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HomeMy WebLinkAbout0200 EVERGREEN DRIVE - Health 200 Evergreen L A= 125-069 t� i i� 1 P i ���� �� �� � �,� �� 0 � o �� � �, � � -� � ��� TOWN OF BARNSTABLE �',.00ATION SEWAGE VILLAGE V\A4` 4d-, ASSESSOR'S MAP&PARCEL NAME&PHONE NOSRq"4e1 r pS"� SEPTIC TANK CAPACITY go© _ LEACHING FACILITY:(ty ee L p ac,1,, (size) 'NO.OF BEDROOMS OWNER_b�N PERMIT DATE: COMPLIANCE DATE: / 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 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) Feet FURNISHED BY ,m-Q6 t3 3a' day 3 ����; J Q y r ;c VAj 1, 11 jJ 3 1 e Commonwealth of Massachusetts Title 5 Official Inspection Form COPY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2012 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out 1 forms on the �f IvJ computer,use ttt VVV��f p 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name ti P.O. Box 371 Company Address Sandwich MA 02563 City/Town state Zip Code 508-888-6055 S1 12843 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 16.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority May 29, 2012 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of Completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. '*'*This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 1 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every 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: ® 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. Comments: Recommend removal of garbage disposal. System is not designed to handle. 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" , N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years d*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial i iltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is eplaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspe ion if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tan is less than 20 years old is available. ❑ Y ❑ N ❑ D(Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. Gityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leve d 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 y the Board of Health: ❑ Conditions exist which requir urther evaluation by the Board of Health in order to determine if the system is failing to prot public health, safety or the environment. 1. System will pass u ess Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the stem is not functioning in a manner which will protect public health, safety and the envir nment: ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 I� ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and AS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS nd the SAS is less than 100 feet but 50 feet or more from a private water supply wel Method used to determine distance- **This system passes if the well w ter analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absen and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided 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 %day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] 0 ® 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 withi 400 feet of a surface drinking water supply ❑ ❑ the system is in 200 feet of a tributary to a surface drinking water supply El ❑ the system is ocated in a nitrogen sensitive area (Interim Wellhead Protection Area—IWP ) or a mapped Zone II of a public water supply well If you have answered "yes"to y question in Section E the system is considered a significant threat, or answered "yes" in Section above the large system has failed.The owner or operator of any large ` system considered a signifi nt threat under Section E or failed under Section D shall upgrade the system in accordance with 10 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is y required for Marstons Mills MA 02648 May 29, 2012 every page. City/Town 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): 355 GPD t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 6 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is Marstons Mills MA 02648 May 29, 2012 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry Y p system inspected? El Yes El No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2010= 90 GPD g ( Y g (gp ))' 2011=46 GPD Detail: Recommend removal of garbage disposal. System not designed to handle. Sump pump? ❑ Yes ® No Last date of occupancy: January 2012 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on/R5 - Gallons per day(gpd) Basis of design flow(s , etc.): Grease trap present? El Yes ❑ No Industrial waste holdin ❑ Yes ❑ No Non-sanitary waste disle 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 it Commonwealth of Massachusetts IM Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is requi red for Marstons Mills MA 02648 May 29, 2012 every 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: No records found. 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 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System em•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is y required for Marstons Mills MA 02648 May 29, 2012 every page- Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: System installed 06/11/1997. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'7" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2feet 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: 11.5'X 5.5'X 5' 1500 gallons Sludge depth: 3" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 f Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M <' 200 Evergreen Drive Property,Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Recommend maintenance pumping by next spring (2013). Risers bring covers within 6" of grade. 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 op of outlet tee or baffle Distance from bottom of s um to bottom of outlet tee or baffle ' I Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is requi red for Marstons Mills MA 02648 May 29, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal /EE1 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 bins•11/10 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �y 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is y required for Marstons Mills MA 02648 May 29, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): One inlet,two outlets. Equal flow. No solids carryover. No high water staining over outlet inverts. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pum 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•11r10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is y required for Marstons Mills MA 02648 May 29, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 1-40'X12'X 6" ❑ 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.): Camera used to locate and inspect both laterals. Lines dry at time of inspection. No sign of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. Citylrown 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, signTydraulic ure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments v 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29,2012 every page. c4rrown State Zip Code Date of Inspedfon D. System Information (cunt.) 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 l 3 A Tit ° L! 0 3D' i f 3VC 01, 1 0 --A4 / 3 . a I --------------- t5ins•»no Title 5 official Inspection Form:Subswface age Dislmsal system-Page 15 of 15 N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑, Check Slope ❑ Surface water ® Check cellar Shallow wells Estimated depth to high ground water: >g 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: 05/19/1997 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: ma.waterusgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole to 12' (elv=87)found no ground water(1997). Base of SAS at elv= 96.25. Accessed local ground water contors and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address Jay Sutherland Owner Owner's Name information is required for Marstons Mills MA 02648 May 29, 2012 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is Marstons Mills Ma. 02648 11/05/2009 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important'When filling out A. General Information 1 forms the jp'L_ ✓�/ computer, r,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ FOS ❑ Needs Further Evaluation by the Local Approving Authority k --- W 11/05/2009 Inspector s Signat a Date The system inspector shall submit a copy of this inspection report to the Approving AuthT�rity( lard of Health or DEP)within 30 days of completing this inspection. If the system 0a share42ystegor 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. G6 Title 5 Official Ins ection Form:Su rf t5ins•09/08 p bsu ace Sewa Disposal SIteDj 1 of 17 j T -Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,.•'" 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. CirylTown 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: ® 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. Comments: The septic system is in proper working order at the present time. B) System Conditionally onditionall Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 j 1) Commonwealth of Massachusetts 4 u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. . ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR.15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 CM 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town 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. El ® 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 t5ins•09/08 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 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon tank,D-Box and leaching field. Number of current residents: 5 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 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 11/05/2009 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 2' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of leakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 18"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: 1500 gallon Sludge depth: 0 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every 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 NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? Tank pumped at inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of leakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass. ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not'for Voluntary Assessments �M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 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 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: .1-40'x12'x6" ❑ 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.): Sandy soil.No signs of hydraulic failure.No ponding or damp soil. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Size Zoom Out; 'In Ala tee. Pink La J � EJ,C f t , t H � 0 Set Scale 1" = 20 I Aerial Photos MAP DISCLAIMER (`nnvrinhf 9llnF_9M0 Tn-n of P—nefohlo NAA All rinhfe roenne httn.//((.9.01.95.2.16/arc.im.q/annaenann/man.a.nx?nrnnertvTT)=l25(1h9&mannarhack= 11/7/9.009 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is required for Marstons Mills Ma. 02648 11/05/2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of Leaching 20' 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: 1997 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: As-Built Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You,must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USE D:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 200 Evergreen Drive Property Address James Meehan Owner Owner's Name information is Marstons Mills Ma. 02648 11/05/2009 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Z System Information—Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FRONT ELEVATION Lai EF WALSH RESIDENCE EVERGREEN CIR. MARSTONS MILLS miw 7 Mill 2X12 RIDGE BOARD VENTED RIDGE 12 5/8 CDX SHEATHING 2X10 9� RAFTERS ASPHALT 3 TAB SHINGLES 16"O.C. 2X10CEILING JOISTS16"O.C. R-30 FIBERGLASS INSULATION 2X8 HEADERS-� R-11 FIBERGLASS INSULATION 9 1/2" TIMBERSTRAND RIM BOARD 9112"T.J.I.FLOOR JOISTS 2X4 EXTERIOR WALLS W/1/2"CDX 3/4"T&G O.S.B. SHEATHING SUBFLOOR 9112"T.J.I.FLOOR:JOISTS 2X6 P.T.SIL PLATE CONCRETE 13'4 FRAMING CROSS STEELL --� SECTION LOLLY L MN 36' I ts'afi5 SIB rtas.'to d'1 63 I'll 32 wo 33 47 110-F5'1 BATH oM.-BATH WALK IN CLOSET . BEDROOM k 1I �Cr1 -- -- — . -- BEDROOM#3 MASTER BEDROOM p 2nd. C, �I FLOOR __ _ _ PLAN �az�.A�s�r7�4'1o�xs�s1�e�e�3�i1 LIVING Af�EA 100y 6y ft F--�13'3 r3-.—.-- 39 a� s4 en sn sa 47 s g g In I H u o �W , I m T O O STEP DOWN 7112° r Ii I I GREAT ROOM Ii I I ___________ __ ONING Oro m 14'9 J I I r DFFICE/DEN f < a � gt 7Y e' k—IB C4 Y7•---�.-4•t1 E'1� �c-Y9�{.•--B'4 4' 411 9 S, 24' k 10' 197 'F g 'I��'9-� •—tM -� ta' I LIVING AREA WAL$H RE$IDENCE 2WBagR 1st.FLOOR PLAN SARNSTABLE Board of Health Town of Bamet" P.O.Bast 534 Hyannb,Massachusetts 02601 w �131 1'6 8'B T T10 T 1'8 3'4 T 9'4 3'S�4'6 1111 -5Y ------ -- -�----T. -1 ° I FUT(JRE O o I UNFINISHED o 'BATH FUTURE UPSTAIRS . �(.�M•BATH ROUGH IN HEAT& i BATH I PLUMBING i m I I I DIECK I I 17'9Xiy'1 --------------------------------------- =7 ----------- i I I I � FLUSH BEAM I FLUSH BEAM 15' I I i I � 2ND. FLOOR 5'— ! 716 a' PLAN k-- �--13' 23' LIVIN /4R 3e' I 1011 Sglt Board of Heal% Town of Barnstable P.O.BOX 6..34 Hyannis,Mad.kghugetts 02601 i Doc: IP035PS32 06-08-2006 3=43 BARNSTABLE LAND COURT REGISTRY RESTRICTIVE COVENANT WHEREAS MICHELLE L. LINN(hereinafter"Linn") of 200 Evergreen Drive, Marston Mills, Massachusetts is the owner of real estate situated at 200 Evergreen Drive, Marston Mills, Barnstable County, Massachusetts pursuant to a deed dated September 1, 2005 and recorded with the Barnstable County Registry of Deeds, Land Registration Document No. 1011867-1 on Certificate No. 11 7804; and WHEREAS the residence on the above described property presently consists of a three bedroom single family home, Linn hereby agrees to grant to the Town of Barnstable, acting through its Board of Selectmen a restrictive covenant, providing that the above described property shall not be used or considered as a residence consisting of more than three(3)bedrooms. This covenant shall run with the land and shall be binding on Linn and her heirs, n executors, assigns, and successors in title until it is released of record. This covenant may be released by a statement from the appropriate local government officials of the :-Ip- Town of Barnstable, who are then serving as the Board of Selectmen. M This covenant is provided based upon current 'state and local laws and regulations regarding septic system construction. In the event that such laws and regulations are modified in the future to permit a system to be constructed on this property which would 1 permit a system designed for more than three(3)bedrooms to be located on the property, �1- this covenant shall be released by the Board of Selectmen upon receipt of an appropriate plan for septic system construction which has been approved by the Board of Health. This covenant shall also be released by the Board of Selectmen in the event that this property becomes connected to municipal sewer service. !n Signed this V1^- day of June, 2006 i6 Michelle L. Linn COMMONWEALTH OFMASSACHUSETTS On this a day of June, 2006, before me the undersigned Notary Public, personally appeared the above named Michelle L. Li proved to me through satisfactory evidence of identification, which were .J' 11 to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. Notary Public `# BARNSTABLE REGISTRY OF DEEDS vQ TOWN OF BARNSTABLE LOCATION Y' //vlr�yot., h �C SEWAGE # c?7y��� VILLAGE. � r f�oh s /101i7� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. vrOrlr� �G���" 22 SEPTIC TANK CAPACITY LEACHING FACILITY:.(type) ? �"l'` {t (size) yy�X�? x 6 NO.OF BEDROOMS BUILDER OR OWNER u'tq t s I•va 3� PERMTTDATE: l �-9� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet - Private Water Supply Well and Leaching Facility (If any wells exist on 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) Feet Furnished by A AI 1 z ' y' 3 2 � 3 ,� AOO TOWN OF BARNSTABLE (D-P /17 LG�`"A' fON � `vrrg''`�e�, "$" SEWAGE # 7—IS-0 d:i.LAu ^::: a ®�s ASSESSOR'S MAP& LOT 9 �'° INSTALLER'S NAME&PHONE NO. u •-� 1-7G `f'I 8` SEPTIC TANK CAPACITY 7J'10C� LEACHING FACILITY: (type) P�� {e (size) '�10�x 12 x C. � NO.OF BEDROOMS BUILDER OR OWNER u,"e s PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on 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) Feet Furnished by 1 1 13 Y n 2 3 ���; i;. .\ '�f ,�/ ill. �s- Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Mizpool 6potem Con!5truction Permit Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) � complete System ❑Individual Components Location Address or QW w Q,1( ��e-Vl r n - Owner's Name,Address and Tel.No. Ma,,,rs Mi11s �� P,.S 1>Ja1sh, Assessor's Map/Parcel O d 5 1 O W t I lG 4L Installer's Name,Address,and Tel.No. Des. ner's�N�a"m"e,Address and Tel.No. 1��kmy� 51�V�� ka�^Yt40 C7 U r ' O Type of Bu' ing: Dwelling No.of Bedrooms Lot Size Of. sq.ft. Garbage Grinder 4) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3D gallons. Plan Date S-6- 9-) Number of sheets Revision Date 3-27 9 7 Title 51 PA'5u J r Size of Septic Tank 1600 Type of S.A.S. SEL Ian Description of Soil u- D (i t't Nature of Repairs or Alterations(Answer when applicable) Date last inspected: �S 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 Certifi- cate of Compliance has been issued by o d of Health. Signed e Date 1 Application Approved b Date r-3—2,c -J,—Z Application Disapproved for the following reasons Permit No. -2 Date Issued i ' .0, No. Fee �� THECOMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH'DIVISION -TOWNtOF BARNSTABLE., MASSACHUSETTS ZIppltcation for ;W5pont *p5temc Construction Permit Application for a Permit to Construct(/Repair( )Upgrade( )Abandon( ) Vomplete System ❑Individual Components f Location Address or L C J QY �(22 11 Owner's Name,Address and Tel.No. Assessor's Map/ParcelM 0-"( "5 M t S fQ i e-5 V10.-1 Sh Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. `�0.nke C- 5v r^j �rn-,Styan�,j liD 3 nC�cc Q ic Type of Bu ing: Dwelling No.of Bedrooms Lot Size Wq,Q b(, sq.ft. Garbage Grinder(�p) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow ��i gallons per day. Calculated daily flow 3 30 gallons. Plan Date -I D-9 Number of sheets .2 Revision Date 3" Title Size of Septic Tank 15'00 Type of S.A.S. 5ee_ j21dr7 Description of Soil 5eL 016 n Nature of Repairs or Alterations(Answer when applicable) 4, Date last inspected: r" 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 Certifi- cate of Compliance has been issued by ' o d of Health. 6—//- ,• Signed Date 7 Application Approved b Date- , 2 X'`7 Application Disapproved for the following reasons Permit No.�y .* � Date Issued s .. THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired ( )Upgraded( ) Abandoned( )by at E n c M1,11S A has been constructed in accordance with the provisions of Title 5 and the for Disp sal System Construction Permit No. dated yr Installer Designer The issuance of this permit shall not be construed as a guarantee that the systet�vill function as designed. 7 Date h " ' 7 Inspector "`'�S"`7 --------------------------------------- - Fee- 4V THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwi!6pogal *pgtem (Construction Permit Permission is hereby granted to Construct( Repair( Upgrade( )Abandon(, ) System located at 1105a rK V1 tlafsltm Milk and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: ��- C/ Approved by TOWN OF BARNSTABLE LOCA 110N SEWAGE # ` ems �;�s '/ —�j V�.LAG:�: s� // ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. A�G SEPTIC TANK CAPACITY ®� LEACHING FACILITY: (type) 2 eIV (size) 'y"X 1:2 X G j NO.OF BEDROOMS J /l BUILDER OR OWNER ,u m e.5 �� h j PERMITDATE: COMPLIANCE DATE: 11 i I I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on 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) Feet Furnished by � I 13 14 - - -A i- � Q s � i a CATCH - • B \\( ASSESSORS \ MARSI'ONS MILLS BASIN \\\ UTILITIES LOT 70 240. 73 \\\� N83°49'07T ASSESSORS � o \ i _ LOT 69 LOCUS � \ AREA=44,006:-S.F. `4��' �� a LANE ° \ / o C) \°\ \ �/ 100 ,--,\\ ram\ Ioo o ASSESSORS LOT 71 \ R__OED �� 60 s�H �L o N 0 t cs �\\\ �� � � rn 2 \ 0 6• S.0 \ RO oV PON \\ � \ �' \ LOCUS MAP PROPOSED 4I0USE � \ ;EADW 8 w 15 o i ° ° PLAN REF.- 12034D SH 6 OF 6 RES. ZONE. „RF,,, 0 6 21N. s Io2 \� FLOOD ZONE' C \ TP#1 HEADWALL ASSESSORS MAP 125 BENCHMARK. 1903 PROJEC T L OCA TION TOP OF TAGBOLT ON 12 0 �v ASSESSORS LOT 69. HYDRANT ELE V 100. 0 (ASSUMED) O EVERGREEN LANE MHO 4 MARSTONS MILLS, MA. 0�Li APPLICAN - . T. JAMS WALSH \ DRAINAGE I YAWEE SUR VEY CONSUL TAN TS \• EASEMENT P. O. BOX 265 ASSESSORS l/Nl T 5, 40B INDUS TR Y" ROAD LOT 68 \\ X !/ MARSTONS MILLS, MA. 02648 • got \ o ,' PH. (508)428-^0055 - FA X(508)420-5553 OF 1w, PAUL `s�' �1 Bgl1GE � � \\ � ' SCALE.' 1 "=30' DA TE. 316197 A. - �"o. 3299II �� , / , `� ' REV. �121 REV.• 31271973297 JOB NO. 51210 SHEET 1 OF 2 TOP OF FOUNDATION 20' MIN. 10' MIN. CONCRETE COVERS 4" SCHEDULE 40 P. V.C EL. = 101 MIN. PITCH 1/8 PER FT. 2"LAYER OF 1/8"-1/2" 6" MAX. i „ , CONCRETE COVER WASHED STONE i � � � � � ii EL. =101 - 4 CAST IRON PIPE (OR EQ UAL) MINIMUM PITCH 1/4 ' PER FT. �' CLEAN SAND 9 FLO W LINE j 8 MIN.' INVERT 1 10 EL=97 25 XX MIN. 14 _ EL.= 99 -- INVERT ( l—=-J ° oo ° oo ° o0 00 o 'o ° om o GAS LEVEL 0 - 0 - 0 0 - 0 00 6" INVERT BAFFLE EL.= 98.50 INVERT SUM o o ° o 0 0 0 0 0 0 ° 00000 co °0 0 0 0 0 0 c o INVERT o 0 0 0 0 0 0 0 0 ® 0 0 0 ° EL.=96.25 EL.= 98. 75' EL._98' Z TEL.= 97. 75' (TO BE PLACED ON FIRM BASE) DISTRIBUTION INVERT MECHANICALLY COMPACTED OR 6" OF STONE BOX EL.= 96_ 5 1500 -_GALLONS t E TO BE WATER TESTED 40' X 12' TRENCH FORMATION SEPTIC TANK IF MORE THAN ONE OUTLET � PLACE ON 6" STONE 3/4" TO 1-1/2" SOIL. .. ABSORPTION PROFILE OF WASHED STONE S YSTEIVI (SAS) SEWAGE DISPOSAL SYSTEM BOTTOM OF TEST HOLE OR USES PROBABLE WATER TABLE ELEV. = 87 NOT TO SCALE f NO OBSERVED WATER TABLE (11/20/96) ELEV=_87 'P OBSER VA TION HOLE 1 ELEV. __ 100.5 ' PERC. RATE -<5- MIN./ IN. OBSER VA TION HOLE 2 PERK AT 48__ INCHES ELEV= 99. 0 0' 0' TOP TOP & SUB—SOIL & SUB—SOIL GENERAL NOTES 32"" 30" STRATIFIED } STRATIFIED SOIL TEST 1) ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P. TITLE 5 AND THE TOWN OF _BARNSTABLE RULES AND SAND & SAND & DATE OF SOIL TEST 8/18/88 REGULATIONS FOR THE SUBSURFACE DISPOSAL OF SEWAGE. f GRAVEL WITNESSED BY: JERRY DUNNING 2) ONE COVER ON SEPTIC TANK SHALL BE BROUGHT TO GRA VEL WITHIN 6" OF FINISHED GRADE, OTHERS WITHIN 12" SOIL TEST DONE B Y STEVE WILSON ( BARTER & NYE ) 3) ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE 12 NO WATER f. I2 NO WATER D_ESI(;N CALCULA TIONS,, USED UNDER OR WITHIN 10 FT. OF DRIVES OR PARKING AREAS 4) ANY MASONARY UNITS USED TO BRING CO VERS TO GRADE SHALL NUMBER OF BEDROOMS 3 BE MORTERED IN PLACE. __ _ ' GARBAGE DISPOSAL NO _ . 5) NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH- TOTAL ESTIMATED FLOW DEEDED OR ZONING REGULATIONS. 0 WNER/APPLICANT. IS TO ( 110__GAL./BP/DA Y x _3__ BR) 330 � GAL FDA Y OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY - 6) UTILITIES SHOWN ARE APPROXIMATE ONLY, EXCA VA TION CONTRACTOR REQUIRED SEPTIC TANK CAPACITY 1500 GAL IS TO CALL 'DIG- SAFE" AT 1-800-322-4844 AT LEAST 72 HOURS , SOIL CLASSIFICATION . 1 PRIOR TO COMMENCING WORK ON SITE. DESIGN PERCOLATION RATE < 5 MIN./IN. 7) CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE. r, EFFLUENT LOADING RATE . . . . . . 74 GAL/DA Y/S.F. 8) PARCEL IS IN FLOOD ZONR __"C" . LEACHING CAPACITY (AREA X RATE) 355 GAL/DAY 9) LOT IS SHOWN ON ASSESSORS MAP 125 AS PARCEL _69 RESERVE LEACHING CAPACITY . 355 GAL/DAY (12X40X . 74 ) 1 SHEET 2 OF 2 JOB NUMBER__ 51210------- i {z1i7��v�'N"n►�c Gof`YrINU6DUs , Zu X l'Z" }�1171.I�t3oG�i7 9 � ,.,• GdL.L�� ,/L" t�rvoot�4zooP s�-r�a�t�+iNG i5rru1'7\V�LL INStJL.acf IoN !v r9 t .�IGtN G�21-re�l�s. �`. -�� 9+ �/L" �L rv001���/�LL LIV1NGl ADS(�'XG f sL INGt 4i2-was ) >x� Live LClAt2 w z 5+-F��'(ti tiN� 51 �1N�Dimas x� 1v. L11\/*-�-Low w f..IMI'r O� E �o �Llyc Low -10 �i�ai�Low ��CIS'rIN� a1rL 1r1�1L-i1���nON t3a��.oN1�s cNt� bo >x. L1y� t�ai� ,o Psc-- VtaAt.,�oa� t3aslG SNo�u Loaf zroN� � � �.�F LIVE Lda'l� -10�..�1�.�LOa1� ,ro I N s 11�NG To MaTG�+ �. 4,U-S'{ tJU�U1 1- �2,43�IIN�'TO t3E INSTD LLE17 1N S'T1ztllr DGlo1Z1�D1�Y���/1'j{t ra�,.,�aG�-t,�,�e�-Ts sTaT� uN1F�t3u1L1�1N�Go��7ao Gt�s1kTFt �r�10N �- 7 � To ,1Nl �. 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