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HomeMy WebLinkAbout0020 WINTERGREEN CIRCLE - Health 20 Wintergreen`Circle Osterville A=119-043 0 i a Ad ° a UPC 10 247 No. H63GN ,��, w HASTINGS. MN / __ _ �/,7/;� -��r �; a �� (��� � � �� G����� � �p�� ;���� �I ���omm �rr� � � p�� - �� ���a�> �. ���; �� �,�P ���� � ����l��D ������ � �, �u�� _ C`� � ��� �'�n�� u ��° ,����omm �� �, �i�� a ���� �r� � ; � �� ��� � � 1"' 1 1 f r i r' 1 t�f• � w ' Tiv { v_ 1 r� G L L � I r 1 f i q,*,W ' 1 I y t PUlt j r 3 _ _ �d P g A p � .ice,•` � I � , l A C sf 106 - DEED RESTRICTION Wher eas, Peter C. Fit zpatrick Trustee of Fitzpatrick Realty Trust`u/d/t dated 9/24/07 and recorded in Book 22564, Page 166, of 20 Wintergreen Circle, Osterville,'MA, is the owner of Lot_ 6, as shown on a plan of land named"Plan of Proposed Roads over.Land of Annie F. Cross, Osterville, Mass, Scale 1 in=40ft October 20, 1961 Nelson Bearse-Richard Law, Surveyors, Centerville, MA,"which said plan is recorded with.the Barnstable County Registry of Deeds in Plan Book 166, Page 107 (hereinafter, the"Lot"); and Whereas, Peter C. Fitzpatrick, Trustee of•Fitzpatrick Realty Trust,as the owner of the Lot have agreed with the Town of Barnstable Board of Health to-a restriction as to the number of bedrooms which can be located on any home built on the Lot`as a pre-condition to obtaining a disposal works construction permit in with 310 CMR 15:000, State Environmental: Code, Title V. Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; and Whereas,the Town of,Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for aseptic system in compliance with 310 CMR 15.200,' State Environmental Code, Title V Minimum Requirementsfor the,Subsurface Disposal of Sanitary Sewage, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the Lot be put"on recorded with the Barnstable County Registry of Deeds and/or the Barnstable Registry District of the Land Court, as applicable, byreeording this document. Now, therefore; Peter.C. Fitzpatrick,,Trustee of-Fitzpatrick Realty Trust does'hereby place and impose the following restriction upon the,Lot�iri accordance with his agreement with the Town of Barnstable Board of .Health, which said,restriction shall runi with the land and be binding upon all successors in title: t The dwelling constructed "upon the Lot shall contain no more than Three (3) bedrooms unless and until it is connected to the in sewer or the Board',of.Health of the Town of - Barnstable permits otherwise. Property Address: 20 Wintergreen Circle;Osterville, MA I. For title,,see deed recorded with said Registry of Deeds in Book 22564, Page 168: I further certify as follows: I am the sole trustee; the Declaration of Trust has not been altered, modified, amended or terminated since its recording;except'as may already appear of record at said Registry of Deeds; no beneficiary is'a minor; incompetent, a corporation selling all or substantially all of its assets, of a.personal representative of an estate subject to tax liens; the beneficiaries of the Trust have authorized and directed the Trustee to.;execute this document. r Executed as a sealed,instrume-t this; `day of June,:2015. Fit t i R Trust' uSz S Peter Fitzpat k; Trustee '#' COMMONWEALTH.OF MASSACHUSETTS; bd Barnstable, ss. On this ��day-of 2015, before me, the@ undersigned notary g �' public, personally appeared Peter C .Fi zpatrick, Trustee personally known to me to be the persons whose names are signed on the preceding or attached'document,and acknowledged to me that they signed it voluntarily for itE stated purpose: I j . Notary Public My Com ission Expires: f,\. JENNIFER .GREEN SNDWDEN Notary Public COMMONWEALTH OF MASSACHUSETTS My'Commission. Expires piember 25,.2020 t _ - a BARNSTABLE REGISTRY,OF DEEDS John F. Meade, Register !" r C TOWN OF BARNS�T�A,BgL�E -o LdCATION Q �L-e �h6ow C/A SEWAGE # -;.. VILLAGEASSESSOR'S MAP & LOTS 9 ( - INSTALLER'S NAME & PHONE NO. 'RC)L)'s ��ccpu► l,�� -F/yf SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 1606 -(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes' No (/ t) � I TOWN OF BAi4 NSTABLE _ 4, C c �1 cC�—� I:C)CATION���_ LoT 6 ,SEWAGE_ _ VLL.I.A.GIa _ I .— ASSESSOR'S MAP ti L 0 1 � ay --�- — )NSTALLER'S NAME & PHONE NO.__Ajj _�UCLrL� LEACHING FAC lLITX:(type)__-2 /l/6, NO. OF BEDROOMS PRIVATE WELL OR PUBLIC` 'WATE QC-� BUILDER OR OWNER DATE PERMIT ISSUED: _ DATE C OMPLIANC'E ISSUED: VARIANCE GRANTED: Yes_ __ No ____ '� i .----- - t Cr .j�� �' � a �� i � ,,,, `1 o , � A Q ^ ry n ..,... - � (\v\Y e � FInc.......0.6......... APPROVED THE COMMONWEALTH OF MASSACHUSETTS BamazaDlw nrcdM►DePOrnnent BOARD OF HEALTH //-a—>-ST WN OF BARNSTABLE Si AppliratiuttDaie fur Bi-nVnuttl Wor1w Tomitrnr#inn rani# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ Location-Ad rss or Lot No. Owner ..........................•-•------•--------Address W Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms---_______----------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons......................... Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. tx Septic Tank—Liquid capacity f_�vgallons Length---/0------ Width_._.------- Diameter_...------- Depth________________ W Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No_____________________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit._.__....--_________ Depth to ground water........................ C3, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1:4 ._...-•-•••--•----------------------•------•-----••------••---•-•----•--•-----•-•-•-••-••-•--•-•••••......................................................... Descriptionof Soil —x Awo-------------------------------------------------------------------------------------------------------------- V ------------------------------------------------------------------------------------------------------------------------------------------------•----------------------•--•...............•-•-••......•. W UNature of Repairs or Alterations—Answer when applicable.___- -----_--_ -tcn.f...... 3� �1---__. j -e-`-` ....Is--- - 6.4. .....-..4--"-lc.......b------9.4..........6.6.0 S�l..... ioA-__:L.k...P .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ..... � ✓ ����;� `....... ........... .. Date Application Approved By --------------- .�,�''� �Z - -^-- ----------------------------------------------------------------------- ...... Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ------- ---------------------------------------------------------------------- ........................... Q Date Permit No- ---------------- ..-.. �� ------------ - Issued -----------.............................................. ........... Date A. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -TTOWN OF BARNSTABLE Applirotion for Divi-Vinial Wor1w Tonotrnrt"inn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • h? ►f?I`Py1 ?_ o ? ' /-e------•---• -- ---•-------------•-------...----__._._.•---_____...------------.....-......_-•-•-- Location-Ad �---------------------•'-'-•----......or•Lot Na. 21 Owner �( - Address a _........-..\ .c�-S--••----�. f::Z-1 IF -S�• F-•----•--•------ •--•---------•............................. Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ----------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/_57 YYgalIons Length---'C?-.-_-- Width..6-n---------- 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........................................ W ,.a Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water--.--.--__._--_-_-_-_--- Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0+ ------•------------•-------------------- •-------------------------••--....--------------____................................................................ ODescription of --•---•--•-----------••---------•••--•-•---'•----•--•---•---------. V ...-•••-•---------------------•----------•-•----••-----•---•-•--•----••-•---•-•-•-•-----......----- •----••---------•-----•-•--••----------•-------------------•-•---•------••-----•••-...--•--•-------- W x ----------------------------------------------------------------- ................................... ----------------------------------- ........................................................... U Nature of Repairs or Alterations—Answer when applicable__--- e.___a(- ----- ..... ...... v..C.AJ........ ........7------g=y......... ....PL. ................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -----9 ! r ��:y/ ....... - � .. Dare Application Approved By r--------------- � - ..... __�, --,.. - /1.-..�.. ..-.4'. . � ----------------------------_..------T t)are Application Disapproved for the following reasons- ------------------ ------------------------------------------------------------- ------ .............. ............................................................ . . ...... . ..... ................... ............. ---------------------------------------- Permit No. ................ ....... 3 Issued ......................... Date .......... . Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BAR(.�NSTABLE �Prtifirate of (Clomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by -_------------------ ------- -------------- -------_..----------.----.___.....-----------------...---------------------------------------.-------- ----------------------------- InsrAer at ......... .A'Vc_4,-1/ -----._...-------------------- t_ --. �' . - - .... - - - _.._............ _.. has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------? -3...... dated ---------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE rCONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------.�.1.__...."J..I_, ���� - ------------------- Inspector ---------------- - -- -------------------------------------------------- I ' THE COMMONWEALTH OF MASS CHUSETTS BOARD OF HEA TH > TOWN OF BARNST BLE . � �i��rn�tt1 or�� �n�n�tr�trtion �rrmit Permission is hereby granted.......... -__ _........................................ to Construct ( ) or Repair O° an Individual Sewage Disposal System at No .I ..................•••. as shown on the application for Disposal Works Construction Permit No----.__•.._b 3�1 Dated........................................... Board of Health DATE (.�_-_�� . :_ _ ._.....-•-•----•--•--••----•-•-•---- V FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS Page 1 of 1 Home g Details for 20 Wintergreen Circe - _ _. _ _., .. 180,Days on Trulia 1,562 v'ews „ 20 Wintergreen Cir Huge Gambrel Style Home in sought Schools after Neighborhood in Osterville.Lots of Versatile Rooms for `� Sc r growing Family or Guests,therms is also a�ossible I - aw set - --_.,I Elementary School u�._Plenty of Modern upgrades,Sky lights,Ceiling Fans, r,,..•",i W"—A r.A+ ri—, rj­ Average stable High School i rage ,t E DETAIL REDB€ OOK Crime Lowest Write d personal note about this h5tiog �• -- - 2 1Cik [f•"Ai1. - � � - Features for 20 Wintergreen Cir Information last updated on 05/08/2015 12:00 AM: Price:$349,000 Status:For Sale MLS/Source ID:21307383 tip 3 Bedrooms Lot Size:0.31 acres Zip:02655 2 full Bathrooms 2,326 sgft Single-Family Home „ Public Records for 20 Wintergreen Cir _ _ _... _. . ,_,. , . .. .. x Official property,sales,and tax information from county(public)records as of 04/2015: Single Family Residential 3 Bedrooms 2 Bathrooms 2,326 sgft Lot Size:0.31 acres Built In 1960 Stories:2 story Heating:Hot Water Exterior Walls:Wood Siding + Roof:Asphalt 8 Rooms 1 Building Style:Contemporary County:Barnstable _ t a r` http://www,trulia.com/property/3127781913-20-Wintergreen-Cir-Osterville-MA-02655 6/17/2015 i ,♦ • M I t .. t : , _ _. __; 4 . . 1 _ . . . . .. . . . r TER •Fo 13►�:qD�:SF! : r i I r 1 : .i. I n r . .:_... T -7--,U . .sac Tio.C/ .4T TIE a v Cis r L�: �. :. .... . . .4 LG— S/oE.0/.�i� A,c/o SETB.�1 Fvs - ,A; r . r .o N ,B.4�•XT,E,C 8 A I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28 2014 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information _ on the computer, use only the tab 1. Inspector: V --q key to move your p cursor-do not David D. Coughanowr, IRS use the return _ key. Name of Inspector ;I Eco-Tech Environmental ICI Company Name :� 0 P.O. Box 1265 ' Company Address dr"] West Chatham MA �02669 l9 Cityrrown State lZip Code t.a 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: �H OF ® Passes DAVID ❑ Conditionally Passes ❑ Fails ❑ Needs ` � vai © a Local Approving Authority No.13Z8 s � G �S pR 0 � 't0� J� f April 28, 2014 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If,the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. l�I ffSsurface �/ v G t5ins•3/13 Title 5 Official Inspection Fo Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osteryille MA 02655 April 28, 2014 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or specified by local regulations. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. 11 %.j. an?"T, The septic tank is metal and over 20 years old*or thWsepticlta^nk(w ether metal or'not) is structurally unsound, exhibits substantial infiltration or exfiltratio,h, ;or'tank failure is;lnlminent. System will pass Z�{1. �h^ inspection if the existing tank is replaced with a cornplyng septi�e tan k., a�rapproved by the Board of Health. r *A metal septic tank will pass inspection if it is structurally,soundb,not-.leaking and if a Certificate of Compliance indicating that the tank is less than 20 year`spold'is'a aiIable. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM , 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014 page. Cityrrown State Zip Code Date of Inspection, B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ brokenpipe(s) are replaced Y N ND (Explain below): P ( P ) ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Wintergreen Circle Assessors Ma 119 Parcel 43 9 P Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28 2014 page.e. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is Osterville MA 02655 Aril 28 2014 required for every p , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. El Any portion of cesspool or privy is within 100 feet of a surface water supply or ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be, necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ • ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to.any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28,-2014 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: System was installed by Ron's Excavating in 1993. i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 98 gpd. 9 ( Y 9 (gp ))� Detail: 2012: 34,000 gallons 2013: 37,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ 'No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner 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 Disposal System-Page 8 of 17 f Commonwealth of Massachusetts u w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments' °M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 21+ years. Certificate of Compliance for new system issued.11/22/1993 (Permit#93-630) Were sewage odors detected wren arriving at the site? '❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron '® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer lines appear structurally sound with no evidence of leakage or backup into dwelling. Septic Tank(locate on site plan): Depth below grade: 0.5 feet Material of construction: t ® concrete ❑ meta- ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 x 5 x 6-1500 gallon' Sludge depth: 4 in t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments µM 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Permit Application Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years with year round occupation. Tank and inlet tee appear structurally sound and functioning as intended. Outlet end of tank is under hardscaped area and not accessible for inpection. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑' Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is Osteryille MA 02655 Aril 28, 2014 required for every p 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 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.): Distribution box is under hardscaped area and not accessible for inspection. System has been evaluated on condition of the leaching pit instead (see page 13). Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 20 Wintergreen Circle Assessor's Map 119 Parcel 43 r Property Address - Fitzpatrick Realty Trust- Peter C. Fizpatrick, Trustee Owner Owner's Name " information is required for every Osterville MA 02655 April 28 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ 'leaching galleries number: ❑ leaching trenches '* number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of scil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding,breakout„lush vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed to a dept-i of 2 feet below the top of the leach pit. 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 i Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014 page. Cityrrown State Zip Code Date of Inspection D. System Information cont. Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- PeterC. Fitz-patrick, Trustee Owner Owner's Name information is Osteryille MA 02655 April 28, 2014 required for every page: City/Town State p Date of Inspection . . Zip Code D. System. Information (cont.) Sketch Of.Sewage Disposal System: Provide a view of the sewage disposal system, including ties to. at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building..Check one of the boxes below: ® hand=sketch in the area below ❑ drawing attached separately. THIS SKETCH IS BEST VIEWED IN COLOR FORMAT P ' �. A %0+.. ot . .508. 364-0894 -1 O 8 1 . 11 M EXISTING DWELLING n o .2® rn - OF SEPTIC- E DISTANCES INO DECIMAL COMPONENTS ET -� 41 . . 2'q i 2 . 49 35 i V�1 iNT,ERC�REEN CIRCLE l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address Fitzpatrick Realty Trust- Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014 page. City/Town State Zip Code Date of Inspection D. System Information (cont) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 25+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database -explain: Barnstable GIS Department records You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 25 feet above the groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 20 Wintergreen Circle Assessor's Map 119 Parcel 43 Property Address. Fitzpatrick Realty Trust= Peter C. Fitzpatrick, Trustee Owner Owner's Name information is required for every Osterville MA 02655 April 28, 2014_ page. Cityrrown State Zip Code . . Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 13, C, D, or E checked Z Inspection Summary D (System Failure Criteria.Applicable to All Systems) completed Z. System information—.Esti„ated,depth to high groundwater ® Sketch of Sewage Disposal System eitherdrawn on page,15 or attachedin separate file GEOHYDROLOGICAL . PROFILE NOT TO. SCALE l PRECAST LEACH 4J PIT w v7 04 BOTTOM: . _ OF LEACHING PIT LEACHING IS ABOVE HIGH GROUNDWATER GROUNDWATER ELEVATION PER GIS MAPS l5ins•3/13 Title 5 Official Inspection Form::Subsurface Sewage Disposal System•Page 17 of 17 4 Rt � , 32'-p" S 24310 24310 3Q EXISTING STRUCTURE o '�' in FIRE CTAFZAG TID {. Z O o O 4° FIRE - cI _ RATED •� e— f t MUD ROOM 4' CONCRETE FLOOR o �U1 ry. 21 LITE+' 24" k', 2446 2446 - 24310 243f0 -p_3. 2'_q° E q=_8° .�. 5,_p° 5,-0 3.._b„ FIRST FLOOR PLAN O r SCALE: 1/4"24=_o° = 20,_b u 32'-O' _ ————————————————————— 1--------------------- —� --- Q m I I 1 u 1�' EXIsnNG' Z 0 LA I _I I BULKFIEAD o to �, ----r 'a I U) 00 r. EXISTING_STRUCTURE (� I 2- 12=o b'-o°` 251i 32' FULL BASEMENT I I -oP t i Y Q I U � 6 I I GARAG60NCRETE FLAOR: I •I\ O.G•4° Q \ Uj Qr I I I I I I ►L Q I i I m g I r I I l!5 o . 2 I I L__ I to Ln I . IL———————————————————————— r ------------------- o SHEET 24,_ps 44'-6' A 2 . - 20'-61 FOUNDATION PLAN SCALE: 114" JOB: 671 DRAWN BY: KW DATE= 4/23/02 P 32'-0" 24310 243t0 9� ~ EXISTING STRUCTURE TN 2'—O" O GARAGE .. - FIRE - R ® 4" CONCRETE FLAWR teaTc� ul MUD ROOM 4" CONCRETE FLOOR 21 co UTE FIRST FLOOR PLAN T-3°' 2'-�7" 4,_aa 5,_Oa 5,_pr 3i_6a SCALE. 114" 1'-O" 24'—O' 20_6n 44'—6" --------------------------- 1LS V (� I o I B OUue au o L----p pC 4!L f I — EXISTING STRUCTURE y 26'.W FULL EASEMENT ,C f2'-Or ' i2'-o �'_0" �p 1 I i I WS i' I GARAGE W. tw 6 f J. 4"CONCRBTE I I FLOM I I.. ---JiD m ——————————————————— o —————————————------------� SWEET ' A2, 24'-0" 2a-6" FOUNDATION -FLAN 44'-6' SCALE: 114" 1'—O" JOB, 0226 DRAWN 5Y, KW DATE- 4/23/02 I i I F �