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HomeMy WebLinkAbout0216 EBENEZER ROAD - Health i 1) EI3ENEZER ROAD t ea } ` Osterville } aIt A — 122 - 088 w, I i` �j S M EAD No. 2-153LGN UPC 12134 smead.com • Made In USA .e"' SUSTAINABLE FORESTRY INITIATIVE Certified Fiber Sourcing —Afiprogramorg No. Fee 1 17V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliLatlon for 30ispoBal *pstrm ConstrULtlon permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 'a/ -r'9%ne 1Z,cA 4 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel l Z 2/O S � �`c � � vi rvw--'`'3 Installer's Name Address and Tel.No. Designer's Name,Address,and Tel.No. e_4p2w.,(Le l�'�ylt�'�°a�eS S o 8 y77 - a T7 3 3 G v i+vr-.a sum-9 IS rd ter' c rr� wr.h 1 Type of Building: -1- Dwelling No.of Bedrooms Lot Size ZZ� Cep sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Jj Grp) D r3,hr�1_A-?L-, �. u ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H Signed Date Application Approved by Date Application Disapproved by kj Date for the following reasons Permit No. �.G 5 v '1 2 Date Issued No: go 1 �� Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _ r Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS . 01pplicatioii for Misposal 6psteiii Construction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4�r3e,j-e Zed 2o4 cR Owner's Name,Address,and Tel.No. Assessor's Map/Parcel. / Z 2 O S$ ti �( Installer's Name,Address,and Tel.No. s 6, 2 M 7_7 7-_) Designer's Name,Address,and Tel.No. 3 �o/n w�/U lA�► S r�c-e.i- .�>V . ��� .t Type of Building: , Dwelling No.of Bedrooms ' ` Lot Size 2 2/ 000 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) / gpd Design flow provided gpd Plan Dare 14 Number of sheets Revision Date Titie Size of Septic Tank Type of S.A.S. Y Description of Soil i i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance.of the afore described on-site sewage disposal system in ` accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of He Signed Date Application Approved by Date,_)� — S Application Disapproved by Date for the following reasons 1,5 `l Date Issued / Permit No. G 2 �a THE COMMONWEALTH OF MASSACHUSETTS u� BARNSTABLE, MASSACHUSETTS �R Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by _►'-I.9 pt.o i eke L ,.I tr �1 I!- at / . .mod o S.Iry li r ..- . has been constructed-in accordance --- -- with the provisions of Title 5 and the for Disposal System Construction Permit No.�fl/S dated Installer ow 6 , (r�?-� L l.c. Designer n r #bedrooms Approved desi n flo_�1 gpd The issuance of this ermi shall not be construed as a guarantee that the system wVILAVnlction as designed. Date 1 Inspector - �C ---- ------------------------_------------------------- -----------` -------------- No. ��t Fee ------ ---y;-----------------------------------THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS t Misposar 6pstem Construction Vrrmit Permission is hereby granted to Construct( ) Repair(>) Upgrade( ) Abandon( System located at rr1-eZ-elf, (2.10 j 0 S w� and as described in the above Application for Disposal System Construction Permit. The applicant recogn'zed his/her duty to comply with Title 5 and the following local provisions or special conditions. j Provided:Construction must be completed within three ears of the date of this permit. f _ P Y p Date �� / S Approved by Varfn W,,�An Ala- 4J 1 ry S TOWN OF BARNSTABLE LOCATION C,(3E.M.t=ZeP_ RnAJO SEWAGE# 0101-5' q-; -7 VILLAGE 65i CVV(L.C. ASSESSOR'S MAP&PARCEL a INSTALLER'S NAME&PHONE NO.eA PEW LD6 EJJTV?QISE'S U-C- SEPTIC TANK CAPACITY N L pr LEACHING FACILITY:(type) (size) NO.OF BEDROOMS p,e D 4,,X OWNER C VGLYA! MCe?_ls 6� PERMIT DATE: COMPLIANCE DATE: l a.-3 r aol,5 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on l p site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) j� �9 Feet FURNISHED BY �AQ6waZ� L �rJ'�� 'S LU PC- 0 0 A,1 =a®i 3 A-3 -.30 A 3, 0- 4 : fto -5 = 2-7 o sir ` Town of Barnstable �O4 °lyti Barnstable Board of Health IARNSfABM MAS& 200 Main Street,Hyannis MA 02601 , 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: '508-790-6304_ Paul Canniff,D.M.D. Junichi Sawayanagi November 29, 2015 John W. Kenney, Esquire 1550 Falmouth Road, Suite 12 Centerville, MA 02632 RE "216 Ebenezer Road Ostervllle Number of_Bedroomsr Dear Mr. Kenney, You are granted approval, on behalf of your clients Richard and Evelyn Morris, to maintain five (5) bedrooms at 216 Ebenezer Road Osterville. On November 10, 2015, you appeared before the Board of Health to represent your clients, Richard and Evelyn Morris, concerning the number of bedrooms at 216 Ebenezer Road, Osterville. You testified that there have been five (5) bedrooms in existence at this property since July 1989. An affadavit was submitted from the owner of this property indicating the same. A floor plan was also submitted showing the layout and locations of the five existing bedrooms. You also testified that the septic system was upgraded at that time, with the addition of a leaching pit to accommodate the additional bedrooms. The system was upgraded within days of issuance of the building permit. In addition, this property was apparently located outside of any of the public water supply well zones of contribution at that time. A copy of the Town of Barnstable Public Supply Well Zones of Contribution Map dated 1987 and revised in 1989, prepared by SEA Consultants , Inc. Boston Massachusetts was submitted for the record. Based upon your testimony and the information provided as described above, the Board voted unanimously in favor of allowing a maximum of five (5) bedrooms to be maintained at this property. S*Ier, M.D., Chairman Q:\WPFILES\KenneyBedroomCountDecisionEbenezerRoadOsterville2015.doc AFFIDAVIT I, EVELYN MORRIS, being first duly sworn on oath depose and state that: 1. My husband Richard and I purchased the property located at 216 Ebenezer Road, Osterville, MA on June 28, 1983. (See copy of deed attached hereto as Exhibit 1). 2. The model style of our home is called "The Crosby". The standard Crosby style,home was a two-bedroom home with a base price of$53,900. (See Floor Plan for the Crosby attached hereto'as Exhibit 2). 3. The Crosby had as.an option a third bedroom located_ on the second floor (see Exhibit 2- upper right hand corner). 4. We elected to include the third bedroom as part of the home we had built - increasing our purchase price to $67,000 (See Agreement of Sale page 1 and page 3 paragraph B 2) attached hereto as Exhibit 3). 5. Our home was inspected by the Town of Barnstable Board of Health on April 22, 1983 and an Occupancy Permit was issued on June 28, 1983 (see copy of Occupancy Permit issued June 28, 1983 attached hereto as Exhibit 4). 6. My husband and I and our four daughters used the home at 216 Ebenezer Road as a summer family gathering spot.' Between 1983 and 1989, three of our daughters got married and started families of their own and our fourth daughter become engaged_. My husband and I decided it was time to enlarge our Cape Cod home to accommodate our growing family. 7. In 1989, we commenced construction of an addition to our home on Ebenezer Road. The addition included converting the existing garage to a family room; dining room; two-car garage; two full bathrooms upstairp,; and two bedrooms upstairs. (See Floor Plans of ho,use attached hereto:as Exhibit 5). 8. Prior to commencement of construction, we were informed that we had to increase the size of our septic system to accommodate the increase in bedrooms from three to five. 9. We hired Hickey Construction Co., Inc. (hereinafter "Hickey') to increase the size of our existing septic system by adding an additional 1,000 gallon leach pit (see proposal from Hickey attached hereto as Exhibit 6). 10.Hickey installed the additional 1,000 gallon leach pit on March 8, 1989 (See copy of Invoice from Hickey attached hereto as Exhibit 7). 11 The work on our septic system was done pursuant to a permit issued by the Town of Barnstable,Board of Health on February 27, 1989 (See Application for Disposal Works Construction Permit No. 89-1.15 attached hereto as Exhibit 8). 12. Permit No. 89-115 is marked Repair(s) and the Nature of Repairs is identified as "Add one,1,000 pit with 2" Stone to Existing System" (See Exhibit 8); 13. A Certificate of Compliance was issued by the Barnstable Board of Health on March 9, 1989 (See Exhibit 8). } 14.After upgrading our septic system, we immediately began constructing the addition to our home. We completed the addition in July of 1989. 15. From July, 1989 to the present, our home has always been a five (5) bedroom home. 16. Although I have been informed that our home is now located in a Zone of Contribution to a Public Well Supply which would prohibit it from being a five bedroom home if it was being constructed today, in 1989 it was NOT located in such a zone (See copy of portion of Town of Barnstable Map showing Public Supply Well Zones of Contribution Revised September 1989 attached hereto as Exhibit 9). 1 have marked the approximate location of my home on the copy of the portion of said map, showing that it is outside of any zone of contribution. 17: Also attached is copy,of a portion of the current Town of Barnstable - Zoning Map amended as of February 6, 2014 showing the location of Ebenezer Road (See Exhibit 10). , 18.Upon information and belief, the 1989'Map showing Zones of Contribution reflects enlarged zones which were adopted by the Board on November 4, 1989, several months after completion of the addition to our home making it.a five,(5) bedroom home. 19. My husband, Richard Morris, died on November 21, 2014. 20. 1 am in the process of selling our home and have it under agreement for sale as a five (5) bedroom home. 9th Executed under the pains and penalties of perjury this day of November, 2015. qJA-P 146&-- A-I EVELYN MORRIS - EXHIBIT Uo0a.3783 rat( 299 24040 I, RARL L. SOLLOWS, JR., Trustee of OSTERVILLE HEIGHTS REALTY TRUST; under Declaration of Trust dated July 22, 1982, and recorded with the Barnstable County Registry of Deeds in Book 3524, Page 331, j of 129 Airport Road, Hyannis, Barnstable County,xssaaahuaetts, In consideration of kSIXTY-SEVEN THOUSAND AND 140/100 ($67,000.00)•DOLLARS pain grant to RICHARD R. MORRIS and EVELYN L. MORRIS, husband and wife as tenants by the entirety, both of 10 Hawthorne Road, Wayland, Massachu- setts 01778► • A� w(th quttdaim tauenants the land*x together with any buildings thereon, situated in Barnstable Waterville), Barnstable County, Massachusetts, bounded j and described as follows: i NORTHEASTERLY by Lot 57A, as shown on plan hereinafter mentioned, one-hundred fifty-six and 29/100 (156.29) feet; EASTERLY by the sideline of Ebenezer Road, as shown on said plan, by a curved line having a radius of two hundred thirty-nine and 60/100 (239.60) feet and an arc distance of one hundred sixty-one And 93/1 AA (161.2A) feat.; SOUTHERLY by portions of Lot 39 and 400 as shown on said plan, one hundred twenty-three and 87/100 (123.07) feet] and WESTERLY by portions of Lots 58, 59 and 60, as shown on i said plan, two hundred forty-one and 28/100 (241.28) feet. Containing 23,763 square feet, and being shown as LOT 57B on a plan entitled "Plan of Land in Barnstable (Ostervf e), Mass. for Peterson Enterprises, Scale l" a 60' April 15, 1977, Baxter & Nye, Inc., Registered Land Surveyors, Oaterville, Mass.", which said plan is recorded at the Barnstable County Registry of Deeds in plan Book 316, Page 92. Said promisee are conveyed together with the right to use all of the roads and ways as shown on the aforementioned 'plan and the roads and ways shown on the Land Court Plan No. 32225•-B with Certificate of Title No. 63052, as all public ways may be used in the Town of Barnstable in common with all others entitled thereto. For title see Barnstable County Registry of Deeds, Book 3635, Page 299. j • .;...,,.,fir;o � t��••::t '• i Y �r "`�� �'dL�� J Zr 1 b ' r 1 - �Cal:•hi.• SN �$ 8t p'3°j,,f gOntlxo uo;m�wwoc dye .?a��a 1 H �i,� mu m00aptimii—Owd 4AM .'Cut IInS 1 i ea�enay 'POOP PuC eoa OW) $T4 qI&I luolurui !SUiORNol MD PdPOimoq.m PUY •tr aMoTTOg 'q TAGN pOwiru"ll aq;Pa>t dv Vjj wmad uOu test aunp .Os 'aTc(e�suzs$ Oita" W WNMU"V ' t i i ea-4snal "IXF,"eMoTT Tavx '£8 6t eunr jo AeP ¢po 1110wnalsui"two a aC p"Mom i 1 1 I - Doe era SB�g�oo� i { z 1 aed Lot,..,.x;:.:;.. .. InclEXHIBIT • ,: Two Beelroom%�Rar'c Z F h - u-1'I�Bat:hs- TI ." • ;C)p7rIUNAL. CX-TRAS 1 ,b..E.0 K - -� r N 1 a'E p.R.0 WA '.. I I I 19 - :`• I Y ('N t7 R .0m` y, IBi 21 1 a i � EX�6 f fix; t; 1 3 i 05'2ERVLLLC +E� 1•GHTS, AGPZ-Di qr- OF, SALE LOT .57 I ST F;hPnPwr Rr�a I d MASSACHUSms tI AGI made th2s_ 2nd day of April , 198 3- , bettaeen: QSPE VX7� HEIC �'IS V, &TX TRUST, a Massa'cl-usetts Uszr ess corporaticxn, of :129'Ai y rG Road 8axnstable; (ktyannis)', ;N�assachusetts ; '02601 ,. hereireafCer _ +�q� - ' referred Co as 'SELLER :an kC!-MRD R and EV ,T,� MQPRV� of 10 Hawthorne i rea:nafCer referred. to' as BUYER.. WTt'ESSEI�-i, that the S'a- LER agrees to .sell. and convey,, and the. BUYER agrees to buy that lot!, of land with the house to b.e const:i-u;~ted thereon, sic- and�n, the area lsnrr.�m as asCervill& Heights, located, an Bamstable 0steivafil ):, ,$arristabl;e County, Massachusetts., being s`hosan as oii a certain .plan fled with the Barns tab7:e Ccuncy Regis r•.ry o Deeds , Plan Book: ;316: page :g 2 Said ses:t,axe t be conveyed: b3► :a good and- sufficient quitclaim deed pr rur�namg to the BUYER which.•shall convey good and maxketabJ e t�. le free from all enctrnbrancea except zoning and building laws -and regulations, utility eas 'rits; locared:ir► thej;s.treets arid, ways and in strips of land :ten, feet (1.0` )v in w dCh I`` h3 i" n•7 i P ou�,on ts. . ' stxe.Pts and ways and tY e r�PCs of all Chose lawfull. entitled. thereto, to use the: st ,eets acid ways. as, shb;gyj on,s;a� ,lan; and the zeal estate taxes for the cuxxen� year,. SMLER.agrees ro ;cons t-ruct a house anon fire premzses s d-lar to tl-� type cal► he led T .,Crosby of" the •models: located at said os:cerv ;l:l.. ;'lights on•,:d_zsplay therein and: in substantial conformity wath said rr�del S-aa.d cons:trueiri;on wi ll, be in accordance with the: pl.ais .and specifications attached h'reto and made, a part, hereof,:. _ : the: purchase price for the premises. is S;1X.TY THQUSAND acid "06710,0. Dollars ( 6,. '`0 - - ) , payable as fol lamas:. } =-. S 6., A'0 upgn the: sign of this Agxeerpent, of Which 500 . o0 has previously been paid; slid in cash or by, certified :check at the time of the delivery= of the deed as herein-after povded, I The deed shall be. delivered and the conszdera:Ciori paid on or before June 24, 198 1, at .11 A.M. , ac the Barnstable "Comty Regis Cry of Deeds,; BUYER. will reimbutse STLJ R for travel expenses involved for an}? closing ni. held. iri the County of .DarnstabLe,. t E - Takes for the- then current year are. to be apportioned-as 'of the date of:th delivery of the deed. : ItAs understood and•agreed between the parties hereto that this Agreement cannot be assigned` by;the BUYER without the written consent of the SEUM. If: the SELLS shall be unable to give title or to m8ke;canveyance as above stipulated, Chem the: SELLER shall be given a reasonable lime; rot- exceeding thirty '(30) days, fin-Ohich to remedy ariy such defeat in' title•of ter receiving notice thereof from the BUYER and if,, after the time thus:aLIlm ed has elapsed, the SELiER is «,nab e: eo convey title as hereinbefore provided, 'ariy payment made under shi.s A&ek�ent shall be refunded*aand:all other obligations of either. party hereto-shall' cease, and this Agreement shall be.void:kd without recourse do either party. 'It is agreed, hdwever, .that-the BUYER cnay--, at his election, accept such-title as the•Sla-M can deliver to said pi*d.ses.withmut deduction In the purchase'price!thereof. , aind o The acceptance of a deed by the BUYER shall be deemed to be a e perform ance and discharge of1every agreement-and obligation herein'contr ex- pressed, except such as are, by the expressed terms hereof' to be perforind after the•.delivery; of;the .deed. To enable the SEIrM to make conveyance as herein provided, he may, if he so des ices, at the tine of the delivery.of- the deed, use tYie,:purchase money • or any portion thereof to clear the tithe of arty or all' encia�brances -or interes ts -all ingtrtn�ts so:'procured to be recorded simultaneously.'wri6i'the recording of%said deed. M If' the'SELLM"shall.be unable• to complete.gonstrvetLm:,as- prnvi.ded above due to:an inabil.3.ty to •obtain labor, subrofitractors, s.resulting �_ -frown disputes, strikes, ]Lb*outs or sind lar happenings: of-46e tc w Cher co, tions, alb, beyond the:SE[M's control, then and:at the 'o�tiori of• ,ttid SEE,LER, delivery may be made in accepdance with this Agreement wit ;-a reasonable time after the date of. delivery as herein provided s. but in no event longer than ninety (90) days.unless mutually;agreed in writing. The:SEL•TE12'shall iwt be liable for any images to the BUYER due eo extehsi.on of 'tlw` elilery'date. upm damage of the premises by fire or other, casualty, the time'for'performance shall be extended up to sari additional ninety .(90) days to restore-the prmdses (ex�- cept for trees) . The BUYER shall.,, prior to the execution of this Ageheamr- by the BUYER, make all optional col6r, material, and fixture selection's and all extra selec- tions so that the SM*TIER may complete the house.using the SELLEt'•s "Selection Form and Condition's of Selection" which are attached to this Agreement and made a part hereof`.. I£ the.BUYER.sha4 fail to fulfill the BUYER's agreerneints,herein, all de fail the BUYER shall be retained by the SELLER as liquidated 'daanages. - . -2- A. ;Other Provisions: A, Buyersjgnter this contract with the expectation that they will be able to obtain a mortgage - in the amount of $ 41,Lf/C)r-)o . at prevailing interest. .,for,,for th.e term, of -30 ye,ars:. if Buyers shall be unable- to obtain such commitment, on 'or before 30. days, before closing, Buyers shall notify 8'e% -r's. attorney 'of their failure to obtain such :commitment and if, such notice is given b.y Buyers to. Sel er' s: attorney, Sellers shall return to" Buyers all monies paid, by the 'B.uyers out of this contract, and Buyers shall i have•no further interest whatsoever in, the. pr.emis.es described her ezn . x'f Buyers 'shall fail. to give such notice t_o "Sealers attorney, the Sellers may assume 'that, tuye'rs 'have obtained su:ch, comm tment or have made: other arrangements far p;a.yin.g funds_ wh.icY , Buyers need to :fulfill ,Buyers obligation hereunder. 8:. purchl s.e ptice to" include :' 1): S�ing'Ie ar garage; 2} S"econd fYlo.or room finished as per Route: 28 model to, include heating, -'closet, carpeting, skylite and window at gable end; 3) Fireplace with cellar flue.. hoo's0, D ar d, ft :bcdcbom+36s. All" deposits made hereunder .shall. be '.held by Seller as, earnest` money for. the proper performance of this Agreement on the -partz of :the: Buyer subject to the Tterms, of this: Agreement and shall, be du1:y accounted for at -the Time; o.f Closing' without- interest; it being understood that the Seller may use -the same in "the: course of construction' of the above; described premise! ThL.',R er: warrants and ;represents -1-' n:o agent :.or .broker other. than. ADRIENNE G,; SIEGEL :has ,shown" or re- erred the Bt-,ypr to. th:e above describe( ,prem-i,seS:. Buyer will indemnify' .and. save the, Seller harinles'S from any c].aams commission and, expenses and fees. arising therefrom made by any person other than ,ADRIENNE �G. SLEGEL .of Shields Label Realty, Inc. based on the allegation that the cIla' mant' showed- or referred the Buyer to the wit:hin. described premises. " 'Phis, his instrument, executed in quadrupl cat-e is to construed as A Massachusei Contract; is to tak.e 'effec.t as: a sealed instrument, -sets forth the entirE contract between the parties, and inay. be caricell:ed, modified, or amended Only' ,by. a written instrument 6kecuted. by ,both Buyer and. Seller. 2nd April: 1983 This Itistrument,executed this day of is.'to be,construed:as a.Massachusetts contract;;is to tape a feet as.a sealed instrument; sets forth the entire contract between the arties:and m'ay be c-d' led,modified or amended onk?by.a tiyntten instrument executed by both.seller and Buyer. L. SHIELDS-LEBEL-REALTY,INC; SELLER':, By:. BY i.z;enn"� G. - le.ge ar. o aws , J,r: TROSTEE t By;. _ BUYER: R ar R_ Mor3cls. j ,...:... ,..:._ ve ,yn. rr-xs EXHIBIT ; 4 o TOWN OF BARNSTABLE Permit No. 24983 - g P BuRdin Tns ector I s 1 Cash .... . .7ae AMIL ..... 1610. - x tl1 - } OCCUPANCY PERMIT Bond -- -- Issued to OSterville Heights Realty Address Road Osterville' j lot #57 � 2lb Ebenezer wiring inspector ! L / Inspection date plumbing M2spec Inspection date Gas Inspector Inspection date Engineering Department jAwe., Inspection date Board of Health Inspection date ~ THIS PERAW WILL NOT BE YA ID, UILDXNG SHALL NOT BE OCCUF11M. UNTIL SIGNED BY THE BUILDING INSPECTORiJPOly SATISFACTORY COMPLIANCE WITH TOWN RE,QUMEKENTS AND IN ACCORDANCE WITH SECTION I19.0 OF THE MASSACSUSETTS STATE BUIIIMING CODE. Builriing uspector • EXHIBIT I I I LIJ ex cv Llpl3p�,\ t P,5ec-,q„} Qa�R tiL V � e.a-4..sha ItA of h O J�t ICKEY EXHPBY U n jl S wam4acaan WO. Aw.c. j �3aznataGle; �dfie Glod 1',ala sal Su rr» t ted to:: lJor^k to b46- far- ed :.a.t b"ick Morris 216 Ebenezer Road O:sterville. i We 'Hereby propose: to complete: the f011oW,JL,ng Work at 216 Ebenezer Road' If in ;Ostery lle: Adcf 1 one thousand'' gallon (-6XiO leachzn.g pit 'with two: f"eet o€°_'stone toexiksting septic rosystem. j . . I � Total. Cost {. $1,92O.'O0 Terms. Full 'payment due :upon: competron Ndt!es l) Prmice is based., on entering. �Pr:operty' fr.orti north' side of House, l` reoving only enough. trees a',. needed to— get, equipment thro.ug,h to {{ ,Per,for-m work.: f Y 2..) Dump fees to :be pald by Hickey Cbnstructa on; Co..., Inc.. 3) Repair' perm t to be taken, out by Hickey Construction Co,. , Inc.. 4), Unde.rgroun.d sprinkler ]sines to' be lo'ca.ted by o�.rner_ Hickey Co.nstruct< :on Co.. , Inc. will use care in' d ,sgi:ng around lines, but w t.l: not, be responsible for any damage'. to underground lines.. � HLckey ) Gonstruct,aon C.o..; Inc:. will :repl_a;ce loam and. rake dst'urbecl gat^-eas;, but. will not be r,espons.ib.le: for sodding br seeding disturbed areas.. 1 I I ' Respeot:fiu1ly Submitted„" ti Donald i'erk�r�s I - � QQqq j PO. Box 236'. Centerville; MA 026:32 617-771=412B EXHns1T CREY 15 N 9 PO.. Box 236 Centerville, MA 02632 3 2 7 8 9 DATE, j s T0. # Dek Morris` Ebenezer Road j DATE DESCRIPTION CODE AMOUNT3/8 `Install 1.,.000 gallon leach, p .t with two feet of stone to ekistdiitt s stem 1 1 9.20 . 00, 4 .1 4 i a l i I I ff 1 t . t _ TQ.TAT, l 9 2 0 Q0`_ ��■nvJCHUSETTS THE Co BOARD OF HEALTH ....................OF..... ft�wt!13!' [. ,,.....«............_..«.«..._._. •.... A41P attan .fux 11iupuuul uxku C uuu r r iun Permit Application is hereby made for a Permit to Construct ( ) or`Repair { Individual Sewage Disposal System at: -- _ zc . ,Le ...... ! ton ►r�S............................»... .....Loca ....Lot .................._........_:...._.�. Owner .«.... ......... .t:+C:!:`.: -.........»...................................._...... .......... �Q• {� L, JAddress r Installer Type of Address Building •- Size Lot.___ Dwelling---No. of Bedrooms................. ..-..-....•-..--.._-Sq. feet ,.a .....••---••••...........Expansion Attic ( ) Garbage Grinder ( } A, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ..--•.............................. Design Flow........................................_..gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid'capacity_...........gallons Length .... Width................ Diameter...... ......Depth............... Disposal Trench-- No.............:....... Width...........-•---....Total Length....................Total leaching area-...................sq. ft. Seepage Pit No..................... Diameter................. Depth below inlet................... Total leaching area..................sq. ft. Other Distribution box P { ) Dosing tank ( ) a Percolation Test Results Performed by.................«...................................................... Date....................................... Test Pit No. 1................minutes per inch Depth of Test Pit................... Depth to ground water.............._....... Test Pit No. 2.............,„minutes per inch Depth of Test Pit................... Depth to ground water.................. Description of Soil............}..:...........� S`:u�. ................« .."_«..................... ...��-S (" .........------- w .............................................................................«...._.........:................................. _.......... ..............................................•--------......._...._... Nature of Repairs or Alterations— ......... ..............--- ..------ -.._............ Answer when applicable..:.....! '?, ............. '�?. .�.. I...Ucvc�......_.... '.!� . greement: 4_,...«.__..�......... .......•................................................ 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 een issued by the board of health. . Sign ................:•` `.•.....�(---- ?:•:-:t --.............. »..��'. 2f?... r... Application Approved D c1C PP By.............. ..., ............................. ......... Application DisaPP roved for the f owing oll reasons: Date ........................................................................................ Permit No.......Cl..!..:...AS..........._ ........................................................................................ bate.........._ 00 .........--.._ Issued.........»..... .. ............ ................... -Date THE COMMONWEALTH OF MASSACHUSET7S. �:�'V?^� ,<:• HOAR . ,`,,,•°. .. •,�:A_..�:. �:�.- �':;?�,f�.F�. D OF HEALTH ......._... c......................OF......... .!:. :..+ti1.5.!.i!�.`�... ..:................... (9rx#afirtttr of (911m litturle THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( } or Repaired (L.-)—•— by..._.� .........!: .1c.. - ............................ .............................. Installer has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.........1��._J..!. • ^dated.................................«............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL. FUNCTION SATISFACTORY. DATE.....................«3...... ...:�F.o��............... .:f* . ........... Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....' .=1....../..t:.: ...... �-....k......... . ......oF.._...:L.L'.:�..r� r ..�f. .-,.................................. Diu xuu i uxku Tuustrurtion Permit . �.... .. Permission is hereby granted._...�� d �l• B.! ....._...J..... .... ....................:...............................................................»» to Construct { ) or Repair ( z Individual Sm� '-� osal System at No......l to........ .,r:.x.xJ.�..�.�.!�..__.........U...S ..............................-•..................«:.............................................. Street r•- as shown on the application for Disposal Works Construction Permit .... -. __. Dated............... ................I................. -•-e .. .........................DATE......... ..... S a Health ...............r.................................. �........ FORM 1255 :H088S & WARREN. INC.. PUBLISHERS lac 01 2015 '21:23 Jim The Inspector Man 5085349919 page 1 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form -Not for Voluntary Assessments 216 Ebenezer Road _ Property Address H Evelyn Morris Owner Owner's Name / information is required for every Osteryille / MA 02655 12-3-15 ' +--, 19P 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 A. General Information / ���uunurn,� olnithe comng out puter, use only the tab / ��`\...C. . �/ ��� ��+� • . 1. Inspector: key to move your =fir JAMES cursor-do not James DSears use the return key. Name of Inspector Capewide Enteprises, LLC % �`,'•°� �o ' ray Company Name I N 9P�Gp````�� 153 Commercial Street Company Address Mashpee MA 02649 Citylrown State Zip Code 508-477-8877 S 1623 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 12-3-15 spector'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•3M3 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 of 17 D VS Dec 01 2015 21:23 Jim The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is Osterville MA 02655 12-3115 required for every page. CdylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section ❑ 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 is a 1000 Gal. Tank D Box and two pits. B) System Conditlonally 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. • i *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): F t t5in5•3!13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Dec 01 2015 21:23 Jim The Inspector Man 5085349919 page 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is required for every Osterville MA . 02655 12-3-15 page. City/Town 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 ❑ Y. ❑ N ❑ ND(,Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): Ej 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 16.303(l)(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 Inspectlon Forth:Subsurface Sewage Disposal System-Page 3 of 17 Dec 01 2015 21:23 Jim The Inspector Man 5085349919 page 4 q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r( 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Narne Information is Osterville MA 02655 12-3-15 required for every page. CitylTown 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: 1, ;u '9 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 his less than 6" below invert or available volume is less than Y2 day flow Airs t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Dec 01 2015 2123 Jim The Inspector Man 5085349919 page 5 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is Osterville MA 02655 12-3-15 required for every . page. Citylrown 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: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 ® 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, i 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 El ❑ 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. > 15ins•3113 Title 5 Official Inspacilon Form:Subsurface Sewage Disposal System•Page 5 of 17 i Dec 01 2015 2123 Jim The Inspector Man 5085349919 page 6 Commonwealth of Massachusetts . Title 5 Official Inspection Form A a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name. requinlorm r on is Cisterville MA 02655 12-3-15 requiredd for 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? ❑ Z 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 NIA) ® ❑ 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins-3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 6 of 17 i Dec 01 2015 21:23 Jim The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts Title 5 official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is required for every Osterville MA 02655 12-3-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system Is a 1000 Gal. Tank D Box and two pits, Number of current residents: 0 . z Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No 2014-177,000Gal Water meter readings, if available (last 2 years usage (gpd)): 2015-28,000 Gal's Detail: sump pump? ❑ Yes ® No NA Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment; Design flow (based on 310 CMR 15.203): canons per day(9pd) 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 theTitle 5 system? ❑ Yes ❑ No Water meter readings, if available: I&ns•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17 Dec 01 2015 21:23 Jim The Inspector 'Man 5085349919 page 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owners Name information is required for every Osterville MA 02655 12-3-15 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: NA 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-3/13 Title 5 Official Inspection Form:Subsurface sewage Dispose System-Page 8 of 17 Dec 01 2015 2123 Jim The Inspector Man 5085349919 page 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 216 Ebenezer Road Property Address Evelyn Morris -- - Owner Owner's Name information is Osterville MA 02655 12-3-15 . required for every Zip Code Date of Inspection page. CltyfTown State D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank& Pit#1 83 -Pit#2 89 New D Box & line 12-2016. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth belowgrade: 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.): Pipeinq is 4" PVC SCH -40 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3 t5ins-X13 Tille 6 Official Inspection forth:Subsurface Sewage Disposal System•Page 9 of 17 Dec 01 2015 21:24 Jim The Inspector Man 5085349919 page 10 . Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is required for every Osterville MA 02655 12-3-15 '. page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" 1,r Scum thickness . ' Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt -Tape Sludge Judge 9 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 at working level. Tank and covers at 1' below grade. Inlet tee- Out let-tee. No sign of leakage or over loading. i a 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Dec 01 2015 2124 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is Osterville MA 02655 12-3-15 required for 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.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins 3113 Title 5 Officia:Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Dec 01 2015 21:24 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is Osterville MA 02655 12-3-15 required for 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 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-18" below grade w/cover at 6". One line out. Box is new 12-2015. 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: t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Dec 01 2015 21:24 Jim The Inspector Man 50853.49919 page 13 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris _ Owner Owner's Name information is reequiredired for every Ostervil.le MA 02655 12-3-15 page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number El leaching trenches number, length: ❑ leaching fields number, dimensions:. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. pits w/2'stone. Pit# 1 installed 1983- pit at 27" below grade w/cover at 1', 30"water.Pit#1 outlet tee and piped to Pit#2. Pit#2. installed 1989. Pit at 2' below grade w/cover at 1'. Pit is clean &dry, like new. 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 i Indication of groundwater inflow ❑ Yes ❑ No t5ins-W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Dec 01 2015 2124 Jim The Inspector Man 508534991.9 page 14 _,• -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is required for every Osterville ' MA 02655 12-3-15 page. CitylTown 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 G Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of pond ing,'condition of vegetation, etc.): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal SyMern-Page 14 of 17 Dec 01 2015 2124 Jim The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts WHOM Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r ° 216 Ebenezer Road - Property Address Evelyn Morris Owner owner's Name 4r7formation is Osterville _ _ MA 02655 12-3-15 required for every — ---- ---- -- page. CitylTown— State Zip Code Date of Inspection D. System Information (cont.) Sketr Of Sewage Disposal System: Provide a view of the sewage disposal systerrl, including ties to at l tm± eask two peanent reference landmarks or benchmarks: Locate all wells within 100 feet. Locate vv"re;pubk wwaler surely enters the building- Check one of the boxes below . hart. -c'—k an r in(In-area t;2`'a'4tl A AtQ? FOR n a 0 O -1 17 'i if 30 0 0 { 2 7 3.-5 3 i7'- ISine•3H 3 1100 5 05691"Ooc5en Form:Suesu7ace Sewage C)iWeer Syarom•Dege t5 of 17 Dec 01 2015 21:24 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts _ n Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name information is Osterville MA 02655 12-3-15 required for every page. City(rown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells No Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 4-7-83 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: T.H.on Design plan 4-7-83 12' no G.W.. Bottom of pit at T below grade. Bottom of pit at 5' above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Officiel Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Dec 01 2015 21:25 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 216 Ebenezer Road Property Address Evelyn Morris Owner Owner's Name- information is Osterville MA 02655 12-3-15 required for every page. Cityrrown Stale 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 • Wine-313 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i i "a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner rOwners Name information is required for every �'►�� page. Ctty/Town State Zip ode Date o sp for 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 1. Inspector: �C key to move your j j� cursor-return not 0 oollya G�/7 �f�%�� use the return Name:of pecto key. � Compan Name t) {, •+ Company Address State Zi Code Cit rro\ t, P 7` Telephone Number License umber 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: IM Passes ❑ Conditionally Passes ❑ Fails p , Needs Further Evaluation by the Local Approving Authority .7 r Insp ctor'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 40,000 gpd or greater,the inspector and`the system owner shall submit the report to the:appropriate regional office of the DER The original should be sent to the system owner and copies sent cl-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•11/10 - - -` ••�^_^y. ' Title 5 Official InspectionForV,,, wage Disposal System•Page 1 of 17 1 Y ' Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is � O'C' required for every .!-page. Cityll own State Zip Code Date f hn B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: XP 1 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. t Comments: B) System'Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following stet ments. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether meta' or not) itruct fly unsound,.exhibits substantial infiltration or exfiltration or tank failure is imminentSystem vi9t pass inspection if the existing tank is replaced with a complying septic tank as app owed by the-Board ofl Health. o. *A metal septic tank will pass inspection if it is structurally sound, not leaking d if a CeRffiicate Compliance indicating that the tank is less than 20 years old is available. w • ❑ Y ❑ N ❑ ND(Explain below): Y 1- L A t5ins•1 V10' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 O� Commonwealth of Massachusetts Title 5 .Official Inspection' Form Subsurface Sewage Disposal:System Form- Not for�Voluntary Assessments ' y Propert Ad ress Owner Owner's Name. information is - ��a ti, y w,, ti '�: {t 1 r"� < k 4. required for every ✓l�l�/C r page.. City/Town Late 4 Zip Code Da�pection ' u f . B. Certification (cont.) B) System,Conditionally Passes (cont.): ' ❑',Observation of sewage backup'or break out or high static Ovate .F I in the'distribution box due to broken or obstructed pipe(s)or due to a broken, se or uneven distribution box. System will ass ins ection'if with a royal of Board of-He p P ( pP e ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): obstruction is removed , ❑ Y ❑. N- ❑ ND(Explain below): ❑ distribution box isle led or replaced' ❑'Y ❑ `N - ❑ ND (Explain below): ❑J The system required pu ing more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection ith approval.of the Board of Health): ❑- ` broken,pipe(s) are replace .❑ Y ❑ N ❑ ND (Explain below): '❑ obstruction is removed ❑ Y ❑.,N ❑ ND (Explain below):- P, C) Further Evaluation is Required by th Board of Health: Conditions.exist which require further ev ation'by the Board of Health in order,to determine if the system is failing to protect public health, fety or the environment. ' A. System will pass unless Board of Health determines in accordance with 310 CMR 15.3030)(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 fe of a surface water ` ❑ Cesspool or privy is wi in 50 feet of.a.- wetland or a salt marsh l5ins•11/10 - - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 W P I , � Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal) System Form -Not for Voluntary Assessments Property Address 0 Owner am --- Ow er's Name information is rpl/f�_— �n11 ,� ����• required for every (�j11' < l!/7 page. CitylTown State Zip Code Dateii6f IiAp&ofon 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 am ner that protects the public health, safety and environment: ❑ The system has a septic tan d soil absorption system (SAS) and the SAS is within 100 feet of a surface water suppl r tributary to a surface water supply. ❑ The system has a se c tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a se 'c tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S 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'w r analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absen nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t at 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 '/z day flow t5ins-11/10 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 'Property Address Owner 'Owne s Name i information is ,R ...L �x required for every page. City/Town State Zip Code Dla.te,pflris ection B. Certification°(cont.) Yes- No Required pumping more than 4 tim in h es t e ast ear:NOT due to clogged or ❑ � q . p p .9 . . Y , - 99 obstructed pipe(s):Number of times pumped: / El Any portion:of the SAS, cess pool•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. El Any portion of a cesspool or privy is.within a Zone•1 of a public well. . [ Any portion of a cesspool of privy is within 50`feet of'a private.water supply well. ❑ Any portion,of a cesspool or privy 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 - aboratory;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.] ❑ e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. l have determined that one or more of the above failure criteria exist as described in 310 CMR 15303, therefore the system fails. The system owner should contact-the•�Board of Health to determine what will be necessary` to correcfthe 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"for 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 ' D 0 the system is located wa nitrogen'sensitive area,(Interim Wellhead Protection Area- IWPA) or.a mapped Zone 11 of a public water supply well If you have answered •yes";to any question,in Section E the,system is considered a significant threat, or answered"yes'.' 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 s -system in*accordance with 310 CMR 15.304.The system owner should contact the appropriate .regional-office"of the Department., t5ins•11/10, - - _ - - Title 5 Official Inspeclion Forth: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 PropertyT Address Owner _,��y'i'/� • Owner's Name information isj �J required for every � i!� ----- -- -o', `ORA ��, ` page. City/Town _ State Zip Code Dat of I spection 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 Qr 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: X ❑ Existing information. For example, a plan at the Board of Health. rat Ei 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x.#of bedrooms): "-�3 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 zi ' Commonwealth of Massachusetts Title.' 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not•for Voluntary Assessments Property Address Owner Owner's Name .. informati*on is * " 4 6 #+ +k,: .,,.� > .`•. �, required focevery ! mil, L page. CityrFown taS to" Zip Code Da f-1n" ection D. System Information Description: l .rev iz Number of current residents: 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)):` Detail: /� l Sump pump? -- ❑ Yes W No Last date of occupancy: Da e Commercial/Industrial.Flow Conditions,: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(qpd) "Basis.of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Indtastrial waste holding tank present? ❑ Yes El No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No Water meter readings, if available: t5ins•11/10 - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 17 R � Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is �.�j� required for every ,✓ � �',�- -- page. City own - State Zip Code Date In ectio D. System Information (cont.) Last date of occupancy/use: Date i Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No i 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every, page. City/Town . State Zip Code Date,9f1ns5p9ction D. System Information (cont.) _ Approximate age of all components date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes U Ivy Building.Sewer(locate on site plan): Depth below grade: Material of construction: ❑ cast iron: X40 PVC ❑ other(explain): Distance from private water supply,well or suction line: p feet Comments(on condition offidints venting,evidence of leakage, etc.): 17 Septic Tank(locate on site,'plan): ° . Depth below grade v feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal,.list age: — years Cjiv v�a�G Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes ❑ No Dimensions: Sludge depth: t5ins.•11/10 - - Title 5 Official.Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address e , — ;04�01�4 Owner Own s Name ' information is i �� required for every. -� _ - �!'. (��tom. .', 7-��- — page. City/Town State Zip Code Date f In section D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle o 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: , — feet Material of construction: ❑concrete ❑ metal... ❑fiberglass ❑ polyethylene ❑other(explain): 47 Dimensions F4-- ti ft Scum thickness ` Distance from top of scum to top of outlet.tee or baffle — - -' — Distance from bottom of scum.to tiottom:of outlet tee or baffle 4 Date of last pumping: Date y .= t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 a w ,> Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form -.Not for Voluntary Assessments Properj4Address ,. a Owner Owners Name r information is required for eve 4 every ~ 4 page. City/Town State Zip Code w Date In pctlon. . . ®. System Information-(cont.) Comments (on pumping recommendations,-inlet and outlet tee or baffle condition,structural integrity, .: liquid levels a,,related to outlet invert,.evidence of leakage, etc.)' y���e. /ef/Z'ed l>1fi �yv � win r®cv�S R Tight r Holding , o dt Tank tank must be pumped at`time f inspection)n I• o s ect o (locate on site Ian 9 _ 9 ( p P P ) ( P ) Depth below grade: - 777— Material of construction: ❑ concrete, ❑ metal ❑fiberglass `. ❑.polyethylene ❑ other(explain): Dimensions: w Capacity: ti. gallons Design Flow: gallons per day. , Alarm present: ,{ ❑ Yes ❑ No" ` Alarm level' Alarm in working orli �❑ Yes ❑ No Date of last pumping f; µ Date Y Comments(condition of alarm'arid'float switches,etc.): ,�,, F .. .. . _. � :i`F t a ,1;.'"eft' \j ��,. f y •. Attach copy of current pumping co�ntract,(requlred). Is copy attached?.', ❑ Yes . ❑ No i5ins•11/10 Title Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17 • 'w Commonwealth of Massachusetts W ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. Property Address i Owner Owners Name information is required for every., page. City/Town, u State Zip Code Date ol"Inso6cfM D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert �� A L 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.): � ,�/�--�'i/1✓ owe Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: El Yes ❑ No Comments (note condition of mp chamber, condition of pumps and appurtenances, etc.): Soil Absorption System SAS locate on-site plan, excavation not required): If SAS not located, explain why:- t5ins•11/10 - , '..Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Propert Address , Owner Owner's iJ me inforrnation.is � _ v� t required for every page. CltyrTown State Zip Code Date,o sp tion 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: t, ❑ 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.): 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-11/10: - - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts ti. W Title 5 Official Inspection Form Subsurface Sewage disposal System Form -Not for Voluntary Assessments &G Property Address 03"YL , — Owner Owner's Name information is required for every,,-- 11e - page. City own `• State Zip Code Date f In ection 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•11/10 .Title 5 Cfficial Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ' W Title Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's ame ; information is required for every t^ ( �./ �E' - ��R N �- page. °Ci0/ o n�� y •, State Zip Code Cafe 'h pection D. System.Informnation (cont.) Site'Exam: Check,Slope (Surface water Cio;�t, , G[ Check'cellar V Shallow wells 1241W Estimated depth to high ground water: jj** fee . •y, .,A. I - yam. 1 - Please-indicate all methods.used to determinethe'high ground water elevation: 71, 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: { ! f You must describe how you established the high`grourid water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page, t5ins-11/10. - 'Title Offidal•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 rt � �� UU �w :w Propert Address f t; < Owner Owner's Name information is required for every _—(.✓ ��!`Lam' —�� - page. City/Town St Ye Zip Code V Date of spec'6 n 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: " nd-sketch in the area below drawing attached separately ;J A elf?*or) 6 s g 117)ems !° t5ins•11/10 - Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner O+rmer's Name #it. information is required for every page, Clty/fown State Zip Code Date o nsp ction E. Report Completeness Checklist Ins Y ction Summary:A B C D or E checked Ins ction Summary D (System Failure Criteria Applicable to All Systems)completed Sy em Information-Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15.or attached in separate file 15ins•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 LOCATION SEWAGE PERMIT NO. LOCI" do _5 7 ���►�z�rZ r�ri ��3 - z�y r VILLAGE I N S T A LLER'S NAME & ADDRESS . k o�sQ'eka ice, n BUILDER OR OWNER DATE -PERMIT ISSUED O DATE COMPLIANCE ISSUED l i j j �y j' 7:1 CrS J-o7 TOWN OF BARNSTABLE LOCATION ::fi k SEWAGE - E i VILLAGE .�`e" 54 ASSESSOR'S MAP & LOT INSTALLER'S NAME Si PHONE NO. -� ic,ie- x.,j T :, i � -y 1 z. 0 SEPTIC TANK CAPACITY i,.c o (a LEACHING FACILITY:(type) 2. P i'T S& �-A 2 \-°z-{size) 1, 0, NO. OF BEDROOMS . PRIVATE 'WELL JR P -L:IC...WATER' BUILDER OR. WIiiER_= DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No II ... � , �' tIOU�b �� �� . , 5� ,, o L . .�. i� . , .�.. _--- �, VE f Barnstable- The Town o 9 MAIII �� Department of Health Safety and Environmental Services e Division 3¢ , 'n Building 367 Main Street,Hyannis MA',02601 I Ralph Crossen Office: 508-790-6227 Building Commissioner Fax: 508-790-6230 For office use only Permit Date 0 AFFIDAVIT HOME IMPROVEMENT TO PERMIT ATPPLICOR LAW T ON SUPPLEMENT es that the "reconstruction, alterations, renovation, on to repair, .MGL c. 142A requir any pre-existing - conversion, improvement, removal, demolition, or construction of ,units or to owner occupied building containing at least one but not more e b°regur istered istered contractors,ow done by. P structures which are adjacent to such residence or building be y certain exceptions,along with other requirements. Est.Cost l UZ'� Type of Work:_ Address of Work: Owner's Name �. Date of Permit Application:------------- y I hereby certify that: Registration is not required for the following reason(s): Work excluded by law _Job under S1,000. _Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING W RK DORNOT THAVE CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Registration No. Contractor Name Date OR . Date Owner's Name ------------ Assessor's office (1st floor): Assessor's map and lot number ..... 7��......... ............ ,Board of Health (3rd floor): Sewage Permit number ...................... 33ARI9TADLE. Engineering Department (3rd floor): CIA MAAL 1639- House number ............................. ....... ...... -MAI A, Definitive Plan Approved by Planning Board --------------------------------19-------- - APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 PM. only TOWN ,OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ....4...... ...ID...... ... .... . ....CJ............Cy..................... TYPEOF CONSTRUCTION ....... .......................................................................................................................... ........ ...... ... ...... . ..........19--- TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..... ...... ... .......... ...... L&................................................................... 0(4 ProposedUse ........ -:�. ....... .... ........................................................................... ZoningDistrict ..... ............... ............................. .........Fire District ................................................................................ to o"I Name of Owner ...... ...................Address ........ ........... ..... .......................... .. .................... Name of Builder ....).LA ......................Address ...... Nameof Architect ...................................Address..................................................................................... -3 -L Number of Rooms ................ ..... ..'0!� (-"... .1 .. ....Foundation ...... ..... .... .............................................................. .... ...i. ....... .1. Exterior .... .......L', ....................''Roofing .....C.........I....................................... ....................... Floors ...... tl_,:��I.[:e.......- ..........Interior ............ . ..... . .. ....... ............................ ......... ....................................................................... -, I f., I ............................................................. Heating ........ �46 ` ........................Plumbing ........ ............. ....................... Fireplace .......... .................................. ...... ...Approximate Cost ............. C)...................................... Area Diagram of Lot and Building with Dimensions Fee��.' .............. WFH.� IE. SRobi 1 76m,' Sg. Septic SeMce 55 Bodick Road Hyannis, MA 02�601 505-7 Q 5-S Y//�Q/)6 � 0 Fax 508-77 1-8012 INVOICE SOLD TO: PHONE . �� � ��� FAX# PHONE# CELL# SERVICE TO:.y[' /Ae INVOICE DATE 47 DATE DELIVERED CUSTOMER P.O. G? DRIVER i Customer requests future maintenance pump I yr.D 3 yr. 4 yr. SPECIAL INSTRUCTIONS: DESCRIPTION AMOUNT s PAYMENT IS EXPECTED AT�TIME yOF SERVICE SUB-TOTAL .00 SEWAGE ,/� BALANCE DUE RECORDED PAY THIS � AMOUNT ! RETURNED CHECK FEE$39.00 BALANCES OVER 30 DAYS SUBJECT TO A 1'/2% HY. YAR. SERVICE CHARGE WO } .Y mj No IP s i R I, y ����� t. a �' .pRf a.%` rf �£ � ��S"'i� u!•t• �b 3Y?> - f lOTt : ALL FUTURE WELL: .SITE, CATS `` v ARE. APPROX�IM.A 1 P u b I i C S u p p I y W e l I. Zones Of Contribu� ti d _ ZONE 1 Def_ ined Zone Of Contribut 'io -n -- ZONE ? : �. Inferred Zone Of; C pnit ribution 1 Figure ; 4. a 4 in FEB THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH yt�-u/ -----------------------OF......��.... .= ,'VVfirFaftoun for RiipogFal Works Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (- an Individual Sewage Disposal System at: ...... .. ---------- --• ..._......- Location-A ress or Lot IN o. Owner [ a //Address �.. `f _ A!` �fy.......... �`J� ��L` Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g --------•------•-----------• P ( ) — Cafeteria ( ) QOther 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........................................ a Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-____________-----_--_ (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ....................................... ...................................................................................... 0 Description of Soil - ------ ��r�- --5t��------------- x w ------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------ U Nature of Repairs or Alterations—Answer when applicable_-______ft .............A"_ -'....../_"_.d............................... ' 11� greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T':LE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance een issued by the board of health. Signed-----......--••-----r -- - --A D to Application Approved BY ................................ -------•-- Date Application Disapproved for the following reasons--------------------------------------------------------•------------------------------------•--•-----•••-•----- .............................•---------•-----•--------••-----.....---._.....--••------.........------•-----••---••••----••-•-----•••----•--••--•-----••-------••--•-••••-------••••-----•--••-------•--- pp 0 Date PermitNo.......Q-./--......1,5 ......................... Issued....................................................... a]ry 14, No... Cl:._t✓l.. � Fizz....._/...`?..........._ l C4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH L-dv^r... -------.. ..OF..... --- ------------------------------------------- ApplirFatiou for Disposal Work, Toustrurtion Pumit t- Application is hereby made for a Permit to Construct ( ) or Repair (%.�an Individual Sewage Disposal System at: • -g/6 �✓ zr� r"era �S i' .rv�c ............. - .. ....-•-....---..__...._ ._ .....----•••••-•-•--••--------•-•-----•-••------•- Location-A ress or Lot No. ... � .. .__.....0 �" ........................................ ........... '........._......._._....._......_.__.........._...._.._._._..__.____ Owner Address w �L.ldJ [- i C l« •- ..i Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons____________________________ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) d Other fixtures ------------•-------------------------•-----•--- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter________________ Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ ►.a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-_____________________. Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_................. 04 ------------------------------------------------------• -•-•--------•-------------._.......---•-------------•-----•----•-•-••----- - Descri Description o£ Soil_____________ _-_2..___.______...._._. O " ?----------------------�c - --------_ . x P �3 ......... --' — ................. U ..--------•--••................ w UNature of Repairs or Alterations—Answer when applicable________ _ ______ _........!,_.uo .............. 'r tem-ent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 'TILL^ the provisions of i: : of the State Sanitary Code— The undersigned furtQr a reel not to place thers .er in operation until a Certificate of Compliance een issued by the aboard of'heea'lth. Sign 1 - d ' ---------D�....•�---- te Application Approved By............... o _. � c J•--------•---------••--•------- ............--•----•--- = Date Application Disapproved for the following reasons:............................................................................................................. r' , J .............................................._......................................................................................................__.____._.___._____._.______._._________.___.._.._._ Date- Permit No.......?I - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .`:`".............OF:........ .R:.....tS1 ..... .��. , .......................... Trrtifiraib of ToutpliFaxtrr THIS IS TO CERTIFY, That the Individual +Sewage Disposal System constructed ( ) or Repaired (L--)-•••-- by------ _c w... AA A .....................4-----•-a"--------------------•--•-----•-------._......--•----•---•--.....-------------••--•---•--------------- i Installer at = ---------------•-----------------------•--••-•.._........_-------••-••- has been installed in accordance with the provisions of TIT ib,5 of The State Sanitary Code as described in the No t;. C, T application for Disposal Works Construction Permit o_____________�_ _. _;:.__,_..__. _ • THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE6 AS A GUARANTEE THAT THEE"'''. SYSTEM WILL FUNCTION SATISFACTORY. DATE......................3_.. --13._........-•-•••-•........••••-- Inspector....................... ........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 bw..h.....................OF....`,i /\ ac.. .1.. ................................. No....Yt__t:..1_1..i) Disposal Works Tuuatotr ion rrutit Permissionis hereby granted........ J i ------------------------------•----------------------------•---------•-------__------ to Construct ( ) or Repair ( n Individ Sew osal System atNo.•---•-1_1-(----------- ! 3.:xJ f -Ye----------• -S --•.-s�---------------------------------•--------------------•---•----------•-------_____________ Street as shown on the application for Disposal Works Construction Permit No._���_•%�.`-1_�___ Dated.......................................... 1,7` r� �—j LJ Board of Health DATE............................................rjd7 FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS AsBuilt Page 1 of 2 c� - TOWN OF BARNSTABLE LOCATION-2%. 3£N�Lc - � SEWAGE .484- lJ VILLAGE GST (QS i N i K NT S WSESSOR'S.MAP & LOT I Z B a INSTALLER'S NAME & PHONE NO. 44%Cy L CUyJ SEPTIC TANK CAPACITY )l.D o D LEACHINL G FACIL:TY:(type) Z ?R'-s u) 21 s0 size)_./,a" NO.OF BEDROOMS. PRIVATE WELL R.PUBLIC WATER Bulgy-zER':OR'OWNER' A \L v vt-gj s DATE PERMIT ISSUED- DATE COUPLI?NCEISSUED: VARIANCE GRANTED: Yes No�� • /�o v�� OAK (jA I . O 7 ; < Y http://issgl2/intranet/propdata/prebuilt.aspx?mappar=122088&seq=1 9/30/2015 TOWN OF BARNSTABLE LOCA 'iOPJ �21-1 SEWAGE# VILLACE C,ST IDS% li l tG HT-S ASSESSOR'S MAP Q LOT INSTALLER'S NAME'&kPHONE NO. H%Cv-5.`r 00-A ST 991 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) "2- 0) z SIOA(size) /, NO. OF BEDROOMS. PRIVATE WELL R PUBLIC tVA?ER'�~� :C 8U`LQERl0R�W�NER- bAC\L 14--0 Vt-%AS DATE PERMIT ISSUED: DATE COLIPLIP NCE ISSUED: VARIANCE GRANTED: Yes No �.�'} e. �t� '" � �' 4 � �, 7� No. .� ._-.... _ ',- ' Fps ....................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Appliratioo for Ui_qpooal Worka Tooitrurtioo- Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ' h System at: ... ---• --------------a..�A........................................................... Loc ion- dress t o. djf- ner Address a >C r y-----.... -�'�•-T----------------------- --- ' Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.............fir ........................Expansion Attic ( ) Garbage Grinder Other—T e of Building No. of persons............................ Showers a YP. g ------------------------•--- P ( ) — Cafeteria ( ) Otherfixtures -------------------------------------------------------------------------------•-----------------------------------------••••------•--•-••-----•-•-•- W Design Flow.......... ._..................gallons per person per day. Total daily flow............... .2 0............gallons. WSeptic Tank—Liquid capacity�L-M..gallons Length................ Width__/._a........ Diameter................ Depth................ x Disposal Trench—No..................... Width..................... Total Length...............r__ Total leaching area--------------------sq. ft. Seepage Pit- No..................... Diameter...._............... Depth below inlet._.............. Total leaching area..__`AA...sq. ft. Z Other Distribution box ( ) Dosingtattk ( ) Percolation Test Results Performed by._.. ..___ _________________________________. Date...____ ` .__^. _...- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--.----______•__-_____-. G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ------- ---j---------------------------------------------- - - .................................................... - .... -0Descrip ' n of Soil -------�p �" ..I" x ®---- -p' 1 ..-- U VW -••---------•----------------------•---•-•••-••••-•••--•-••--•••••••---•----------------•-••-•--......--•--•-----•------•••-•••-•-•-••••••----•---•--•-•-......---••-•-••••............•.............. 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 TITLi: 5 of the State Sanitary Code— The undersigned further agrees not o place the system in operation until a Certific/oi ,,cf)mpanc has been is by th ar o h th. yP 3 ign -----•-•-•----- ................................... -------......•••-••••----- D Application Approved B -- ..-••---••-•-•••......•-•----••---•••••-......-•---••-•-•--••-•-•--•- •----•...••-•••......... DateApplication Disapproveding reasons---------------------------------------------------- ............................................................ ------------------------ •--------------------------------------------------------------------- Date PermitNo......................................................... Issued-....................................................... Date 4 t FEE..............................047 No'." THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................... Appliration for Bhipoiial W,ark, Tomitrurtion Vrrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: vo ..................................................................... V. ... •..... .................... ................................... . Zed::_ /14) ,�K Address Installer Address Type of Building Size Lot____________________ _____Sq. feet U P­4 Dwelling—No. of Bedrooms............. .__.______._____.._..._Expansion"Attic Garbage Grinder a yp Other—T e of Buildin g ............................ No. of persons____________________________ Showers sCafeteria Other fixtures Design Flow.......... ...............t;._gallons per person per day. Total daily.flow...............-2—.'*!!: 4... . ........gallons. 1:4 Septic Tank—Liquid capacity-A-016allons Length________________ Width.../A....... Diameter.................Depth_________.___-- Disposal Trench—No_.............. Width____._._............ Total Length.________._____..A_A. Total leaching area..........1.i., .._,----sq. ft. Seepage Pit No________ ____________ Diameter___......._. ..:_•Depth below inlet_____*_______ Total leaching area_...12 �A .... .sq. ft. Z Other Distribution box Dosing 0a ................... , 'I ........................................ Percolation Test Results Performed by........ .........M Test Pit No. 1................minutes per inch. Depth-of 'Test Pit____.___:_.____..___ Depth to grobind water................ , ......... rxq Test Pit No. 2................minutes per inch, Depth of Test Pit.................... Depthto-ground water....................... ......... X........7y ................ 0 Descriptl'op. of Soil......0 , Q !!..Z-- ------ f -- ---------*....Z ..................................................................................................................................................... ........................................................................................................................... U ----------- --------------------------------------------------------I........................................I......................................................................................................... U Nature of Repairs or Alterations—Answer when applicable..............I................................................I..................................... ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I TIZ 5 of the State Sanitary Co.de—The undersigned further agrees not place.the system in. operation until a Certificate of Certificate has been ss p?by thWj9h ign ..... ... ......................................... ..... ............. Application Approved By....... ... . ........ ....................... .............................. ........... following g re Application Disapproved t following reasons:.: ,r/ ................................., ............................................................... .................................................................................................................. .................................................................................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................... ....OF Trdifirate of Tompliaurr T . CERTIFY, That the Individual Sewa Disposal System constructed' (A 1-7-oi Repaired by............. .. ....... .............. staller .2.........4 . . .............................................................. at-----. in the application for Disposal Works Constfuction Permit 5.................. dated_-... ............ is 019 E -------r ------------- s been i stal - in accordance r 5 of Pe State Sanitary !�prov of TJZLE ha :e with r�t provisions UANC ,THE ISS �Y� OF THIS CERTIFICATE SHALL.NOT EE'CONSTRR7jU" S A GUARANTEE THAT THE SYSTEM V L F CTION SATISFACTORY. or ................... DATE..,7/:�L... .. .................................. Inspector.... . ..... . .............................................................. THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF..................................................................................... N .................. FEE. . ..__............. ii Tomitrudion "prfutit Permissioni reby granted ............................................................................................................. to Con or Repair, an rIndivid a w' e Disposal System 'A, e at .......... Wr ------------------------------------------------------------------- .......... .......................... S t/rlu-0 t�?(? W Street ,/�� ­�I as shown on the application for Dis,6-/1-L Works Construction Permit No_________ ed... ................ ........................................ ------------- ...................................... rs, Bo of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L 0 C�A T :ION S E W A C E PERMIT NO. 5-7 Zvg_ a Qd 1293 m z1 v VILL &CE INSTALLER'S NAME i A00R.ESS . `' .. - ® UILDE ItOR OWNER �f s►c.tu�� 1-l0��.� _ DATE P [It MIT ISSUED O DATE COMPLIANCE ISSUED �� F 1 h. I r t 5°l1�, r , IV 2 - A9 t i.3 • t t. r { L, p T , r a 41 + 5 p ol 47 d t IV Al �•-- / t'OurJGt,YilJN LCJ h7 �F.AJtc� :=t2 k2v,o. p r!2arzQ `7TA, ALL. , Ma -5:,: f ac�;51r P2 IL 70, 10) Q1 A t yy i p R a a X 9'1 o f r110, =D�L r,A a u'7 b l , M A, . 6ii.g1s Of. Gi."m.. .. . x.., 0'�I eel ,x�f ox ation and aertify 7'e4r_ rl o l �-n�z`a,d/e rosalt o ':`a aurvey made :on ground �° s '`;�, ,tI.' situ ..a AIW 1�✓/��i fig T1+cv�7 ZOriia,.l3rp•L. uy ���µ,OF 4f ': .ins o occup4tidn .of the ; �'` VVILL A n�� 4r 3rL ' �lYld , b f ?' M.WARWICK A4 Lj, No. 19771 y {sip GIST4c Q.y r. ` }. d A }SG by lUN i J 5�i i",E5r3'd ems.Y1 h{�il �.i+. � Pri�4 r� i ,. }S2.f t;M �' ,fit. 6:f i'`�=•i _ e R, i ,' '+rZ TYi3,'TA',•NJS+y w 1 A 1 `..' � 5rrt �' s , afF4,' � . 7Sjr 4y�#• Ytt��� ,^• r f �A1� �1 ,L'r:� .�' �1+'W 33.11 Q�^�' ,sor's map' and lot number .../.;. ..7. ?......... �0*THE r0� wage Permit number .... ^'U.G�..... ..!v .. .�.�.......1 .1.V1:' aE y�y�..{_ ,' $;�'��i �w Z EAR39TAXLE, i .> House number ............................. ... 'q 9Q Maes gyp! �G Ll O.o�i6}9•0 MO �0 e:• r M� I, i' TOWN OF BARN�STAB'LE BUILDING . I"HSPECTOR APPLICATION FOR PERMIT TO . .�I�F�vv.........i.... ../Y.. ..`.`"4:L ..!.. ...D......... ........................... TYPE OF CONSTRUCTION ........(.1 C�. .......I`� �7L ............................................................... .....................1...:... ...........19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: J/ Location ..h�...1...�...S-T...�-.U� L �L� ... Y..........L� �� F�� .............................. Proposed Use .�?./..!/!.C'� /c' '/ �L. ..... ...... ......................................I......................... ZoningDistrict ........................................................................Fire District ..........................................................I.................... Name of Owner S f%L- 114Z 1TJ...��e y./ It ddress 0 ...........................� '4 Nameof Builder .... ...........Address ... .......... ...............`.................................................. Name of Architect �V�G...............................................Address .......... Numberof Rooms 2 t�'� ..........Foundation U ... � �.......................................................... .............................................. ................... Exterior ......�. .�.(}.i ....s!�l (;r !`....:..............6...&fA oofing ..... � / ✓ ' T.................................... ........... , L . U r—'...........Interior .....�1.!.T (�.C. ... Floors .... ...... ................................... ..Heatmg ... ... .......................... . Plumbing, ��'�. f// Fireplace .. /V.. ............ ........ � .. ��p�r imate Cosh.................... Definitive Plan Approved by Planning Board -----------_-------------------19-------- - Area ...V ......... ...... Diagram of Lot and Building with Dimensions Fee 1 SUBJECT TO APPROVAL OF BOARD OF HEALTH / OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 1 hereby agree to conform to all the Rules and Regulations of the Town f Barnstable regarding the above ~ construction. Nam -r;. .. ................. ..... ... z ........... Construction Supervisor's License -�C ` '�i f lAssessor's map and lot number ..:,�,��.......:......'............. CFTHETD Sewage Permit number ! .................... �P o Z 33A"STULE, i House numberMAM pp 163q. 0 paC aMA-1a�9 TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ......J � ,c...-............................................. ............................................ TYPE OF CONSTRUCTION ........ ..........1..... 1.:�� ............................................................... l....... ...........19.`�� TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information:�n: J Location .. d�..�...5/fli.... �-/�� /ter„!1 ...� '.........f :��?..!.1.�. L .,. .� ..:............. Proposed Use .. ?.. <'!! '¢: (. .....� � ....� �y`................. ZoningDistrict. ........................................................................Fire District ..............:............................................................... i Name of Owner � i�� �LLC�4i31`T-(' � ry.I- fNA7 dress . lQ.�.. C�?.!�� 4-!l.....n f7-A C'.VrG 4 ...... ..... ... ............. ............ Name of Builder t, ....................Address ....:.........................:.................................................... Nameof Architect A. .4115..............................................Address :................................................................................... -S - 2 -)-;,;'4- au r�d C 5 Gt C t,� e�-7 Numberof Rooms ..................................................................Foundation . ...........................................................................: Exterior .......C.L .K....Sl'! �L � .....Cl' dfioofing ..... / 1- ................................................... r r- � ' ... =":...................... ...�..... a :......... Interior ....` � :Floors Heating, A G C.l � ,f. f, :.... ._...... Plumbing .. .............................. ............. Fireplace .. .'.y..!�'''..... ��.�.. ........�'? `\ ...f ' p r xiinate Cost :3.��. �.�.. . . ...`.......:...... ..... .... ..C. Definitive Plan'Approved by Planning Board ---_-------____----_---------19_______. Area ...1..0 ........ Diagram of Lot and Building with Dimensions Fee ... . ....................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH lF �j OCCUPANCY. PERMITS REQUIRED FOR NEW DWELLINGS,, hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name �fi.. .r-t-�e Construction Supervisor's License -�`l EIBIT 1 } <.. - �' -t' .. ... - .. .,,;rt;Y•r� .`^ � -. -, t� m, v9:�.,:,/= ,v.% / `y 1�"� .tom CJ:�. - _ .�\ -C',.. � �*> - !, t ' 71/ -o a r0, '.m �� O � yh�J .� � •`o. 'e \..,. ''OST < - ^- \ \t .� `-.,G �`a„ .. c-\R. C>, .� �tfR..hy��' c r„ dr"eF� t`at•c ''' 30` P`. ``a`+eF �? i - ,.; '\ .;,,f: .; ., 1. .k � .. `�` w :, Ram.;�'OF- ��. �O C ''o ! -ao _.. _ !.l.C-Vi't•`c - `F�<_DRIV. ..'� - _: :_ '� � r v , _. �', ..J.C•v < �� Jig i a5' � �,�- �Fir. 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E--,1, a _ ,. :. v ,a r :, , _ �'._ ,t$ - s. , .:S. t � >./ -S .r ^; . rr4 r i . �p . . . — : � — , .. . .� i+� i V .. t_ \ ,�` `,s ; pY ^.:/`" ••') '� F�: a,-3 :A R"" a,< :f,t K,L` 1 -" �. t arc,, F a s - .( - "€' $. 'p-" 4- ;c 1 . I a - •r}a �\ { a t R - ,'fi'� S �x -Y w yq, ' 4! 9 S s{., ..cf,; 3 V 9.. . 4 a �. '9: - -1 x -x k. a R y. 4 '� % ra, see"='�' '..r: 1. _;" w=� S/ TE PL A /V T Y'PICAL PROF/L E NOT To SCALE SCALE � l " - � .CL. EL. 4G. �" /B"STD. L L WGT. Cl MH COVER 46 4"C.J. PIPE !_� ' ; � 4"BIT. FIBER PIPE- r/ HT ✓PIN TS OUTLET LEVEL FLOW L/NE - TO FIRST JOINT - &WEL L ING �/O /4" O — -- ¢.�.co 1 43. 70 C.1. TEE C./. TEE ----- STANDARD PRECAST -- -- 4 CONCRETE IjWQ GALLON SEPTIC TANK 8„ o/STR/BJTION Box TO BE INSTALLED CN LEVEL , S'ABLE BtiSE. SEPTIC TANK �� I TO BE INS TA L L ED ON LEVEL , STABLE BASE �$ 2 1/6 TO 1/2 WASHED PEA STON L EACHING PIT .a ` ALL AROUND FREE OF IRONS, FINES BASF. TO 8E LEVEL k6l' s k ; AND DUST 1N PLACE y [�� BRICK B MORTAR C•OURES ��- � �w� AS REOU/RED TO BRING ` 3/4" TO l-112" WASHED CRUSHED STONE ALL AROUND FREE OF COVER TO GRADE. 24"C. /. MH COVER AND FRAME �! IRONS, FINES AND DUST IN PLACE�----- FRAME IJ ti �INLET - - -- LEACHING P/T SEC T/O/V— TA 33/44�' ,S. >r 8 FLOW LINE ; PIPE -- '- --- - I. CONCRETE TO BE 4000 PSI 28 DAYS 2, REINFORCED WITH 6'' x 6" NO. 6 GA W.W.M. 3. 2' AND 4' SE:CTIONS ARE AVAILABLE FOR GREATER DEPTH REQUIREME NTS OPEN/NG WITH 4 //B 4. NUMBER OF PITS REQUIRED 2A/­` 59 1� F QJ 1 3/4R /N Q DE DIAMETER NOTE EXCAVATE TO ELEVATION '&,D OR LOWER AS 3 REQUIRED TC REMOVE ALL LOAM AND CLAY BENEATH PIT REPLACE EXCAVATED MATERIAL WITH CLEAN �ro. .�aeecasrcaue �l awe H 1 +� ^l GRAVEL TO DESIGNED GRADE N _ 4, O„ 2 6 -o �y MIN. EFFECTIVE 014METER (NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH) WATER TABLE JV4�t/E SELL 4 ND FEFrC. DATA GENERAL NOTES ! PERC. RATE < 2 MIN. /IN . P -%�D.S NO HEAVY EQUIPMENT TO RUN OVER SYSTEM 8' ¢3 SEP''IC TANK, CISTRIBUTION BOX , LEACHING PITS TO BE STANDARD TEST 8Y PRECAST REINFORCED CONCRETE UNITS WITNESSED BY. Z-/41/,fiV ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE r q� TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE �8 TEST PIT GR EL. 4G.5 pgTE ' '¢ 7 B• __..___.. MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF 3cj TEST PIT NO.! TEST PIT NO. 2 SANITARY SEWAGE EFFECTIVE I JULY 1977. 0' 0 ------ —i ANY CHANGES TO THIS PLAN MUST BE APPROVE[` BY THE ¢© Too f �u.9�piL BOARD OF HEALTH. AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILLING, THE BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION. PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED OTHERWISE. DESIGN DATA BEDROOMS DISPOSAL EST. TOTAL DAILY EFF. 200 GALS. LEGEND _ SEPTIC TANK %DOO GAL. SIDEWALL AREA -, - ,.5 ^GAL./SO. FT BOTTOM AREA _._ / GAL./SQ. FT. SEWAGE ISPOSAL .�YS/ E/V% Ox00 EXISTING GRADE LEACHING REQUIRED /39. 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L ��'t'_I It-L. _Z %\ i i �, - / I . 4. . , I. 1, . 1. ?� . '. ­�- , . , I - ��,, *, j.-" - .ATTFNTION: ZON � � .. I I I I ; / _. 1. . , ., I . - I L I I 11 .� . .. '' ,�, ,,i,., It 4 I ,/ I,- , , T�- j � . . z .1 � , ) . . . .4 - . I I 1. I I � .1 . . 4 'O", IAL ! . ,­ I , :, . , I , 0,^ ' L, , T, �- * .. . t,4) - - LL. . "1, i Wk V . . . I I I . .1 V 4�' , k Jlk�"wi. , .�; - /I 1w I I t I I �t 1,- ' ' ' I . : , I . __ 11, � ,� I " 4�� F � . 7'� -- -1� - .., - : .� TO A SUBDIVISION MORATORIUM UNTIL JUNE 1, 1986 (REFERENCE ARTICLE 3, SPEC - ": I . 'L * ., Itr ;.. ,1�. 11 �� / , . . . �: ..­1 4, � : .. , # 41 1 1 .. . I I 11 . .1. . . I .1 , . #I� '. I - ''. , , - - 1. . q . I ' ' .. . I f I I I a IV 1 � � 'A, � . 4 1 � �-i � I I 14 . I ,,,,. I .- m . I � � 1� f , :t � I%:,. �­' :, �, - - , J 11 . If'; \ TOWN MEETING FEBRUARY 28, 1985 - "DEVELOPMENT RESTRICTIONS TO PROTECT P U B14C � %4 y) . . . o � - 1: I . ' '� .4 . ' . . � . I I L I ; I I I I I . L -- ,L , . L . ' L ' a - " � : . 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