HomeMy WebLinkAbout0063 EAST OSTERVILLE ROAD - Health 63 East Ostery lle Road.
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NOTICE: The Town of Barnstable
recommends that the applicant
seek legal advice to prepare a
properly worded deed
restriction document.
DEED RESTRICTION
WHEREAS of
(owner's name)
MA
r (address)
is the owner of lc located
(address O /
at n — b
MA (hereinafter referred to as
and being shown on a plan entitled "Subdivision of Land in
MA, Property of 0!L K ('n (6 • A�
et al, duly recorded in Barnstable County Registry
of
Deeds in Plan Book Page ;
Or on Land Court Plan Number
WHEREAS, 6 , �t,���— as the owner of said lot has
(owners name)
agreed with the Town of Barnstable Board of Health to a restriction as to the
number of bedrooms which can be included in any home built on said lot as a
pre-condition to obtaining a disposal works construction permit in compliance
with 310 CMR 15.000 State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage;
WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to
granting a disposal works construction permit for a septic system in compliance
with 310 CMR 15.200, State Environmental Code, Title V, Minimum
Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing
the issuance of a building permit for the construction of a single family home on
this property, is requiring that the agreement for the restriction on the number of
bedrooms in any house constructed on the lot be put on record with the
Barnstable County Registry of Deeds by recording this document,
deedr
NOW, THEREFORE, KA11 G-1�1— does hereby place the
(owner's name)
following restriction on his above-referenced land in accordance with his
agreement with the Town of Barnstable Board of Health, which restriction shall
run with the land and be binding upon all successors in title:
1. �0o 9A- "' may have constructed
(address)
upon the lot a house containing no more than J ( ) bedrooms.
e ! R-t\N&L_ agrees that this shall be permanent deed
(owner's name)
restriction affecting located on MA, and
being shown on the plan recorded in Plan Book Paged <<j
Or on Land Court Plan
For title of see the following deed: Book -S Page
— . Or Land Court Certificate of Title Number
Executed as a sealed instrument day of !V
Owner's signature
Owner's signature
Owner's signature
COMMONWEALTH OF MASSACHUSETTS
`` �Q' ••�j,iSSipN�'��
ss
20B
�.
Then personally apper/ dth/^pe above-named obrr •' ;'�
ACM ,.
known tome to be the person who executed th foregoing instrument anc�
acknowled ed
the same to be free act a d deed, e4foree,�LDAiV�
Notary
Public
My commission expires: ,� r
,J (date) L�w
deedr BARNSTABLE REGISTRY OF DEEDS
John F. Meade, Register
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 EAST OSTERVILLE RD __ y
Property Address
RANGEL _ "-
Owner Owner's Name
information is OSTERVILLE MA 12-18-16
required for
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information S� o
forms on the
computer, use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN _
cursor-do not
use the return Name of Inspector
key. D.A.BROWN INC
Company Name
r� P.O. BOX 145
Company Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
508-420-4534 S14297
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. 1 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
�� 12-18-16
Inspe�rs �ture 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for O_STERVILLE MA 12-18-16
-
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM IS FUNCTIONING PROPERLY BUT THE SEPTIC TANK IS ONLY 1 FT OFF BACK OF
BUILDING. BACK OF BUILDING APPEARS TO BE A PATIO THAT SITS ON SONO TUBES.
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):
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
REM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every page. Citylrown State Zip Code Date of Inspection
B. Certification (coat.)
❑ 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 ❑ 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•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every 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:
THE SEPTIC TANK IS ONLY 1 FT OFF OF THE BACK OF THE BUILDING. THE ROOM THAT THE
SEPTIC TANK IS ONLY 1 FT FROM APPEARS TO BE A FORMER PATIO THAT WAS
CONVERTED TO A ENCLOSED ROOM. IT APPEARS TO BE ON SONO TUBES.
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ms•3/13 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
63 EAST OSTERVILLE RD_ _
Property Address
RANGEL
Owner Owner's Name —
requinforma
retion is OSTERVILLE MA 12-18-16
required for
every 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.
❑ ® 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 drinkingwater supply
PP Y
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive r
El Ely g t e area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
P PP Y
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.
t5,ns•3/1 3 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
_-_- -
every page. CityrFown 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
t51ns•3/13 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
63 EAST OSTERVILLE RD
f Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
A SEPTIC TANK AND ONE LEACH PIT WERE FOUND.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2014---------307 2015--------337 GPD
Sump pump? ❑ Yes ❑ No
Last date of occupancy: CURRENTLY
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: ---- - - -
t51ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal
System•Page 7 of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENTLY OCCUPIED
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):
TANK AND PIT LOCATED
t5ins•3/13 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
63 EAST OSTERVILLE RD
Property Address
RANGEL _
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
_ _ -
every 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:
APPEAR TO BE ORIGINAL
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: - -
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.):
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: 1000 GALLON
Sludge depth: VARYING _
t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
G,M 63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
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
Scum thickness LIGHT
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.):
TANK WAS ONLY 1 FT OFF OF THE BACK OF THE HOUSE. AT TIME OF INSPECTION IT WAS
FUNCTIONING PROPERLY.
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
t51ns•3/13 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 63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owners Name
information is required for OSTERVILLE MA 12-18-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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.):
I - -
Attach copy of current pumping contract(required). Is co attached? Yes No
PY ❑ ❑
151ns•3/13 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
,M 63 EAST OSTERVILLE RD
Property Address
RANGEL _
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every 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 N.A. -
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,
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:
t51ns•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
m Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63 EAST OSTERVILLE RD
Property Address
RANGEL _
Owner Owner's Name
information is required for OSTE_RVILLE MA 12-18-16
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1 FOUND
❑ 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.):
THE PIT THAT WAS FOUND HAD ABOUT 20 INCHES OF USABLE SPACE AT TIME OF
INSPECTION WITH NO SIGNS OF FAILURE OR HEAVY STAINING.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every 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.):
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•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 63 EAST OSTERVILLE RD
Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every 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
® drawing attached separately
t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' M 63 EAST OSTERVILLE RD
Property Address
RANGEL _
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
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: GREATER THAN 5
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:
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
Commonwealth of Massachusetts
W0 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M a, 63 EAST OSTERVILLE RD
\ Property Address
RANGEL
Owner Owner's Name
information is required for OSTERVILLE MA 12-18-16
every page. CitylTown 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
t5ms•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 17 of 17
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ACCESSORY AFFORDABLE APARTMENT
SEPTIC QUESTIONNAIRE
FOR STAFF USE ONLY
1. Is the dwelling connected to Town sewer? ❑ Yes k No
2. Dwelling located ❑ INSIDE ❑ OUTSIDE the Saltwater Estuary Protection Zone
3. Dwelling located ❑ INSIDE ❑ OUTSIDE public supply well Zone of Contribution
4. Dwelling is connected to ❑ ON-SITE WELL ❑ PUBLIC WATER
5. Disposal works construction permit on file? ❑ Yes ❑ No
6. If yes, how many bedrooms were allowed by this permit: bedrooms
7. Were building permits obtained for additional bedrooms? ❑ Yes ❑ No
8. Engineered septic system plan:
a. On file at the Health Division? ❑ Yes ❑ No
b. If proposed accessory unit is detached from principal dwelling, is that plan
on file? ❑Yes ❑ No
9. Existing septic system capacity is bedrooms
For the accessory unit to receive approval from the Health Department the
following action must occur:
❑ Existing system accommodates proposed additional bedroom(s)
❑ Upgrade existing system to accommodate additional bedroom(s)
❑ Must remove a bedroom from the main house
❑ Must connect detached structure to the existing septic system
❑ Must install septic system for the detached structure
[�1s Other -F;a- III rjom �24 he tea& no•/�w u
rern`�v i�� �.0�f S !a• C� �7 !i l s� M i� n„� !'C,'/' �u� Kt���eti 1�S
l n jV61 K2
Signed /?2c Date
2
Health Department Drop-Off Hours: 8:00 AN — 4:30 P.M
Town of Barnstable Received by Health
�of1HE Regulatory Services Department on
Richard V.Scali,Director
• BARNSI'ABLE.
b 9 ,e Public Health Division
P'ED1A"� Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
ACCESSORY AFFORDABLE APARTMENT
SEPTIC QUESTIONNAIRE
Property Address: (0 ,
Assessor's Map/Parcel Numbe��V�2-0
Applicant(s) Name: �� ��P R- 0 6`G L
Phone:���5-ot t y�-�-(� E-Mail: �u tr,lc�40 rctc,...Q
Size of Lot: 0 t
2a. How many bedrooms exist at your property now?
2b. How many bedroom are you planning to add as part of the Accesso�y
Affordable Apartment Program application? � �
2c. How many bedrooms total are proposed at this property (including the
Accessory unit)?
2e. Is the proposed Accessory Apartment contained within:
V the main house; OR
a detached structure
2f. Submit floor plans for all buildings on the entire property.
Show all existing rooms in the dwelling and the proposed
accessory apartment. Label each room clearly. Label measured
width of all open doorways. Use straight edge for hand drawn
plans and be sure all labeling is legible.
` —
Signed: �"���4�^^'` L ��_Ojo Date: C0
l
No. ......75.. Fss...�.5...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
`..---.....OF......
Appliratinn for Dispuiittl Works Tonstrur#uan t rrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
systt ••-....__- ••�.-.-.... �`--•-•••-----.�-�------------•--------------------------•-•••--
Locat -Address / or Lot No.
- --- -
Owner Addresp
'a Installer Address
T e."&4
uilding Size Lot___ feet
U g— .Expansion Attic ( ) Garbage Grinder ( )
,.�.. Dwelling No. of Bedrooms----------- ------------------------------
pa Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ----- '�- ------------------------ -
W Design Flow___________________��_-0...............gallons per person per day. Total daily flow_._...__._3.9_U.....................gallons.
WSeptic Tank—Liquid ca.pacity,Lo. 6ns Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width... .... Tow Length._.____._...____._ otaWeaching area....................sq. ft.
Seepage Pit No.........l ame nl ___ _____________ leaching area____ ft.
Z Other Distribution box ( ) Dosing tank7rofTest
Percolation Test Results Performed by.r _X _ _ ........................ Date_._.fC_-;4:.?7...._.........
Test Pit No. 1__,4?-_____minutes per inch Deptt____________________ Depth to ground water........................
Li, Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
x .................................. ........... ...........
O Description PPf So' _ ____ __________ ____ - --
U
W
UNature 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 issued by the oard of health.
agne r._.... _... � .. �/ ••. ..._
Date
Application Approved B
PP PP y----•-...... { ...... .!` f -- -•--•--------•--. ..._ •11 -. = 7 7.
Date
Application Disapproved for the following reasons:--__•_______________________•___________________________________________________.._._...__-____________________
-------------•----•---------------•-----•-----------•---------------------•--.......__...--------.---•-•--•-----•-•-••••--•-•-•••----••-••---•----------------------••-------••-•-•••----•---•---
Date
PermitNo......................................................... Issued_.......................................................
Daft
No................ .. FEs.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H A H
---------------------- ......... OF.....:: .. --
Appliration for Disposal Works Tonstrnrtiun Frrmit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
................................
Location Address // o�t No.
... 5% r.................•-•--•-•-•----•----•--........... ........................... -•---.... .:..............
Own Address ....... ...-
Installer �LA� Address
d Type of Building Size Lot..1 _ '� Sq. feet
Dwelling—No. of Bedrooms................................. .Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building .._..._...._ No. of persons............................ Showers — Cafeteria
a YP g --------------- P ( ) ( )
04 Other fixtures ---------------------•-
r r7P..............gallons per person per day. Total daily flow..._.._..1.4 ...._.............._gallons.
W Design Flow................... -g P P P Y• Y ••----
WSeptic Tank—Liquid capacit/.4 al`ro-ns Length................ Width................ Diameter---------------- Depth................
xDisposal Trench—No. .................... Width____......_..._..._ To 1 Length............ : To leaching area....................sq. ft.
Seepage Pit No...........' am _______________ > ._ :._ ..... : to 1 Ching area.... 0 2..sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) d '� J f"
77
aPercolation Test Resu is Performed by j'X Y.___. .__ ..................... .Date.._11-: . i_ ...............
Test Pit No. 1.,,�," ......minutes per inch Depth of Test it.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 ! p------------ ------- ..t......--'* ...............
O Description of So `" .... _" A + !Z '� �' j `"' •!!�!'!�
v .. ...... Rs4.GC ...................................................
W - ----------------••----------•--------•-••-----------------..............
U Nature of Repairs or Alterations—Answer when applicable._____•........................................................................................
....., ..--•-
Agreement
The undersigned'agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1,, 5 of„the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Complianceas beeri issued by the' oard f.health.
Sign ......
-----------• ----
Date
Application Approved By_—..... {.. ----------- - ---.......... . ............--•--- ..... "-�- �-...._..
Date
Application Disapproved for the following reasons---------------------------------------------------------------•-----------------------••-----•-------•-----....
-----------------------------------------------------------------•-......•-•-•-------..........------------•...---•----••--------'--•-----------•------------•-------------------•••--------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTFt
.....OF..........
Trrtifiratr of Tout rlianrr
THIS IS TO CERTIFY Tha e Individual Sewage Disposal System constructed ) or Repaired ( )
by ..... --- �.... ................... ..............................-- - - .............................. . -----...------.......
alley
at-:. � ��----- .. ----- -- •------- ..---............................. ......................
has been installed in accordance with'the provisions of � F 5 of The State Sanitary Cede as d cribed in the
application='for Disposal Works Construction Permit Nol,,e%__ 21 f................ dated-..�-'_:--2 P-777._________._._._.
p};'TkE ISSUANCE OK THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYATEM WILL FUNCTION SATISFACTORY.
DATE._ ...,1��....... .................. Ins pector.......... -.1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT
Gl ...OF....!' C '..
f
No......................... FEE........................
Disposal Works (ton n frrinit
•
11
}Permissio is y granted �'-........................ ........................................................
to Construe or Repair ( ) n I dividual Se age Dis o Sy t /
_,/
atNo...- - - i S�"�----------- •----- -----...........................
' Street '
as shown on the application for Disposal Works Construction P N ._ Dated_.�l"__2._' 7
401-------- ---------------
-
Board of Healt
• h
DATE---- - (/ ----------------------------------------------- a
\ FORM 1255 HOSES & WARREN. INC.. PUBLISHERS
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