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0455 SAMPSONS MILL ROAD - Health
. - - - � �.7 455 Sampsons Mill road k Cotuit A= 039—150 i , 4 I A 1� I f i I IC - - � � - r � .. � _ - �- .. _. .✓. 'y� `� �. - � �." _ ,. - ',�' ,r ,: � ���� ,r"- y VILLAGE I 'NSIA LLER'S NAME ADDRESS �8 U 1 L 0 E R 0R OWNER 0 AA.T r PERMIT IS5U D OAT C0MPL ; ANCE ISSUED o. Our s Q No. F�s.........��..._..........E3 I b THE BOARD OF FHEALTH Ts ....... .............. ................OF.....................-................. Appliration for MipogFal Workii Tonotrurtion runfit Application is hereby made for a-Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: a io_____ d -ess No W Ow er Address Installer Address Type of Building 3 Size Lot. ;_ 8�_1 -__.....Sq. feet F Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage,Grinder ( ) '4 Other—Type e of Building No. of persons........................... Showers G-� YP g ---------------------------• P - ( ) — Cafeteria ( ) dOther fixtures ---------------------------------/F..................I................................. ................ Design Flow....................�� ..._...........gallons per person er day. Total�aily flow_______----�._ �..................gallons. WSeptic Tank—Liquid capaci,, .-..gallons Length/_. ?_.._. Width_- _.gip_... Diameter.:.............. Depth_4 .�!..__. x Disposal Trench—No..................... Wid h _ .............. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-- 4 ......... Depth below inlet.......6......... Total leaching area..:�� ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................ __ .SU'2 L ' y° Date___._ `I a -•-••••-•••-••••--••••--•-•----•-- a Test Pit No. L.'�:Z�n..minutes per inch Depth of Test Pi/ ........... Depth to ground water...1f-4, ...... G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ /� -----•------------- Description of Soil 4 y �'�- '-`S ` J........................ Ab (� ---.---•-•---•---------------•----••----••---------_---•-•-----.-..--_---------------•-------__ ------------------------•--- J W •••-------------------•---•- x --•••-•--•-•..__.......... .............. .•----•••--------------------•..........•-•---••-•--•-•-•-----•----•-•-•------•------•-----••-•••............................................................ V Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed by th and of health. Signed .............. Application Approved By..••-•--••----•••--•-••••---._�....-- /���---------- Date Application Disapproved for the following reasons---------------••--------------------------------------•-------------------------•-----------------•••-•-----•--- ----...---•--•--••-••---•••-----•-...-•--..._•••-•-•-•••••-•....---••-•-•---•-••-------------•----•....•--•-•-•--...-•••••---••---•-•••-•••-----•-•-•-•-•-•--------•-•---•-----•----••......-•---------- Date PermitNo......................................................... . Issued_....................................................... Date } No ............._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..._......... .......:...............OF............................................................... ....._.................._. , ppliration for Bispos al Works Tomitrurtinat 1hruat Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: / ......... r ._ l......iAd-ress. ..� ^ .._... � /-f" t No �^ >` 0 tr �. Ow er Address a .. . � V �'2 ... • ..... .........................•................. ..............--•---......................._........._.....---._.................................. Installer Address A UType of Building Size Lot_•.._...3...t_�_b......Sq. feet Dwelling—No. of Bedrooms....._........-.............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — a Other—Type g --------•------••----------- P ( ) Cafeteria ( ) Other fixture w Design Flow____________________��r...._......_._____gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacih `�:?...gallons Lengt ___.7_....... Width._._�X _... Diameter................ Depth-!{ (>._._-. x Disposal Trench—No_____________________ Widlh�_,;__............. Total Length....._.........._. Total leaching area.................... ft. Seepage Pit No------------------ Diameter..../.....__._... Depth below inlet...... Total leaching area..T�'0A" q. ft. Z Other Distribution box ( ) Dosing tank (, Percolation Test Results Performed by...............'`'�__ .:r �E 'L�% `�'��'�L ------- r� Date ...... Test Pit No. 1.�_ -_._minutes per inch Depth of Test Pit'.�___.....1-__-- Depth to ground water..�J_��'..................... fX4 Test Pit No. 2-.:.............minutes per inch Depth of Test Pit............ ----- Depth to ground water........................ w , ..... ------------ Descr>Description of Soil .......................................................D. " w / 7� �; ,j_.��� ` p �---------_- ---- ..... .--------------------------------------------•--...----------------------------------------------------------• ------------..._..-------..../ t� , tea w U Nature of Repairs or Alterations—Answer when appl;ble..!.................................................•...._...._..............._._._......_...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT L L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the9ard of health. Signed....... , .",7 ate Application Approved By.....` Date Application Disapproved for the following reasons:-------•-------------------•----------..-----------------------•------------------......--•------••----••-•----- ..............•------•--......---••------.....--•--------._...---------••---••---•-••-...._._...-•------•-----------------•••---••--•••-------•---••••-----------•-•••--•-----•••••-----•-••------------ Date PermitNo........................................----------------- Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.................................. .....................�...................... Trr#if iratr of Tont pliatta THIS IS-TO-CERTIFY;-That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----------- --------- =' _ _ c ------------------------ ------------.......---------...........-----------------------.........--------------•--------- In filer at..... Z'Y -- r - .... � - I. =�----------------------------------------------------------------------------------- has been installed in accordance with the provisions of TIT IF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.` .�e..a'-_=15Z7Y_....... dated_-. l. . '................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1 _ r-- DATE.......................1------•-•- -----................-----...._.. Inspector !!�\---...._...--------•---•---------....----...------- ........... ,THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , ,�� ........ . .....OF...................................................... ....................... w No. . .... FEE.. 1 . '' Permission is hereby granted == ... ............. --------------•----••---------•--••----.....-------••-•----.................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy tem ° at No.......kz_(......_( .1..............-�tV t __._._.' t •� t �u. -•-••--•-•••......•---•-•. ------•................... Street as shown on the application for Disposal Works Construction Permit No. _ bated.... .__ ..... r �, -e`----------------------------- .-- ... -----............... F 5s....................................... Board of Health .DATE---....�: :` ....�--•--' FORM 1255 A. M. SULKIN, INC., 60STON I t. 'l Dos_. 1 Y 2C13 P 6 5 i U-12-2012 10--03 dF IMF �i L E I_ t-€D - F. R EU s S c R 7 Town of Barnstable AGo -3 p=a UID Zoning Board of Appeals Decision and Notice Appeal No. 2012-044-Edmonds Section 240-47.1(A)(3)- Family Apartments To establish a family apartment in an existing detached accessory building with new expansion Summary: Granted with Conditions Petitioner: Lillian Edmonds Property Address: 455 Sampsons Mill Road, Cotuit Assessor's Map/Parcel: 039/150 Zoning: Residence F District Hearing Date: July 25,2012 Recording Information: Deed: Certificate No. 189891 (Doc. 1]26840) LC Plan: Book 36608-D (Lot 61). (Also filed with Land Registration Book 774, Page 113 with Certificate of Title No. 95033.) Background In Appeal No. 2012-044, Lillian Edmonds petitioned for a variance from Section 240-47.1 A(3) Family Apartments. She proposed to establish a family apartment consisting of approximately 1,128 square feet in an existing detached 456 square foot garage with a new 672 square foot addition. Relief is requested from Section 240-47.1 A(3), which requires family apartments to be located within or connected to a single-family dwelling. This request was filed and heard concurrently with Special Permit No. 2012-045. The subject property is 455 Sampsons Mill Road, a one-acre lot located south of Route 28 in Cotuit. There are two structures on the subject property: athree-bedroom, 3,156 gross sq.ft single-family dwelling constructed in 1985 and a 24' x 26' detached garage. The detached accessory building currently has a two-car garage on the ground floor and an upper half-story. With this proposal, the Petitioner seeks to construct a 672 sq.ft addition to.the accessory structure that would include a lower-level living room and kitchen and upper-level bedroo bathroom, and living area. The existing two-car garage would remain. The total proposed area of the family apartment was 1,128 square feet; this square footage did not include the two-car garage. Procedural & Hearing Summary Appeal No. 2012-044 for a detached family apartment was filed at the Town Clerk's Office on June 26, 2012 and also at the Office of the Zoning Board of Appeals. A public hearing before the Zoning Board of Appeals was duly advertised and notice sent to all abutters in accordance with MGL Chapter 40A. The hearing was opened July 25, 2012 at which time the Board found to grant the variance subject to conditions. This appeal was filed and heard concurrently with Special Permit No. 2012-045. Board Members deciding this appeal were Board Chair Laura F. Shufelt, William H. Newton, Craig G. Larson, Alex M. Rodolakis and Brian Florence. Ed Lacey, Jr. represented the Applicant before the Board. Mr. Lacey reviewed the proposal with the Board. He indicated that the p slope of the pr operty operty prevented the placement of an addition to the house and, even if it could be accomplished, would obscure the glass sunroom on the back of the house. The stated the land around the garage was more level and the improvements would be Town of Barnstable Zoning Board of Appeals—Decision and Notice Variance No.2012-044-Edmonds behind the house, not visible from the street. He indicated that the family apartment would be lived in by the owner of the house and her daughter would live in the main dwelling. He stated that having the family apartment would allow them independent lifestyles without financial hardship. Mr. Lacey explained that the apartment would fit in with the rest of the.neighborhood. The house was on a dirt road and there was room for parking on the site. He indicated he has received no objections from neighbors. The Board questioned if the family apartment could be created without variances from the Board of Health. Public comment was requested and no one spoke in favor or in opposition to the request. Findings of Fact At the hearing of July 25, 2012, the Board made the following findings.of fact for Appeal 2012-044, a request for a variance filed by Lillian Edmonds for a detached family apartment at 455 Sampsons Mill Road, Cotuit: J 1. Lillian Edmonds applied for a variance from Section 240-47.1 A(3) Family Apartments. She is proposing to establish a family apartment consisting of approximately 1,128 square feet in an existing detached accessory structure with a new 672 square.foot addition. 2. The subject property 455 Sampsons Mill Road, as shown on Assessor's.Map 039 as Parcel 150. The property is a one-acre lot located south of Route 28 in Cotuit.. It is in a Residence F Zoning District. 3. There are two structures on the subject property: a three-bedroom, 3,156 gross sq.ft single- family dwelling constructed in 1985 and a 24' x 26' detached garage. 4. The Petitioner seeks a variance from Section 240-47.1(A)(3), as the proposed family apartment is not attached to or within the principal dwelling. A special permit is also required pursuant to Section 240-47.1(A)(1), as the proposed family apartment is between 800 and 1,200 square feet. 5. There exist circumstances related to soil conditions, shape, or topography.of such land or structures and especially affecting such land or structures but not affecting generally the zoning district in which it is located. 6. A literal enforcement of the provisions of the zoning ordinance would involve substantial hardship, financial or otherwise to the petitioner. 7. Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of the zoning ordinance. The vote to accept the findings was: AYE: Laura F. Shufelt, William H. Newton, Craig G. Larson, Alex M. Rodolakis, Brian Florence NAY: None , Decision Based on the findings of fact, a motion was duly made and seconded to grant Variance No. 20.12- 044 ubject to the following conditions: 1. Variance No. 2012-044 is granted to establish a family apartment within a detached accessory building at 455 Sampsons Mill Road, Cotuit. The family apartment shall not exceed 1,128 square feet and shall have no more than one bedroom. 2. The family apartment shall be maintained in compliance with the requirements of Section 240-47.1. 3. There shall be no renting of rooms (lodging) permitted on the property during the life of this variance. 2 Town of Barnstable Zoning Board of Appeals—Decision and Notice Variance No.2012-044-Edmonds 4. The property shall be in compliance with all requirements of the Building Code, local Board of Health, and Title V. 5. When the family apartment is vacated or upon noncompliance with any condition or representation made, including but not limited to occupancy or ownership, the use of the family apartment shall be terminated and this variance shall become null and void. At that time, this variance shall cease. The applicant or property owner shall be responsible for the removal of the kitchen, unless the unit is properly permitted under the Accessory Affordable Apartment Program. 6. The applicant shall apply for a building permit for the family apartment unit. The Building-`" Commissioner, or his designee, shall determine that the unit conforms to the approved plans as submitted with the building permit application and meets state building and fire codes, prior to issuance of an occupancy permit and certificate of compliance. 7. The Health Division shall determine that the unit is in compliance with applicable on-site wastewater discharge requirements. The Applicant shall obtain all necessary disposal works construction permits in accordance with Health Division requirements. 8. This decision shall be recorded at the Barnstable County Registry of Deeds and copies of the recorded decision shall be submitted to the Zoning Board of Appeals Office and the Building Division prior to issuance of a Certificate of Occupancy for the family apartment. The rights authorized by this variance must be exercised within one year, unless extended. The vote was: AYE: Laura F. Shufelt, William H. Newton, Craig G. Larson, Alex M. Rodolakis, Brian Florence NAY: None Ordered Appeal No. 2012-044 for a detached family apartment at 455 Sampsons Mill Road, Cotuit has been granted subject to conditions. This decision must be recorded at the Barnstable.Registry of Deeds for it to be in effect and notice of that recording submitted to the Zoning Board of Appeals Office. The relief authorized by this decision must be exercised within one year unless extended. Appeals of this decision, if any, shall be made pursuant to MGL Chapter 40A, Section 17, within twenty (20) days after the date of the filing of this decision, a copy of which must be filed in the office of the Barnstable Town Clerk. Laura F. Shufelt, Chair Date Signed I, Linda Hutchenrider, Clerk of the Town of Barnstable, Barnstable County, Massachusetts tq reby certify that twenty (20) days have elapsed since the Zoning Board of Appeals filed this-t�ecs and that no appeal of the decison has been filed in the office of the Town Clerk. pF •c44p ,• E i'� Signed and sealed this L�day o d/ under the pains�p¢•pzv _ f• perjury. 4 UJJ vi (A j . � A,V Linda Hutchenrider, Town CIk b� ••...... •�p�' .:" 3 Town of Barnstable MARM-AK.E. ` Assessing Division 367 Main Street,Hyannis MA 02601 www.town.barnstable.maxs Office: 508-8624022 Jeffery A.Rudziak,MAA FAX: 508-8624722 Director of Assessing ABUTTERS LIST CERTIFICATION July 5, 2012 RE: Adjacent Abutters List For Parcel(s) : 039-150 455 Sampsons Mill Road Cotuit, MA. 02635 As requested, I hereby certify the names and addresses as submitted on the attached sheet(s) as required under Chapter 40A, Section 11 of the Massachusetts General Laws for the above referenced parcels as they appear on the most recent tax list with mailing addresses supplied. SL FC , � Board of Assessors Town of Barnstable Attachment 1 i I r "'u�" '.ter"•` Fage 1 of 2 Zoning Board of Appeals (ZBA) Abutter List for Map & Parcel(s): '039150' Parties of interest are those directly opposite subject lot on any public or private street or way and abutters to abutters. Notification of all properties within 300 feet ring of the subject lot. Total Count: 26 Close Map &Parcel Ownerl Owner2 Addressl Address 2 Mailing Country Deed CityStateZip 038002 BARNSTABLE LAND PO BOX 224 COTUrf, MA 23007/170 TRUST 02635 039001 BARNSTABLE, CONSERVATION 200 MAIN ST HYANNIS, MA 4973/151 TOWN OF(CON) . COMMISSION 02601 039032 MELCHER, ALFRED L MELCHER, LEE 37 THANKFUL LN COTUIT, MA C59990 LENNOX 02635 LAGADINOS, N &P REALTY TRUST COTUIT MA 039033 NICHOLAS A& INSTRUMENT 13 THANKFUL LANE 02635 C134402 PANDORA P TRS 039056 LARNIERE, GLORIA 14 THANKFUL LANE COTUrr, MA *D1144195 02635 039057 BARNSTABLE, CONSERVATION 200 MAIN STREET HYANNIS, MA C81016 TOWN OF(CON) COMMISSION 02601 039058 SCUDERI, 46 THANKFUL LN COTUIT, MA C145160 CATHERINE T 02635 039059 SAAD, LUCY L 8i 119 CONSTANT I N COTUIT, MA C149629 DALE 02635 039130 SNEEP, RALPH & P 0 BOX 642 COTUIT, MA C173913 TERRY 02635 039131 GOODMAN, PETER A 28 ROOSEVELT RD COTUIT, MA C163557 &CHERYL1 02635 039132 ROBINSON, PHILIP P 0 BOX 1988 COTUrI, MA C185344 H &MARIE A 02635 039133 TROMBA, MATTEO& 54 ROOSEVELT RD COTUIT, MA C140627 WILMA 02635 039134 HERBERT, ELLEN L HERBERT REAL 66 ROOSEVELT RD COTUrr, MA C171004 TR ESTATE TRUST 02635 039136 DILORENZO, 80 ROOSEVELT COTUIT, MA D667463 LUCILLE M ROAD 02635 039137 SANDLER, CAROL W 75 ROOSEVELT RD COTUIT, MA C153090 02635 039138 MCGRATH,JOHN F P 0 BOX 2083 COTUIT, MA & ROBERTA A 02635 C190627 039139 SCHIPS, HELMUT F 49 ROOSEVELT RD COTUrr, MA C115390 02635 039140 WOLFF, GERALD C& 33 ROOSEVELT RD COTUrI', MA SUSAN C 02635 C141009 039141 BALLOU, KENNETH 19 ROOSEVELT RD COTUIT, MA C174773 &ANN TRS 02635 039142, ASHER, DAN B TR DAN B ASHER 5 ROOSEVELT RD COTUIT, MA C159005 REVOCABLE TRUST 02635 039147 SILVAMAR, LLC 77 LIGHTHOUSE MASHPEE, MA C186037 LANE 02649 039149 LUCASHENSKY, 471 SAMPSONS COTUIT, MA C137473 LUKE P MILL RD 02635 E , 455SAMPSONS COTUIT 039150 RICHARDICHARD G& ' MA C189891 LILLIAN S MILL ROAD 02635 mhtml:file://C:\cache\Temporary Intemet Files\OLKMAbutterReportImht 7/3/2012 f rage 1 of 2 039152 KUZYK, ELAINE& LEIGHTON, PAUL I P 0 BOX 1013 OSTERVILLE, MA C163865 02655 039153 RYAN, DAVID] & 415 SAMPSONS COTUIT MA CHERYL A MILL RD 02635 C140261 039154 FIERCE, ROgERT W. COTUrr, MA &FRANCIEN R. 87 ROOSEVELT RD 02635 #801824 This list by itself does NOT constitute a certified list of abutters and is provided only as an aid to the determination of abutters.If a certified list of abutters is required,contact the Assessing Division to have this list certified.The owner and address data on this list is from the Town of Barnstable Assessor's database as of 7/3/2012. r mhtml:file:HC:\cache\Temporary Intemet Fi1es\0LK4\AbutterReport3.mht 7/3/2012 s� g 10, T Or �a p AAR d� aQr voI5 T. Gr 0 s�;. gd Ste. acA :. v� rl o P? rj Q o lop W� w _w is ov M 11 0. 50 0 ' •ate `=� ., . .. a� o � BARIS NSTABLE COUNTY r�1ti eYD S�A° acA�l a . REGISTRY OF DEEDS A TRUE COPY,ATTEST Ld ' rG: �q V. lk - - -- -- t� JOHN F...MEAB€ R€AI�T BARNSTABLE REGISTRY OF S ' DEEDS �» ,A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „ ^M 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms the computer, r,use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental "ITV Company Name . 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority �J Q ��►r�'In-,-_ IDS June 26, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 455Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. Cityfrown 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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•09/08 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 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every 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. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 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•09/08 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 ^M 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 333 gpd Detail: 2007-2008 Sump pump? ❑ Yes ® No Last date of occupancy: 1 week agoDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpdj 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-09/08 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 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is Cotuit MA 02635 June 26 2009 required for , every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 22+ years. Certificate of compliance issued 7/3/86 (Board of Health permit#85-587) Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC t ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 1 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: 10.5 ft x 6 ft x 5 ft(1500 gallon) Sludge depth: 6 in t5ins•09/08 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 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required Cotuit MA 02635 June 26 2069 every page. Cityfrown 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 28 in Scum thickness 1 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Permit application Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments, ^M 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: ; gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.):- *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every 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 liquid level_above outlet invert at 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.): D-box appears level with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System SAS locate on site Ian excavation not required): p Y ( ) ( P If SAS not located, explain why: l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to be dry No staining at cover interface, on sidewalls or in overlying soils was observed 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .P., 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. Cityrrown State Zip'Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , ;M 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is. required for Cotuit MA 02635 June 26 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enterp the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately •\ 3S, z � flit N\.?o i t5ins-09/08 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 ° 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. City/Town 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: 14+ 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: Permit issued 4/27/2001 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: Permit application form shows no groundwater was encountered to a depth of 12 feet in a test pit on 2/11/85. A hand augured test boring showed no groundwater at a depth of 5 feet below the leach pit. Applying a groundwater adjustment of 4.7 feet(Index well SDW-253 zone C, May, 2007 reading = 49.3) demonstrates that the bottom of the pit is above adjusted high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 455 Sampsons Mill Road Property Address Donna R. Pariseau, Tr. Owner Owner's Name information is required for Cotuit MA 02635 June 26 2009 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file (Sins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABI E 2012 OCT 12 P t� r. `JO 00-1 LA7 - 0� z fJ/ f - -- - - -- --- XJ ` - N zoat�J o - ST�FZOOR Bruce Devlin p De81giie wm: 6�3 G1 c nev eeo 774238-6773 / x;. 11 # ;` :'., n:' -: � '.: • ' :/ �2 t c..ta<l-RffiSEE_. 2 8-6�1i.EC1UCYEF��'�Q6tG'E7rIS"7'cl - t.0 r,ro�bTs_ I ow R_ezPag' "P3wH4t5 c ao _ 5 ` 1 "zo Q94 - -_ ' M�Im rma E r . � ,-•.. '::..._ .I _ :, 6�Q11_V_'3.9€-`�6S'S TF11C FC_q R,�� . 7 .....__.._. ..KPEI`,-vvAu... '---�l- r .•� (v. IY:�. for - _ _..4�_J Q - .:.:. ..::, ._.-_.._.._. EXlis`Scb7'�I_<70'B-CagniYC� � •:. 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