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 1.5.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official InspectionFormit Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02535 "" 1/22/16 page. City/Town State Zip Code. Date of Inspection D. System Information Description: The system contains three cesspools and a 1000 gallon leach pit in series. There is more than addaquit leaching available throughout the entire system. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?.(Include laundry system irfspectibn'" information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 118 GPD Detail: Sump pump? El, Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W -:.`Title 5 Official Inspection ®r a p Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c� 38 High st M yray`'v Property Address William Crocker Owner Owner's Name information is - required for every Cotuit Ma 02635 1122/'16—' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Othe.r...(describe below): General Information Pumping Records: Source of information: Owner pumps every two years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Cesspool acts as septis tank t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title -5 .Official lnsecti®n Ford Subsurface Sewage Disposal System Forum - Not for Vol untary.Assessments 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635' 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if.known) and source of information: 20 + years Were sewage odors detected when arriving at the site? ❑ Yes ❑" No Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank(locate on site plan): Depth below grade: 1 ft 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: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form - Not for Vol untary.Assessments M 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge.to bottom-of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee-or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations,-'inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to,top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: -Date t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 �� LAh Commonwealth of Massachusetts . : . Title.-5 Official Inspection-Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `M 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma" 02635 1/22%16 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.): Tees are in place and levels are normal. 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): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes ❑ No Date of jast pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 f Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 C` l I Commonwealth, of Massachusetts Title 5 official Irspecti®n FOrm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,••'' 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit M8"" " 02635`" 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth_of.."liq.uid,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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If or alarms are n pumps of In working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title- 5 Official., Inspection Forte Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 38 High st Property Address William Crocker Owner Owner's Name information is required for every M ""'"" ' COtUIt 02.635 1722/16 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ®,. .. leaching pits number: 1 ❑ leaching chambers _ number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: El 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.): No signs of carry over and no signs of hydraulic failure Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 3 in series Depth—top of liquid to inlet invert dry Depth of solids layer dry Depth of scum layer dry Dimensions of cesspool 3 6x8 Materials of construction Block Indication of groundwater inflow ❑ Yes ® No t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 �, L �► >L Commonwealth of Massachusetts u W Title 5 Official lnspecti®n F®rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments- °M ,•''v 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. City/Town State Zip Code Date of Inspection- D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydraulic failure Privy (locate on site plan): Materials of construction: Dimensions Depth of solid s ds Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 ®fficialInspe lion Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma— 0263S`" T722116 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties'to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below drawing attached separately Sy gq `0. -S r \ 0 i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts . . W - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °� >••''� 38 High st Property Address William Crocker Owner information is Owner's Name required for every Cotuit Ma 02635""` 1122/'16'" page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope,. . . .. ® Surface water El 'Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water,elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Property sits well above closest body of ground water. 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 r Commonwealth of Massachusetts W Title 5 ' Offlcia-1 ,Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 38 High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma' 02635 1/2211'6 page. Cltyfrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection.:Summary D,(SystemTailure Criteria-Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ET Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 _' Commonwealth of Massachusetts b�� .H W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 High st -- Property Address " William Crocker... • --.. Owner Owner's N a a , information is required for every Cotuit 7 Ma 026,35 1/22/16. _ page. City/Town � - State Zip Code Date of Inspection Inspection'results must be submitted on this form. Inspection forms may not be altered in an-Tj way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms # 1139 on the computer, ' use only the tab 1. Ins-ector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Q Company Name 8 Johns path Company Address Br� S Yarmouth MA 02664, t, -,fCitylTown State , '=Zip Code -',..508-364.-9587 SI 13522 ;0jTe1ephone 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.-- Needs Further Evaluation by the Local Approving.Authority 1/25/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving'authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �D �S Y. 1 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of a single 600 gallon leach pit. at time of inspection level in pit was 32 inches below invert. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is ;petal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failures in-iminent. Systern"wiil pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): } t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. Cityrrown State Zip Code 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 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 El ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain.below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions.exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system.has a septic tank and soil absorption system (SAS).and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent'and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M •'y M A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR'15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. z E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"'to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in.the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on.- 0 ❑ Existing information. For example, a plan at the Board of Health. E ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information - Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN.flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For* Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'' 38 A High st Property Address William Crocker Owner Owner's Name information is COtUIt required for every Ma 02635 1/22116 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of a single 600 gallon leach pit. at time of inspection level in pit was 32 inches below invert Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ .Yes ® No Water meter readings,-if available (last 2 years usage (gpd)): 158 GPD Detail: Sump pump? ❑ Yes ® Np Last date of occupancy: 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: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotult Ma 02635 1/22/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner pumps every two years Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption.system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•°'� 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma _02635 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 + years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): ; ` Depth below grade: 18"feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank (locate on site plan): 1ft Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon , If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24° Scum thickness 3,. Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. .Grease Trap (locate on site plan): Depth below grader NAfeet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 b Commonwealth of Massachusetts H u Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 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.): Tees are in place and levels are normal. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: Q Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At normal level 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.): f ' Distribution Box is level and at normal level with no signs of carry over or decay. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If-SAS not located, explain why: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): No signs of carry over and no signs of hydraulic failure. } Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 33 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 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.): No signs of ponding or hydraulic failure. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts i v Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below 0_drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 1/25/2016 Assessing As-Built Cards f 4 l:01//-"' TOWN OF BARfNSTABLE LOCATION / / SEWAGE # J o r VILLAGE V ASSESSOR'S MAP /& LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 00 'C LEACHING FACILITY:(tgpe) Co NO.OF BEDROOMS_PRIVATE WELL OR PUBLIC WATER WATER BUILDER OR OWNER U E' � DATE PERMIT ISSUED: D DATE COMPLIANCE ISSUED��d��9d VARIANCE GRANTED: Yes No i 17 hUp://www.townofbarnstable.us/Assessi ng/H Mdisplay.asp?mappar=035047&seq=2 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 A High st Property Address William Crocker Owner Owner's Name information is required for every Cotuit Ma 02635 1/22/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high.ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Property sits well above closest body of ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ' Commonwealth of Massachusetts H v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 38 A High st Property Address William Crocker Owner Owner's Name information is COtUIt required for every Ma 02635 1/22/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information-- Estimated depth to high groundviyater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file !Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I ( i TOWN OF BARNSTABLE Approved: Z BOARD OF HEALTH — MLD Ceff: ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date o Time: In 2�� Out 3 D,a Owner C L.A e. C 2oc,4 g:2. Tenant A y(, &o y Z A, Address Pu &v>t 2 '1 Address Cb-Tug. V,.-A 0Z(-o Co-TvOZ63A Compliance Remarks or Regulation# Yes O Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 0 O 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal ly-C 16. Sewage Disposal 93Z t VA--[. 17. Temporary Housing /Vx- 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; �� Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (Tqq Person(s) Interviewed Inspector - If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE Z��✓6� BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 2' 0 Time: in ' Out Z 30 .) " / r Owner C L Q 19-C C. iloc,,x f 9- Tenant PA UG �;c7 r Address 1 n b Address 35 u 1 a kA S-T • f C o c yo„j v�n/k 0 ZCo 3 s Co-r u i�� M O Z 6 3 S Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities �✓ ' 000 6. Heating Facilities �L /:i yW 7. Lighting and Electrical Facilities ✓ 8. Ventilation r 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits l' 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal ✓ — "�/A brt 16. Sewage Disposal t/r PIZ 1 VA"rt 17. Temporary Housing AIX 18. Driveway Width 19. Number of Tenants Observed r PART II 37. Placarding of Condemned Dwelling; RVA f4 k., Removal of Occupants; Demolition 5 i Number of Bedrooms Z A/6 Number of Vehicles Allowed (max) Number of Persons Allowed ( a}) � „ Persons Interviewed Inspector - A ' ✓v f If Public Building such as Store or Hotel/Motel specify here . s ,% FORM30 CH W HOBBS&WARREN TM THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH CITY/TOWN W P I m` D PARTMENT _ ADDRESS GSM SV O�`0� TELEPH NE Address — Occupan Floor Apartment No.of Occupants No.of Habitable Rooms No.Sleeping Rooms No. dwelling or rooming units No.?Vries Name and address of owner Cy{�•( Remarks Reg. Vio. YARD ut Id s.: Fen es: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls.- Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 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 Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: I S General Building Posted 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) "THIS INSPECTION REPORT I G ED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR TLE DATE TIME A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is 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 11, 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 include 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 the 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 for a 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. (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. (P) 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. � ti �� 3 � 1'nS4ec dc� FORM30 C&w HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H A H CITY/TOWN W �( DEPARTMENT ADDRES J (� Cl t� 4�M sey`0 b G TELEPHO Address �_� ��_�"" _ Occupant Floor Apartment No. No.of Occupants , No.of Habitable Rooms .S No.Sleeping Rooms No.dwelling or rooming units No.Stories Name and address of owner _ 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: Roof �"— 4: Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Liqhting: Ell STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Su ply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 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 Living Room Bedroom 1 , Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation . Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted + 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) "THIS INSPECTION REPORT IGNED AND CERTIFIED UNDER HE PAINS AND PENALTIES OF PERJURY." INSPECTOR TITLE r� A.M. DATE _ TIME P. A.M. THE NEXT SCHEDULED REINSPECTION P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is 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 11, 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 include 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 the 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 for a 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. (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. (P) 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. I {� � ` • � 'iA e f ._ E & F ENVIROCAENTAL SERMKZ% LJ Environmental/Demolition Contractors Commercial/Industrial/Residential r January 24, 2018 Barnstable Board of Health 200 Main Street Hyannis, MA 02601 t RE: 38 High Street, Cotuit, MA 'Dear Sir/Madam: Please be advised that we will be conducting an Asbestos Abatement at the above captioned address on February 3, 2018. , 1 have attached a copy of the Notification filed,, with the MASS DEP for your records. Kindly contact us with.any further questions or comments you may have. ti Very truly yours, Susan A. Pappalardo E & F Environmental Services, LLC /Enclosures ' 129 NEWTON ROAD, PLAismw, NH 03865 (603)974.2503 FAx: (603)974.2471 Massachusetts Department of Environmental Protection 100280044 `` - BWP AQ 04 (ANF-001� Asbestos Project# i Asbestos Notification Form 1 f Project Revision .1; Project Cancellation A. Asbestos Abatement Description 1.Facility Location: RESIDENCE 38 HIGH STREET Instructions 1.All a.Name of Facility ' b.Street Address sections of this form BARNSTABLE MA 02635 0000000000 must be completed in' order to comply with C.City/Town d.State e.Zip Code f.Telephone MassDEP notification N/A requirements of 316 N/A CMR 7.15 and g.Facility Contact Person Name h.Facility Contact Person Tide Department of Labor Worksite Location: .. I4TCHEN Standards(DLS) notification i.Building Name,Wing,Floor,Room,eta requirements of 453 2. Is the facility occupied? r a.Yes r b.No CMR 6.12 3. Is this a fee exempt notification (city,town, district, municipal housing authority, state facility,or owner-occupied residential property of four units or less)? W, a.Yes r b.No MassDEP Use Only , 4.Blanket Permit Project Approval,if applicable:' Date Received - - Approval ID# 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Original if applicable: Approval ID# Form To: r Commonwealth of Massachusetts 6.Asbestos Contractor: P.O.Box 4062 Boston,MA 02211 E&F ENVIRONMENTAL SERVICES LLC 86 CAROLAN AVE ° a Name b.Address HAMPTON , NH 03842 6032345581 a City/Town d.State e.Zip Code f.Telephone A0000767 h.Contract Type: P 1.Written r 2.Verbal g.DLS License#7. , GUILLERMO A MARGARIN FRIAS AS060373 a.Name of Contractor's On-Site Supervisor/Foreman ;.'—DLS Certification# 8. N/A a.Name of Project Monitor b.DLS Certification# 9 ASBESTOS NOTIFICATION LABORATORY AA00208 a.Name of Asbestos Analytical Lab b.DLS Certification# 10. 2/3/2018 2/3/2018 a.Project Start Date(MM/DD/YYYY) b.End Date(MM/DDNYYY) N/A 7-4 c.Work Hours-Monday Through Friday d.Work Hours-Saturday&Sunday • 11.What type of project is this? r a.Demblition r b:Renovation r c.Repair I✓ d.Other-Please Specify: REMOVAL Revised: 11/13/2013 Pagel of 4 Massachusetts Department of Environmental Protection - r 100280044 BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form { T— Project Revision r Project Cancellation A.Asbestos Abatement Description: (coat.) 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation.1- c.Enclosure r d.Disposal Only r e.Cleanup TV f.Full Containment s g.Other,-Please Specify: u . 13.Job is being conducted: 1✓ a.Indoors r b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed,enclosed;or encapsulated: 0 120 1.Linear Feet(Lin.Ft.) 2.Square Feet(Sq.Ft.) , b.Boiler,Breaching,Duct, c.Transite Pipe ` Tank Surface Coatings. 1.Lin.Ft 2.Sq.Ft 1.Lin.Ft 2.Sq.Ft d.Pipe Insulation e.Transite Shingles 1:Lin.Ft 2.Sq.Ft. 1.Lin.Ft 2.Sq.Ft f.Spray-On Fireproofing g.Transite Panels 1.Lin.Ft 2.Sq.Ft 1.Lin.Ft. 2.Sq.Ft. h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft r 2.Sq.Ft j.Insulating Cement 'UNOLEDM 120 1.Lin.Ft 2.Sq.Ft 1.Lin.Ft. 2.Sq.Ft 15.Describe the decontamination system(s)to be used: FULL CONTAINMENT 16.Describe the containerization/disposal methods to comply with 310 CMR 7.15 and 453 CMR 6.14(2). (g): , ALL METHODS 1MLL COMPLY e 17.For Emergency Asbestos Operations,the MassDEP and DLS officials who evaluated the emergency: a.Name of MassDEP Official b.Title of MassDEP Official c.Date of Authorization(MM/DD/YYYY) d.Waiver# e.Name of DLS Official f.Title of DLS Official g.Date of Authorization(MM/DD/YYYY) h.Waiver# 18.Do prevailing wage rates as per M.G.L.c. 149,§26,27 or 27A—F apply to this r a.Yes 1✓' b.No project? Revised: 11/13/2013 Page 2 of 4 „ Massachusetts Department of Environmental Protection , • 100280044 � -- BWP AQ 04 (ANF-001) Asbestos Project# Asbestos Notification Form I—.Project Revision r Project Cancellation B. Facility Description } RESIDENCE r. 1.Current or prior use of facility: ` 2.Is the facility owner-occupied residential with 4 units or less? r a.Yes C 'b.Now . 3 ERIC J.CEDARHOLM&SARA MYCOCK 38 HIGH STREET- a.Facility Owner Name b.Address COTUIT - MA 02635 0000000000 c,City/Town d.State. e.Zip Code f.Telephone 4.N/A N/A a.Name of Facility Owner's On-Site Manager b.Address N/A MA 00000 0000000000 c.City/Town r d.State e.Zip Code f.Telephone' r 5.N/A N/A a.Name of General Contractor b.Address N/A MA 00000, 0000000000 c.City/Town d.State e.Zip Code f.Telephone LIBERTY MUTUAL INSURANCE COMPANY g.Contractor's Worker's Compensation Insurer - 0000000000 12/30/2018 ' h.Policy# i.Expiration Date(MM/DD/YYYY) 2029 2 6.What is the size of this facility? a.Square Feet b.#of Floors C. Asbestos Transportation& Disposal 1.Transporter of asbestos-containing waste material from site of generation: r a.Directly to Landfill or. ry :b.To Temporary Storage Location/Transfer Station E&F ENVIRONMENTAL SERVICES,LLC ,, .86 CAROLAN AVENUE c.Name of Transporter d.Address Note:Temporary storage of Asbestos HAMPTON Ni 03842" 6039742503 containing waste e.City/Town f:State g.Zip Code h.Telephone material is only , allowed at the place of business of a DLS 2.If a temporary storage location/transfer station is used,list name of transporter of asbestos containing licensed Asbestos waste.material from temporary storage location/transfer station to final disposal site: contractor or a transfer p �' g _ P ' station that is permitted by SERVICE TRANSPORT GROUP INC. 58 PYLES LANE MassDEP and a.Name of Transporter, b.Address operated in compliance with Solid NEWCASTLE " CE 19720 8779999559 Waste Regulations 310 CMR 19.000 c.City/Town d.State e.Zip Code °f.Telephone .• . • Revised: 11/13/2013 Page 3 of 4 Massachusetts Department of Environmental Protection s BWP AQ 04 (ANF-001) 100280044 Asbestos Project# Asbestos Notification Form y r Project Revision T" Project Cancellation C.Asbestos Transportation&Disposal:(cont.) 3.Name and address of temporary storage location/transfer station for the asbestos containing waste material: _ N/A N/A § a.Temporary Storage Location Name b.Address N/A MA 00000 0000000000 c.Citylfown d.State e.Zip Code f.Telephone 4.Name and location of final disposal site(asbestos landfill): MINERVA LANDFILL N/A a.Final Disposal Site Name b.Final Disposal Site Owner Name 9000 MINERVA ROAD c.Address WAYNESBURG OH 44688 3308663435 d.Cityrrown e.State f.Zip Code, g.Telephone D. Certification, . FRANK BALOGH FRANK BALOGH "I certify that I have personally 1.Name 2.Authorized Signature examined the foregoing and am OWNER 1/24/2018 familiar with the information 3.Position/rrtle 4.Date(MM/DD/YYYY) Note:Contractor must contained in this document and sign this form for DLS all attachments and that,based 6039742503 E&F ENVIRO: notification purposes on my inquiry of those 5.Telephone 6.Representing individuals immediately 86 CAROLAN AVENUE'- HAMPTON responsible for obtaining the 7.Address 8.Cityrrown information,I believe that the Ni 03842 information is true,accurate,and complete.I am aware that there 9.State 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment.The undersigned hereby states that I have read the Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection), and that I am aware that this ' permit application or notification shall not be deemed valid unless payment of the applicable fee is made." Revised: 11/13/2013 Page 4 of 4 1 • II _ _ L ygdeTOWNOF BARNSTABLE LOCATION � 571 SEWAGE # O VILLAGE. ASSESSOR'S ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY �c oaly / LEACHING FACILITY:(type) 14!�269® ® J ) )- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 122 VARIANCE GRANTED: Yes No G� N r. t. b TOWN OF. BARNSTABLE CATION4 SEWAGE # ^ ��O VILLAGE (' G ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY d r LEACHING FACILITY:(type) C7 (size) = ,S NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: O DATE COMPLIANCE ISSUED: /b/-c��/ 9, 7 � P VARIANCE GRANTED: Yes No r 1 � 3 r i} . No.. . ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Disposal Workii Tonstrurtivit ramit Application is hereby made for a Permit to Construct ( ) of Repair (�� Individual Sewage Disposal ... .. ...systems •........................................ 2(El -...._ Z or Lot No. ................. ....................... • ----- ----------___---_-__-----__---__--_-- er�� ----------------- ................. ... r r-CI-.�A eS `- Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Pa Other fixtures .-•--------------------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................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 ( ) '~ Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1....._----------minutes per inch Depth of Test Pit____________________ Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water________________________ a ----------------•-----------•---•-•---------------------------------------------._._....------------......................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------- W c., W -------------------------------------------------------------------- UNature of Repairs or Alterations— er wh n applicable__ ___-_____J___ ____:. /-e p--............... . f-l� .-------------- a -----------••-----------------•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—,The undersigned further agrees not to place the system in operation until a Certificate of Compliance has-be sued by the and of health. a Signed .. 6' 'L � - e ----------- / C> to Application Approved By .......... .........................................-------------------------------------------------------- ---------------------------------- -------------- ------ Da[e Application Disapproved for the following reasons: ....................................................................................... _--_----------_-----------_-- -------------------------------------- Date PermitNo- ------- ----------------------------------------------------- Issued ---- ........................................................... N. • , \ zi j . V No. ............ Fes$............._....._....._ Y THE COMMONWEALTH OF MXSSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Npp tratinn for Disposal Works Tons rnrtiun ramit YApplication is hereby made for a Permit to Construct ( ) or air dividual Sewage Disposal • Sys at / 15r ...... ..a- - .............., •-•-------------------• �.. _ ... Loctattor7�7d A(7 or Lot . ` -------!-- -------•--••---- ...... .. = a �./..................... ....... !/-------------•— ........_.. -------- Installer Address QType of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms......................_-------_-_________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Sowers ( ) — Cafeteria ( ) a Other fixtures ------------------------------------------------------.--------------------------...------------------------------------•--•-------------------------• Design Flow............................................gallons per person per day. Total daily flow............................................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 ( ) \Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.- ............... G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ P4 -----------------------------------•---------------•------.-----.-.-------------•-------------------------------------------•------------------------------- ODescription of Soil-------------------------------------------------•--•'-'•-------•-••---•---.---- x -------------------•......................j.......................................................................................................................................................UWx --------------------------------------------------------------------------------------------------------- A -- . —---------------- u N t-u-re of e a or A eratiorms-- �_ - -------------��- _q-----•-------•-------•------------------------•-••...........----------•----- ---------U..........................................................-......... Agreement: - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance:with the provisions of TITLE 5 of the State Environmental Code—The under�s ned further agrees not to place the system in operation until a Certificate of Comp AR-0 eWi�d b -mWlloard of health. Signed ------------------------------- ..................................................... .............. -------------- Da[e ----------------- ApplicationApproved By ----------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- Date Application Disapproved for the following reasons- ........................................................................-------------------------------------------------------------- -------------------------------------- Date PermitNo- -------------------------------------------------------------------- Issued ------------------------------------------------------------------- Date - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cer#ifiratr of TomyIianrr d S 0 Tha . e- t •Indiv du 1 wage Disposal System constructed ( ) or Repaired ( �� j�� --------------------------------------------.---------------------------------- 1,0 Installe 0 /r V at -- --------- .... -- ....... -------------------------------------------------------------------------------------- ----------------------------------------------------------- _................................ has been installed in aczdance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ...................................... ...... dated .... ----------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A GUA �NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. �- l Inspector ....... .... t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O D D TOWN OF BARNSTABLE No..pC�..... h. FEE........................ Dispu r �un w L}9, rmtf Permission is hereby gran '----•-----................... ----------------• ............. to Constr�uEt or 'e 7_ ar ,.IIn ualo . r ispr sa s ern at No..v .,_ � _ ` � Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... •------•------------------.............. --------•-••------------•-----••--....._ odrd&f—fl ealth DATE..............=................................................................. 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DELKING I I h D? =F e e c'�'c c•F a Es !- ON P.t.FRAME 7 --�' --_-- - , ' -- E9�:_�Y F.T.6X6 FOST DX r ---- _ •�, , , t , 1 o Ix ARAP „ m ' TO WWI FIR DII.IJ 11--.._ �.{:!• , v � /1 _ ------- IX4 IRE OELKINS-J w f- ON P.T.FRAME . ^` a BEHERAL PLAN NOTES W N-0 _ O C ry APE 04M�iF�ro®OTHENAW)16' O O 7 Cu :I (D EL L$ -ALL INT.f.RALLS TO BE 2X45 s 16' (fl 'N V L I 10, 04.MdES6 NOW OTIMM50 - vJ 0 O 5"CAU r DOORS TO 0 0 BE v _Y �'- LL I -INTERIOR DOORS LASED OPENING LOLATION9 w =2 I NOT DIMENSIONED ARE TO BEGIN 9 STDS O 00 y-+ (n I (R CENT THERED E T wALL AS SHOWN IN PLAN C CM•j L ��5�� O O LL I I NV IMP T RESISTANT 6L7A D STANTNT U FASTENIN S,SYSTEM MEETING BTH W.OF MASS. I Y I STATE BLD6.LODE(REFER TO ELEVATIONS FOR KNTM PATn3tN5) / Q Al rYl P.O. 16KM AASP�sl�OONOCK R V •MI P HALL ENTRY DOORS BY SIMPSON job no.:1734 •NEW INTERIOR DOORS AND LASED E 'gj �QQ�gj OPENINGS TO MATLH rEI6W OF ,Eggpp°Y ppY 2� i HE � �ppExisnN6 YeERE NorEO date 14 Au6U5r zOIO D9/4' I �s M C „�A scale :As NOTED EOIAL EQUAL EQUAL 4'-T.' '-1a UD 6'-5• 6'-1' T'-0' 11.-0, T-O .90 /Ar, drawn:KMW 1'-0 VDVA - 2140' 0'-0• O'-0• zy-p• 'y rev. rev. EXISTINGD6'-0' g A_2 FIRST FLOOR LIVING AREA(EXIST)•IJD5 SIG FT. FIR 5 T FLOOR PLAN FIRST FLOOR EXISTING DEMOLIS ED)•69 9O.FT. FIRST FLOOR LIVING AREA(PROP)•B53 SQ.FT. SCALE, 1/4• • 1'-O' TOTAL FIRST FLOOR LIVING Af�A=1,914 50.FT. ISSUED FOR PERMITTING sht 2 Of 10 E E u J E/asnNS Ea1AL 4g''O' A y wv 2a41 H m as - ♦ '~' O �Y 6aY Y E�uAl: Eauw � U ui to I lot I WALL/DEMO WALLS AND ITE15 TOBE FIEVIOVED o _ I EMSTINB WALLS TO - ( I RETUVN Y N � rE1'1 MALLS ; E DEMO NOTES c y EXISTING DA51®YUND PATCHED t WALLS m C 1u91 IW TNEEDED OR REFLAr.ED AS NOTED. b V I tS I __________ B A �-JJq C QO V B r WINOO-— e� IN nT.aPvui+S— ILII 4 11 V `w RO.�TO VERIFIED IN FIF1D ———— — —— LOFT ® - - } - C� ar M ALTIINER'S REF. FEFLAUMENT r .._._ s-. LFfIIER 01 OOI�al.S:Z/D F + RD:t0 iFlED Ni FEED `• � �/ � ESA 2 a' Erc nAN.FALTLrERs REP. ------------------------------------------------------------------------------- OOIHL /tl1IDOW — cam IN— trI-Z%Zl------- Ew9r.aFEN ----- \� v, RO VERF 1 '.:TO ED IN FlEID HALL Erc nuaFAcnrRE.Rs REF. - 1 : : : ---------- - : b § {1 - : : GERIN6 fQfifR TO 1 - ' ' MATG1 E%15nN6 M.NrIN`a'2/2 - Q AND ec�R00lt9 RO:2¢:X 4-o . BEDROOM 3 DEDROOM 2 Dae -+ta+S-Nars�r2u7ts_an - - ---------- EXIST. - ' RD.�TIO VcRIFIED IN FIELD ———— OPEN26 EdSE OF FLAT/ -------------�I . er MAIIFALTLIN A5 REP. 1, , SIOPED US. ------------^ ' e � DOIBLE lots-AON 22I/O R0�24X _____ _ / I _____ e c$'�:=e I e� eg. : ' I v - 39 m/ r - ----- 9EAr ------- o cs . 'm FFM � : � I ' Y I - W I y O N +In C I Cu . p (n a �L L m�U) M O 1 I - GENERAL PLAN NOTES u- A"EXT.INAILS TO BE 2A6S EEXIXISTm NNIM5 NOW a ERMSE) q� _� O.cL'li' h-,ssNNOTTEOD�arNu5 0 ISso c M'7 AQA� -INNOOWS TO BE ANOERSEN'A-SERIES' O L O W . Al NON-IMPACT NESISTANT AND FA5TENN5 SYSTEM I�iIN6 BTN ED.OF MASS. N _U SMTT_ ATI (REFER TO ELEVAnQb FOR ^�' W �� '� .. ,• - NTEWR DOORS CASED OPENNIS LOCATIONS NOT DIMEN5101,02 Af TO BE LOCATED 9 STUDS U tPLAN cEW;; IL�T AS SXOYN IN job no.:r7s4 REFER TO S ABOVE R F4 ENS FOR o� NO.MEOWSAeOVE 51sFLoax date :14 AusuBr Zola � 3 p - K - •NEW INTMOR DOORS AND LASED scale :As NOTED OPENIN55 TO MATON NE16HT OF WFE EaJAL EWAL 14'q 2W-V EXI9TINS E NOIED drawn:K7" - - EOVAL - 45.0. rev. _. rev. A S E G O N D F L O O R P L A N 5EL01IIJ FLOOR LNIN6 AREA•895 90.FT. 9LALE, I/4• • I'-O' _3 O T ISSUED FOR PERMITTING snt 5 of to I • SITE ADDRESS 38 HIGH STREET m COTUIT.MA 02635 S n ASSESSORS'OFFICE N/F MAP 35-LOT 47 i SHARON J.MACDONALD TRUST CURRENT OWNER 48 HIGH STREET ERIC J.&SARA MYCOCK CEDERHOLM MAP 35-LOT 46 36 HIGH STREET COTUTT,MA 02M DEED REFERENCE �+! 25.9 BIC 30995-PG.313 J X 31.2 ! I X 34.3 CB/DH\FOUND a za 38 REFERENCES PS 573-PG 77 J n (S 32-39'30"E,0.1T) a I I I TOWN OF BARNSTABLE ZONING DESIGNATIONS PO CB1DH FOUND HELD ac.e `, t ` �\-H-^ RF-RESIDENCE F DISTRICT Q: Q N.87"1 T231 E 175.29, \ AQUIFER PROTECTION OVERLAY OVERLAY DISTRICT W .(5-81'14'2T'E.1.41') \ 1 ` \ t A RESOURCE PROTECTION OVERLAY DISTRICT W Q cc ^;,^.-"'•''�' .�, I I I cNP I - ZONING REQUIREMENTS FOR RESIDENTIAL F DISTRICTS Z 2 Y EXISTING \ > •i;_ 1 NOTE:THESE REQUIREMENTS SHOULD BE CONFIRMED C� - LEACHING PR ` \ t� II WITH THE TOWN OF BARNSTABLE BUILDING DEPARTMENT Z. j n J E BENCHMARK I 2534 7F ' ° 4, \ PRIOR TO ANY DESIGN OR CONSTRUCTION. W2 Ai I cWp W w 1 I- \ \� '� \ ` t MIN.LOT AREA: 43,560 SQ.FfG SET a w - -� i.EV.=44.35 NfXV D88 X ra i'! �! / - - - -I- - - MIN.LOT FRONTAGE: 150 FT Z I ' \ \ 1� ` , P FY SETBACK: 30 FT F v I 1 1a7 I I ` SY SETBACK: 15 FT J X 43.2 - -'� ZONING SETBAIX U�E T /�1� 'l {.. W X / ` ^',I i \ - RY SETBACK: 15 FT '� W = F ;I I i• / 1 cs/�. \ ( iJ 1�10.' r ��_,��1,,,.,� 9.0 MAX BUILDING HEIGHT: 30 PTIOR 2.5 STORIES) H W / ROPOSED 4 IN O I`1 I / I; J I PVC SEWER / X�''> " �✓ \ '-�` �: FEMA FLOOOZONE DESIGNATION go IL ~ I - 1 ZONE X-AREAS DETERMINED TO BE OUTSIDE THE 02.% V Z ANNUAL CHANCE FLOOOPLAIN.AS SCALED FROM FIRM MAP = 17 83' r• (/ i RELOCATED SHED ,'. I 1 ' �� -� NUMBER 25001-C-0756J,EFFECTIVE DATE:JULY 16,2014. F lax z in it ILI SHED N 4 %I A i 23.4 \ I EXISTING SHED TO. I la11 j'Iy ' A I I. I BE RELOCATED t I 1 STING `" \ \ { J 38 HIGH STREET , I I ; LEACl1ING PR\1� \ •` (V� j I EXISTING T PROPOSED GARAGE I ISTING , \�� \ JTD HARBORVIEW TRUST 2 STORY DWEWNG Y I ' i EX.FFE-44.09 I I Wltti A�BIO PACE / f"r �r I -BOX m � DANIEL&TIMOTHY I I LEVERONITRUSTEES H GARAGE FLOORI=3s.W LISTING UNKNOVy �ICi'1 I EXISTING \ `� \ 845 MAIN STREET - _ 'T-- _ _ , I 1MANHO�N�E N I I SEPTIC TANK MAP 35-BLOCK 59-LOT 2 �14 ABAN �. cl- rn. PROPOSED SCREENED j t - \.� 1\ {I I PORCH ADDITION / I - 1 X 4.9 I 1- �. I x a.e / / / ( 1 \ , NOTES: X36•+ i 1 ai9 •I 1. CONTRACTOR TO.NOTIFY OIGSAFE(1.888.DIG.SAFE)TO LOCATE UTILITIES t j - I 1 IN THE PROJECT AREA A MINIMUM OF;72 HOURS PRIOR TO THE START OF IXCAVATION. i j .T___------��PROPpS X 36.4 2. THE PROPERTY IS SERVICED BY MUNICIPAL WATER I / RETAINING WALL I �(34.7 f / X 4.4 is ! 1 3. EXISTING SEWER FEATURES WERE LOCATED USING INFORMATION f" �O B�,OTHERS I a I A ( ) 10 I PROPOSED ENCLOSEI➢ \. � PROVIDED 6Y THE BARNSTABLE HEALTH DEPARTMENT AND 8Y fl STAIRSION SONOTUBEs} ) X 2 9�� EXCAVATING CERTAIN STRUCTURES FOR LOCATION VERIFICATION. ' rn II - 't I i - I l / } _ 4. TOPOGRAPHY AND MAPPING OF EXISTING FEATURES WAS TAKEN FROM j l 1 46 13 % EXISTING 2 STORY i F j % { I I I ��WITH {� 1 / ': I it AFIELD SURVEY BY PRIME ENGINEERING,INC.IN JANUARY OF 2018. / /X 39.9 / / DWELLING is o �+ I, i tL / I / \ 1 1l I FFE=34.10 , �� i n W I ; 29.0 C % I w / 1 h P O SED.EOP ------ 1. / II / /� / / / ++ •Ik o Y? / / I I / CB FOUND w EXISTING EEOP-F_I_ j ! / (HELD) 4 0 (' `? I rn 1 x 2ss o o ` �-Nai AILFOU D j \ ry co X X33.6 I X32.8 N / f O w (HELD LINE) 1 i f / / \, o 0 o H X 357 (N 87"38-4-E.0.84') Ln 41 w / 28.0 1� �( ' •�' � I I I � I I ,l IA lu i \ N/F I Z W 4 O; ANTHONY M.&EMELIA E.PISANI I x M z im 28 HIGH STREET I d 1A % W MAP 35-LOT 48 i = a W o c O (22 Vom I } = F CluzW Mo W�1 0 10 20 1 30 fJ JJ 3