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0192 MISTIC DRIVE - Health
192 Mistic Drive, Marstons Mills Bk 35079 Pg264 #21865 04-28-2022 @ 09:10a DEED RESTRICTION WHEREAS,Nadezhda Pokrovskaya,of 192 Mistic Drive,Marstons Mills,Bamstable County,Massachusetts 02648,is the owner of the land,together with the buildings thereon,situated at 192 Mistic Drive,Marstons Mills,Barnstable County,Massachusetts 02648,which land is further described as Lot 11,as shown on a plan of land recorded with the Bamstable County Registry of Deeds in Plan Book 203,Page 53,and further described in a deed recorded with said Registry in Book 33963,Page 109;and WHEREAS,Nadezhda Pokrovskaya,as the owner ofsaid lot,has agreed with the Town ofBamstable Board ofHealth to a restriction as to the number ofbedrooms which can be includedon said lot; WHEREAS,the Town ofBamstable Board of Health is requiring that the agreement for the restriction on the number ofbedrooms in any house located on the lot be put on record with the Bamstable County Registry of Deeds by recording this document, NOW THEREFORE,Nadezhda Pokrovskaya does hereby place the following restriction on her above-referenced land in accordance with her agreement with the Town of Bamstable Board of Health,which restriction shall run with the land and be binding upon all successors in title: 1.192 Mistic Drive,Marstons Mills,MA 02648 may have constructed upon the Lot a house containing no more than four (4)bedrooms. Nadezhda Pokrovskaya agrees that this shall be a permanent deed restriction affecting Lot 11 located at 192 Mistic Drive,Marstons Mills, MA 02648*and being shown ona plan of land recorded with the Bamstable County Registry of Deeds in Plan Book 203,Page 53. This restriction shall terminate if the property is connected to Town Sewer. Bk 35079 Pg265 #21865 Executed asa sealed instrumentthis Bamstable« (County) On this OKROVSKAYA COMMONWEALTH OF MASSACHUSETTS 22tday of..&ML.ial|y appeared ^ SVrriANA D.GEM80RYS NotaryPublic Mastachuseiis MyCommSsskm Expiirs May 24.2024 .....--—-rr-r I T- 2022,bcforc me, theundersignedNotaryPublic,personalia appeared NADEZHDA POKROVSKAVA,who proved thcojigh satisfactory evidence of identification,which was person whose name is signed ontheprecedingorattacheddocument,and acknowledged to me that she signed it voluntarily for Its stated purpose,and who swore or affirmed to me that the contents of the attached document are truthful and accurate to the best of her knowledge and belief. Notary Public ^y Commission Expires: JOHN F.MEADS,REGISTER BARNSTABLE COONTT REGISTRY OF DEEDS RECEIVED &RECORDED ELECTRONICALLY t Commonwealth of Massachusetts Title 5 official Inspection Form �- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J 192 MISTIC DRIVE -- Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is MARSTONS MILLS MA 02648 09/01/2019 required for every page. Cityff own State Zip Code Date of Inspection a Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. Inspector Information 91gq filling out forms on the computer, JOHN P GRACI-SR use only the tab key to move your Name of Inspector cursor-do not GRACI SEPTIC INSPECTIONS LLC use the return Company Name key. PO BOX 2119 r� Company Address TEATICKET MA 02536 City/Town State Zip Code 508-548-7500 S1468 Telephone Number License Number c B. Certification I certify that: l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails i 09/01/2019 Inspector's Signature Date The system inspector shall s' mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 ys of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the in ector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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 i in the future under the same or different conditions of use. t5insp.doc-rev.W282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form r` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is MARSTONS MILLS MA 02648 09/01/2019 required for every -- page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSES TITLE 5 CRITERIA AT TIME OF INSPECTION 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): NA f t5lnsp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is MARSTONS MILLS MA 02648 09/01/2019 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cunt.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): below obstruction is removed El ❑ N ❑ ND (Explain ): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): NA ❑ 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): NA 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts -� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is MARSTONS MILLS MA 02648 09/01/2019 required for every page, City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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: NA _ **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 pprn., provided that no other failure criteria are t(ggered.A copy of the analysis must be attached to this form. R c. Other: NA 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El ® 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 t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 ti Commonwealth of Massachusetts Title 5 Official Inspection Form i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments e =/ 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owners Name information is MARSTONS MILLS MA 02648 09/01/2019 required for every State Zip Code Date of Inspection page. Cityrrown C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ® 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 1/2 day flow 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. ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ 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. 5) 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 C.4. 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 t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments f; =<a�! 192 MISTIC DRIVE _ Property Address __-__.�__ _ ----------------_-._-- _�.__ SUSAN AND JOHN MAFFEI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] l t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface sewage Disposal system•page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE _ Property Address — SUSAN AND JOHN MAFFEI Owner Owner's Name information is MARSTONS MILLS MA 02648 09/01/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): <440 Description: INFORMATION TAKEN FROM INSTALLERS ASBUILT CARD DATED 06/01/1987 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: NA Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d TOWN g � Y 9 �gP ))� Detail: 2018-291,000 2017- 196,000 Sump pump? ❑ Yes ® No Last date of occupancy: OCCUPIED p Date L,5in.p.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 o Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE_ Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name -----------.___.._._.__---------..-----._.__ - information is required for every MARSTONS MILLS MA_ 02648 09/01/2019 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): NA Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): NA Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: NA — Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: N`a' Last date of occupancy/use: NA Date Other(describe below): NA J 3. Pumping Records: Source of information: ROBERT OUR ON JULY 30TH 2O19 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: MAINTENANCE t5insp.doc•rev.7/28I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / 192 MISTIC DRIVE Property Address SUSAN AND,IOHN MAFFEI Owner Owner's Name information is MARSTONS MILLS required for every MA 02848 09/01/2019 page. CitylTown State Zip Code Date of Inspectlon D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption-system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system es or no e y {y )(if yes, attach previous inspection records if an P � Y) ❑ Innovative/Altemative 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): Approximate age of all components, date installed (if known)and source of information: 1987 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 9' Material of construction: ❑ cast iron ®40 PVC ❑other(explain): 40 PVC Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' Y 192 MISTIC DRIVE_ Property Address -- ----- - ----- -- ___._-v-_--- SUSAN AND JOHN MAFFEI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 8'6"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) SEPTIC TANK IS CONSTRUCTED OF CONCRETE If tank is metal, list age: NA years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1200 GALLON STANDARD SEPTIC TANK Sludge depth: ZERO Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness ZERO Distance from top of scum to top of outlet tee or baffle 6-1— — -- Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? PUMPED 30 DAYS PRIOR Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1200 GALLON SEPTIC TANK AT TIME OF INSPECTION APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY RECOMMEND PUMPING EVERY 2-3 YEARS DEPENDING ON USAGE. t5insp.doc•rev.7/26/2018 rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 o ' Commonwealth of Massachusetts �. Title 5 Official Inspection Form I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 'l 192 MISTIC DRIVE Property Address ----------- --- SUSAN AND JOHN MAFFEI Owner Owner's Name — -- information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: NA _ Scum thickness NA 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 Date of last pumping: NA Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): NA J `- 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene '❑ other(explain): NA Dimensions: NA Capacity: NA gallons Design Flow: NA gallons per day t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: NA Alarm in working order: ❑ Yes ❑ No Date of last pumping: NA Date Comments(condition of alarm and float switches, etc.): NA "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert BOTTOM OF PIPE 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 APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT TIME OF INSPECTION. t5insp.doc•rev.7/26/2016 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments . � 192 MISTIC DRIVE v� Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): NA * If pumps or alarms are not in working order,system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NA Type: ® leaching pits number: (2)TWO ❑ leaching chambers number: NA — ❑ leaching galleries number: NA — ❑ leaching trenches number, length: NA ❑ leaching fields number, dimensions: NA ❑ overflow cesspool number, NA ❑ innovative/altemative system Type/name of technology: NA t5insp.doc-rev.7Y2WO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ': , '� 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owners Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): 2-6X8 LEACH PITS WERE EMPTY AT TIME OF VIDEO INSPECTION. SYSTEM AT TIME OF INSPECTION APPEARS TO BE FUNCTIONING PROPERLY. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA -- Depth—top of liquid to inlet invert NA Depth of solids layer NA Depth of scum layer NA Dimensions of cesspool NA Materials of construction NA ` Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition-of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions NA Depth of solids NA Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): NA t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage'Disposal System Form -Not for Voluntary Assessments s� 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI Owner Owner's Name information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 !Y FWNr Poack! A 0� R . r �. ,JL a C �, ��B0 �2 1-10 1-1$ '4-M 4-41 (.D, e 2-35 1.35 Pt r 8--5 1 g•qq A-,31 &I'la VIT_ t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 ; Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE _ Property Address _._- ----_—�-- ----—.-- SUSAN AND JOHN MAFFEI Owner Owner's Name --� information is required for every MARSTONS MILLS MA 02648 09/01/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGER192 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 192 MISTIC DRIVE Property Address SUSAN AND JOHN MAFFEI _ Owner Owner's Name information is required for every MARSTONS MILLS _ __ MA 02648 09/01/2019 page. Cityrrown v State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate t 4(Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: _ Fill in please: APPLICANT'S YOUR NAME s: BUSINESS YOUR HOME ADDR SS: 2- T a ref ors-1�2n5 k,1 YS TELEPHONE # Home Telephone Number NAME OF CORPORATION: NAME OF NEW BUSINESS A-_� S\ TYPE OF BUSINESS l t CID- cXIC f`e IS THIS A HOME OCCUPATION? _YES NO D�/// _ l ADDRESS OF BUSINESS 1 S MAP/PARCEL NUMBER "" �� -1 (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has been,ir r � f the permit requirements that pertain to this type of business. V �} MUST jompL Authorized Signature** �,A7ARDOUS i`AATFRIN S COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: } DATE: _ 9/22/97 PROPERTY ADDRESS: 192"Mlkstic Drive Marstons Mills Mass 02648 On the above date, I Inspected the septic system at the -above address. Thls system consists of the following: 1 . 1-1500 .gallon septic tank. 2. 1-Distribution box. 3. 2-1000 gallon precast leaching pits. Based bn my Inticy&Ctlon, I certify the following conditions: 1 . This is a title five septic. ys -em. (.. 2 . :The septic`system 78 Code is in proper workin .at the present time. 9.°order 3, pumped septic tank as part of inspection. 51GNATURF, 0 Name:_J. P_M_acomber Jr., Company:_J. P_MacoMber & Son- -Inc . __CentervilLeLMass__02b32 Phone:___SQg-Z7- -�338_______ '• I THIS CERTIFICATION DOES NOT CONSTrTUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER. & SON, INC, D Tanks-Cesspools-Leachflelds PUmP+d L lnsillled - yo��s�� Town Sewer Connections P.O. Box 66 ' Centerville, MA 02632.0066 775-333.8 775-6412 '� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS i b DEPARTMENT OF ENVIRONMENTAL PROTECTION ' I ONE WINTER STREET, BOSTON, MA 02108 617.292.5500 f , i WILLIAM F.WELD I Governor TRU. I ARGEOPAUL CELLUCCI Lt.Governor DAVID B { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Con p PART A CERTIFICATION Property Address: 192 Mystic Drive Marstons Mi jNdress of Owner: Date of Inspection: 9/22/97 (If different) Name of Inspector: 1Tn-,, , �^ M comber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX66 Centervi le,Mass. 02632 Telephone Number: ,a08-773�st CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reposed below is true, acc and complete as of the time.of inspection. The inspection was performed based on my training and experience in the proper function maintenance of on-site sewage disposal systems. The system: Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: r The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30 d inspection If the system is a shared system or has a design flow of 10,000 ) days of completing this the repon to the a gpd or greater, the inspector and the system owner shall sub appropriate regional office of the Department of Environmental Protection. The original should be sent to tiie system o and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C or D: AI SYSTEM PASSES_-" `I have not found any information which indicates that the system violates any of the failure criteria a Any failure criteria not evaluated are indicated below, s defined in 310 CnaR 15.3 COMMENTS: BI SYSTEM CONDITIONALLY PASSES: d2& One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, u; completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. i The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or to failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank at approved by the Board of Health. (revised 04/25/97) Page 1 of 30 DEP on the World Wide Web: http./twwW.rnagnel.state.ma,uyoep + Printed on Recyried Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Properly Address: 192 Mystic Drive Marstons Mills,Mass. Owner: John Maffie Date of Inspection: 9/22/97 B) SYSTEM CONDITIONALLY PASSES (continued) &P Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, senled or uneven dtstrib}jt�io�n box. The syste will pass inspection if (with approval/oy��the Board of Health). Describe observations: , ,p/ y Qv K e broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced � JO The system required pump+ng more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: AID Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) $YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: oVP Cesspool or privy is within 50 feet of a surface water &VO Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. �J The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance 4Ji9 (approximation not valid). 3) OTHER (r•vl••d 0�/2S/97) Y•p• 2 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 192 Mystic Drive Marstons Mills Ma Owner: John Maffie Dale of Inspection: 9/23/97 D) SYSTEM FAILS: You must indicate ew er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CmR 15,303 The base for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to con the failure. Yes No Backup of sewage into facility or system component due to an 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 o cesspool. I' S tic liquid I- I"n`the'distributi. n box above outlet invert due to an overloaded or clogged SAS or cesspool W'/Q�1C/8 Qr9lJI'�. iiquId depth nf,s less than 6" below raven or available volume is less than 1/2 day flow 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water suppls Any portion of a cesspool or privy is within a Zone I 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 r acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis is conform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: AP The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No /AIfA 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further in rmatron ,Ile is ' rr lJ�.r]E� send Gov O•C� 'r, l &Z�Arrr Y (revised 04/25/97) -+. Pay• ) of 10 �' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Properly Address: 192 Mystic Drive Marstons Mills Ma Owner: John Maf f ie Date of Inspection: 9/2 3/9 7 Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes No Pumping information was provided by the; caneroccupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. — The facility or dwelling was inspected for signs of sewage back-up. y The system does not receive non-sanitary or industrial waste flow. — The site was inspected for signs of breakout. — 4 All system components,�*xcluding the Soil Absorption System, have been located on the site. — The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. — Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) (revised 04/25/97) Peso 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly Address: 192 Mystic Drive Marstons Mills Ma Owner: John Maffie Date of Inspection: 9/23/97 FLOW CONDITIONS RESIDENTIAL: Design flow: WQ p.d./bedroom for S.A.S. Number of bedrooms:( Number of Current residents: Garbage grinder (yes or no):VA, aJ Laundry connected to system (yes or no): Seasonal use (yes or no):_AY Water meter readings, if available (last two (2) year usage (gpd): )! c f1X• t�pd, Sump Pump (yes or no):_&A' //yam .lf6 Last date of occupancy.�� COMMERCIAUINDUSTRIAL• Type of establishment: A.-',*f Design now: AA,41 Ratlons/day Grease trap present: (yes or no)A/9 industrial Waste Holding Tank present: (yes or no)-4214' Non sanitary waste discharged to the Title 5 system: (yes or no)AY' Water meter readings, if available:" Last date of occupancy: OTHER: (Describe) AIA Last date of occupancy: GENERAL INFORMATION PUMPING R ORDS and source of information: / System l5umped as pan of inspection: (yes or no) If yes, volume pumped: /S g Ilons Reason for pumping:s%` :� �vli TYPE OF STEM Septic tank/distribution box/soil absorption system / ve cesspool Overflow Overflow cesspool Privy Shared system(yes or no) (if yes, anach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other 4# .AEPROXIMA E GE of a11copyen A, date installed (if kirtgazi and source of information: Sewage odors detected when arriving at the site: (yes or no)— lr•vi••d 0�/]S/97) D•g• 5 of 10 TOWN OF BARNSTABLE 9 SEWAGE # LOCATION VILLAGE ��Al2ST�1�� S 117r�L,S ASSESSOR'S MAP & LOT A n o74 INSTALLER'S NAME PHONE NO.0-nn?e rr'Co•u cT/NG 39 V-�3S�Z SEPTIC TANK CAPACITY 20 d LEACHING FACILITY:(type),._ (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER�I� BUILDER OR OWNER bra m e77 o sT Nc DATE PERMIT ISSUED: DATE .CO'UPLIANCE ISSUED �...✓ �! - VARIANCE GRANTED: Yes Nzj--jqo—f-- w "Slkv.lSdvw ZVQ �►1SILJ h b LF F� v a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 92 MY stie Drive Marstons Mills Ma Owner: John Maffie Date of Inspection: 9/23/97 BUILDING SEWER: (locate on site plan) n Depth below grade:r Material of construction: _cast iron .4/40 PVC—other (explain) Distance from�Prrvate water supply well or suction line 44 Diameter y Comments: (condition of joints, venting, evidence of leakage, etc.l r Tki r l,y e SEPTIC TANK: k-11"bA9 (locate on site plan) Depth below grade:g rr Material of construction: Zoncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age age� Is agile confirmed by Cenifiicaate/of Compliance4 (YeVNo) Dimensions: /`r6i�� b 1O �,ll4 L5�T��hY�7 Sludge depth: ,+� Distance from top of ludge to bonom of outlet tee or baffle:y Scum thickness:_ Distance from top of scum to top of outlet tee or baffle:_ Distance from bonom of scum to bono of outlet t e or baffle: How dimensions were determined: /f�tirov�G� Comments: trecommendahon for pumping, con d t: n,of.inlet and,o.utlet tees or baffles depth of liquid level in relation to outlet inven, structural -41 integrity, evidence of leakage, etc.) difS 7 15 T GREASE TRAP;/J.© (locate on site plan) Depth below grader Material of construct on concrete(��metaLlJAFiberglass4)APolyethylene/1 ther(explain) A iA Dimensions: zZ6 Scum thickne.ss.__ALJ Distance from top of scum to top of outlet tee or baffle:gj Distance from bonom of scum to bonom of outlet tee or baffle:,4.kL Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) l9a A; /LGT ®/V 5�°�' (revisod P•g• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 192 Mystic Drive Marstons Mills Ma Owner: John Maffie Date of Inspection: 9/2 3/9 7 TIGHT OR HOLDING TANK:A2j4j(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:dL Material of construction:�llAconcreteAgmetaWAFiberglassAAPoI yet hyleneA."Aother(explain) A,fk t2h Dimensions: NA Capaciry: d/R gallons Design flow: gallons/day Alarm level: Alarm ,in working order VALYes;A No Date of previous pumping: 01e Comments. (condition of inlet tee, condition of alarm and float switches, etc.) r T-mr a iyo DISTRIBUTION BOX: (locate on site plan) /�� �1 Depth of liquid level above outlet inven:4& 4,sw Comments: In if level and distrib ion is a ual.eviden e oLsolids rry' ver;'evident:e.of-leakage or out of box, et J 6r i PUMP CHAMBER:z /( (— (locate on she plan) Pumps in working order: (Yes or No)� Alarms In working order(Yes or No)-.dl&� Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) • dZ?" (tovis.d 04/25/91) Peg• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:l 92 Mystic Drive Marstons Mills Ma Owner: John Maffie Date of Inspection: 9/23/9 7 SOIL ABSORPTION SYSTEM (SAS):_z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number:= leaching trenches, number,length: li leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: .0 Comments: (note condition of soil, signs of hydraulic failure, level of pgonding, condition of vegetation, etc.) CESSPOOLS: J�1Jf� (locate on site plan) Number and configuration: N!P r Depth top of liquid to inlet invert: 4,4 Depth of solids layer: AJA Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: IVA inflow (cesspool must be pumped as pan of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PR I VY:zbec' (locate on site plan) Materials of construction: Dimensions: Depth of solids:�(e— Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) �T Irsvimod 04/25/97) P&g• 6 of 10 s ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:1 92 Mystic Drive Marstons Mills Ma Owner: John Maf f ie Date of Inspection:9/23/9 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) - r ,6h h F� 7S no v (4?vimod 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 192 Mystic Drive Marstons Mills Ma Owner: John Maf f ie Date of Inspection: 9/23/97 l Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ — bservat,on of Site (Abuning properly, observationhole, basement sump etc.) —ZOetermine rt from local conditions Check %.jth local Board of heal)h _ Check FEMA Maps r Check pumping records ,heck local excavators. installers Use VSCS Data Describe - your o n Words how you Paablished the High Groundwater Elevation. (Must be comolo1114 Cape Cod Water Table Contours And Public Water Supply Wellhead Protection Ares Map Cape Cod Commission September 95 (zwi��d OV15/97) P4y• 10 of 10 i 4 ♦ . y + i (•..q'+�n /1--�,•i-.T-IT'rmrnrJ.n.T.t:•.T+'.'e.I:+n/Ynr. AeT1L AI1nO'Te nTriTvn��n-r.-+•r.—f TOWN OF Barnstable iIOARU OF HEALTH SUIISURFACF SEF(AGF DISPOSAL SYSTF,M 1NSI'FCTIOH FORM - PART U - CERTIFICATIU'a .11VI oe rAINt 0[A AIt- PROPERTY INSPECTED STREET ADDRESS 192 Mystic Drive Marstons Mills,Mass ASSESSORS MAP , BLOCK AND PARCEL 0 OWNER' s NAME John Maffiqe PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME Joseph P. Macomber & 'Son , Inc . * COMPANY ADDRESS Box 66 Centerville , Ma. 02632-0066 Street Tovn or City St,t. ti COMPANY TELEPHONE (508 ) 775 -3338 FAX ( 508 ) 790 -1578 CERTIFICATION STATEMENT I gertify that I have personally inspected the sewage disposa-1 system this nddress and that the information reported is true , accurate , and complete ns of the time of .-inspection . The inspection was performed and any recoln,net)dations regarding upgrade , maintenance , .and repair are consistent With my ,training and experience in the proper function and maintenance of o. site sewage disposal systems . Check one : XXXXXXXXXXXSysteei PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public I�eallh or Lhe. environment as defined in 310 CMR 15 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED' \ The inspection which I have con acted has found that the system fnlis t Protect the public health And the environment in accordance with Title 5 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . .Inspector Signature Date 9/23/97 One copy of this certification must be provided to the OWNER , the BUYER,( ..h.er6 aNplicable ) and the BOARD OF iIEALTiI, If the' Inspect ion FAILED, the owner or"operator shall u aitltin one year of the dnte of the inspection , unless allogeddorthe requi �ecT otherwise as provided in 310 ChiR 15 , 305 , partd , doc /C, < ti � W to Z7 7 P7 THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTH ,D TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of 'the General Laws. Issued by The Department of Environmental Protection.. )unc a. 199S Acting Dircctor of the on u(Watcr Pollutio�Cont�rol TOWN OF BARNSTABLE ¢ LOCATION �.a`T it�1�1 t/S"1"/G �,F-e�lti SEWAGE # .4oT i/ P VILLAGE I AgkSTdNS i�'1�LLS ASSESSOR'S MAP & LOT - o 0-7 9105 INSTALLER'S NAME & PHONE NO.Cn1n/�G77'CorySr iNc 39 V-l3,S�7 SEPTIC TANK CAPACITY ZG C3 LEACHING FACILITY:(type) v 7' Alk. _�size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER_RLaIIG BUILDER OR OWNER Cf-; M m e'17-r-o s f 0-lc DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: ✓ �- i- �) VARIANCE GRANTED: Yes N NoAJI GAnAGE rf , ,8:3 i y Cat ISr� e DR. A;¢Si oA/S�- MiLIS MUST - Mild. _ THE COMMONWEALTH OF MASSACHILLE® IN CO �Q 1 r�� f1 BOARD OF !-�I EA Ll�`i� (((���ODE r @ /� d w ti..................OF......vQ�"�lf. ......-- 4. ' R-REGU .ATI 'a'a Applirativit for Uiipnaal Workii Tonstrurtion Vamit Application is hereby made for a Permit to Construct (Koe ) or Repair ( ) an Individual Sewage Disposal System at: ................_..._...._ w . ........................................... - -----• ....................... Locy' -Address -Al or Lot No. Owner Address W Installer Address Type of Building Size feet Dwelling—No. of Bedrooms.................:.�_Z....___..._...__.._.Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---------------------------• P ( )--- Cafeteria ( ) a ., --••--•---•---••-•......•-•----•----•-•-- ------•... Design Flow.................... ............g lions per person per day. Total daily fl�w.._..::..... ._.............__gallons.Y Other fixtures . ...-•--•-•-----------------•-----•--•--- W WSeptic Tank—Liquid capacity/__.fTOgallons Length/�.....-O.._ Width.f..6..- Diameter................ Depthe.r"...P.. x Disposal Trench—No. ..7............... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--___Z-------- Diameter.A..'-0.`.. Depth below inlet...`.............. Total leaching area. .... .sq. ft. Z Other Distribution box (K) Dosin5tank ( / � '—' Percolation Test Results Performed b. ..__...�e. ._..1-.fF-4. a Test Pit No. 1.....Z-------minutes per inch Depth of Test Pit.... �_Z-. .. Depth o ground water-----/«o.fir-G rX4 Test Pit No. 2................minutes per inch Depth of Tes/tt Pit.................... Depth to ground water........................ 0 Description of Soil------/..?¢ 9�.....u.. cd<v-'-.............. � �` w ----4 ---------------- U ��------ 3 Z------------S..!as..( --••••---- ,/�.6 v N `c� / "-. tf _...----•---•-------•--•------ ... LC... -- wiz- <----•---•--•.•----•-•••- W -----------•-----•---•-------•-•-•-•--•I i......--��Z-- �iy�f. ��•J s N VNature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------•-------------•---•-----------------------•-•---•-••-•-...........--•-•-•----••----•--••••--•••-----•-••----••-•-•---•••---••----•-••••••-•----••--••••----•---•---.....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LIT Li 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued b the board of health. Signed-•---.. .. .•............ •......... •. . .... . ..................... „�!1a ate Application Approved BY = ---• ••----•- ....... • --••---•--•------•------•-- ...... - !�.. r, Date Application Disapproved for the following reas0 s -------••------•••••-•--•-•--------••---------•----•----•••---<-.----------•-•---••-•--••--.....-•-----•-...-•-- ----•••-• ----- -------------•-----------------...-----•-•-•••--•------••----•--. ................. Date PermitNo.......................................................... Issued....................................................... Date No......................... Fx$............._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.-/..G"c"- -- ....................OF..... �"�i� ......� ........ AvOra#ion for Disposal Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System C at: _ /f /.,� ....•..••.-..... _.......................................•_.-•-__..._.....__._'_............... ......._........_:................_...........................................................••- ,,�[ Loctn-Addre7 �[ or Lot No. ••'-•_....•_'.............^•"'..."_......••-•-_•_-_•-••'.....---..._.._.........-___•__•_'__.._ ..........--..................................................................................... Owner Address W Installer Address Type of Building Size Lot._�'!1__G.C! ?.Sq. feet U Dwelling—No. of Bedrooms................. .................... Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures --------------•--•------------------------------•-----••••-••--------••------•---••-----••--••---•---•-••---••••-•••--••--------•---...........••.... W Design Flow..................... gallons per person per day. Total daily flow_._..._..._.f! fK.c.................gallons. 9 Septic Tank—Liquid capacity lz f gallons Lengthy_..._'--'Width._S-".U.`.Diameter________________ Depths. Disposal Trench—NTo. .................... Width............._........ Total Length.....--....._..._..... Total leaching area....................sq. ft. Seepage Pit No......�r......... Diameter..�O..�__ .. Depth below inlet.........G_ Total leaching area._f 2.:.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed b ...... �%lam �v' Y - ---�------ - ---------------------•--._...---•---••---------,�G- ate__.----•------ --•---- /f�-�.. �a Test Pit No. 1......... per inch Depth of Test Pit..... Depth o ground water____. L. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil......................... .................. ` ' ,-- '-•-•- v .. W -------•--•...z. - ..9... `' .mot/rrl.................................................. ...................................� -1.C. ------------------------.............. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ----------------------------------•-------------_--------------------------•------•-----•---•................------...------------------------------------------------------------------------...-----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?:ad. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed........ ............................................................................. Date Application Approved By......................................... Application Disapproved for the following reaso s ..t........................---------.....------...--------•---.......................... Date---------._... ........................................................................................................----------------------------------------•---------...------------------------------------------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ....... .. "4`"" ...............OF....... � to ......................... (Intifira#r of Toutplianrr THIS IS T CERT F , That PeIndividual Sage Disposal -ste constructed (L-Y or Repaired ( ) by .. ,... ....... tt ./� Installer at............ J.` -•--- . -• -- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application fot-Disposal Works Construction Permit No......................................... dated.........................._..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. 2- ............................ Inspector. ' ............................. S,f'pr:L Sy.S [£v,� :T'n1-+-AIt4-tto �VtJJt vtLIL t THE COMMONWEALTH OF MASSACHUSETTS tV!.dAIIA-4IVri t-2W>av^ je; 5d�er�It.rar� C)+ vtriSeI�AGl?') _VA tJhi-,j t.A I 0'( morn_+V_eArv+1 Y5y `fhe BOARD HEALTH t"AAC-Al ty OeSeW iv► toinl!h-eeY ., `� •+. 6�m I C'Ne htM /�t eA �K�d ..OF...................................................................h.:r...V_ �e �C�i4• .. P'EE................ • `7.ipi oral n lt., orko Tudion i L rJ1 WV, �E t� -f'P ti ''J� �•i.�¢: J�-+,:� my S?�r�t►� per{•, 4 Permission is hereby granted. 1,1 - ---------------------------s'.f ecs-4" C -e .�u �9 r,/, to Construct ), or Repair ( ) an Individual Sewage Disposal System at No.• �� t c�'..� t.C i'� ........................��rt� Street as havn on the application for Disposal Works Construction Permit No..-.-_._�` 1. Dated..... _ ,�........:..... ...................................--- � • •-------•- , ©L + Boarr'eof<eallh DATE---_------- - l o V l -•------ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS _1�77,7 �7 77 '77, �77", 77 777- j i,. S YS TEM. PROFIE -NOT LO SCALE ADE , -TOP FDN FINISH GR FINISH, ORA DE 0 VER DIST. , BOX FINISH G DE, 0 VER FINIS14'GRADE.D VER SEPTIC , TANK 'LEACHING :PIT 11A\A 4 'VARIES AST, CONC' OR :OF",. 1/8 PREC SHED PEA S TONE,' :b* BRICK.'S MORTAR, TO 12 BEL OW GRADE OUTLET PIPE LtvtL,, �,y OL OR 2 FT. MN. 7 .6 4 S? OR PVC TEES C T14 0'%�A 500 L7ALLON DIS.TRIBU TION_ BOX. BSMT.:,�',FLR. EL 00 INSTALL ON LEVEL , BASE To I PRECA S T CONCRETE PRECAST , PVA SHED CRUSHED 'CONCRETE H-7 0 REINFORCED 'ONE H—k0 ' SEPTIC TAW INS TA L L ON LEVEL BASE NO TE: EXCA VA TE TO EL E V. OR RE -:1M L OYER TO MOVE ALL , PERVIOUS MA TERIA L BENEA TH. THE LEACHING AREA z REPLACE EXCA VA TED MA TERIA L WI TH , CL EA N, CL A Y FREE SAND, E FECTIVE DIAMETER F 'A 1500 GALLON LEA CHING-- , PIT- PRECASTtOMCRn�,E, GENER L NOTES SEPTC 7-AW T iZ ON LEVEL BASE. INS TA L L 1 '. ALL EL EVA TIONS SHOJVN ARE BASED ON AE�C>UM�-c) ALL PIPES: IN THE S YS TEM MUS T BE ,CA S T 1R01V OR S CHE D UL E 4 P VC 08SER VA TIOA 3. THE BOA RD OF K A L TH MUS T BE NO TIFIED CONS TRUC TION IS COMPLETE PRIOR WHEN PERCOLA 'RA TE.` , TId, TO BA CKFIL L ING Z JON.IrN; ' ED HIS PLAN MUST. BE APPROV 4. ANY CHANGES IN IJE ' BY THE BOARD Or A D BY*1 :WITNESSE L TH AND CAPE 6 ISLANDS SURVEYING CO. INC. 0 5. MA TERIALS --AN0 JNSTALLA TION SHALL BE IN HEA L TH DA TA nA1Z M, BRO. - OF 9ESIGN COMPLIANCE IVITH , rhE STATE, SANITARY� DA TE. 'CODE -TITLE V -AND LOCAL APPLicABLE L RU ES AND REGULATIONS E NUMBEP ��OF BEDROOMS Z- 6 NORTH ARROW IS FROM RECORD PLANS AND GA RBA GE , DISPOSA L T, TO BE USED FOR SOLAR :PURPOSES is NO PRECA CONTETE 7. FL ODD 14AZARD ZONE , (p 8. NA TER SUPPLY 70W N W7E-2 SEPTIC TANK REG T. SEPTIC TA 1VK PROVIDED bEinQ L EA CM N�7C)f UN LEACHING PEGUIPED v 42 SIDENALL AREA 3 PY6 S.F. -Z.5 411 6PO TAaS.F. X G/S.F.BOTTOM AREA -S.F. GPO -IP—S.F.X-L._001S.F� '7'- LEGEND LEACHING PROVIDED f��'Q GPD ALI. r,4fpEqyrbUS OR 'UNSUITABLE MA 7i��IA L' Z F17 wi-rHrm 25-F*T. Or ME L EA CHG t4O WATE'Z rTY S'70 BE REMOVED PROPOSED ELEVA TION AAD 47EPLACED .r TH CLEAN _M __60 EXISTtIVG CONTOUR GLE -,FA IL Y PESIDENCE 6 -S.TN OBSER VA TION PI T , PROPOSED SEWAGE 0 DISTRIBUTION BOX DISPOSAL S YS TEM , s 23. PREPARED FOP fo ol SEP TIC TA A(K, ME TT CONS TPUC TION- - CAM L'OT RVE -MIS Til�! , �opi ARP) �RESE BA , MASS." �, PNS TAE PIPE,- INVERT .EL EVA TION, DA INC I TE: ANDS- S CA PE' & ISL URVEYING, -334 : PLOT PLAN ' SCALE��.AS -NOTED d P. O. _BOX, 7 'SEC 'PC T, MA SS CKE SCA L E.,.I -1-AN WO TEA TI -L :LOT KA _77777777,1'�,77 ROFIL�E TEM NOT �1`0 SCALE NISH TOP-'FDN. rA�IS FI GRADE 0 VER' BOX '56"2� GRA DE: OVER EL FzxrsH GPA DE o vER FINISH PI '_SEPTIC ' ANK �T LEACHrNG T It/A X "W7W79W77=, V. 77A\\ 1A //A\\\ V,�WMWIIA\\11/11\XI/[A\\W/AN\Y//A\N'( \\\\7 VARIES- ft 7! OF �j F. ..0_6 PRECA S T CONC. OR D PEASTONE. SHE BRICK.Z' MOR TAR 'OUT LET L .' ' 70�121" BELOW GRA DE, lPE ,LEVE y FOR 2,�FT. AflAf. '01 -T -T C. 1 - :OR PVC TEES -4D 4; .. .60- 500 GALLON :DISTRIBUTIOff BOX FLR." EL,. ��00 To 1-1 INS L ON L E VEL:,BASE TA L 12 'CONCRETE " �PRECAST PRECAST- .. ASHED D H-r 0 , REINFORCE �_�CRUSHED ETE CONC TO, -S VE c; 4p' b.'o: 0 ', SEPTIC TAW -NOT OR BASE E XCA VA TE or INSTALL ON LEVEL TO ,ELEV. L? LONER TO REMOVE A L L: IMPER VIOl)S MA TERIA ....... L BENEA TH THE L,EA CHING AREA z ��,C) REPL A CE EXCA VA TED TE H - - RIAL WIT CLEAN, Y FREE SAND EFFECTIVE DIAMETER A 1500 SALL& L EA CHING PIT 00 PRECAST CONCREM GENERAL NO TES 0 SEPTC, UNK INS TA L L ON, L E VEL' BA SE U�l t 1. ALL ELEVA TIONS SHOWN ARE BASED- ON AC 2. - ALL . PlPES IN THE SYSTEM MUST BE CAST IRON OBSER -OR SCHED vc. UL�E, 40 VA TION 3 �T 'BOARD OF HEA L TH MUS T 'BE No TIFIE - El H bt XHEN CONSTRUCTrON IS COMPLETE PRIOR PERCOL A TION RA TE.* , BA CKFIL L ING TO MIN 4. ANYChANGES IN �TWS�PL 'By. HE BY T BOARD -OF HEAL TH AND CAPE. ISLANDS -WITNESSED 6 0 Low SURVEYING , CO.,, INC. :,5. , MA TERIA L A NO CompL TA rNg TA L L A TION, SHA L L BE IN 154,rzM'�' BRD. OF, HEA L TH , DESrGN DA JANCE NI TH THE STA TE: SANITARY CODE �,' Tint,- vz—AND LOCAL APPLICABLE , DA TE: RULES AND REGUL A TIONS NUMBEP, 'OF BEDROOMS ,: RECORD PLANS A A0 �ARROW 'JS -FROM 6. , , NORTH GARBAGE DISPOSAL D FOR SOLAR PURPOSES IS, NOT�' TO BE USE PRECA CRE DAIL:Y FL OW, 4 4,LEA 7. FLOOD ,HAZARD -ZONE (2 REO SEPTIC� 'TANK X4 TER SUPPL Y 7OWN 'D D SEP TIC TA NK PROVIDE <4 ACHING : LE PEQUIPED 4 L2 � 51 GOO t f� v SIDEALL. AREA , '16,!,44,7 S F S.F.X �2.5 G S.F. L BOTTOM AREA S.F. ��m [Ljm 7e GPO ND LEGE -S.F.X_L_a— IS.F. -P 'ABLE LL MPERVrOUS OR LWSUr7 MA 7=-PlA L L EA CHING RO VlDED GPO h4lMlff 5 F,T. OF THE L 8A CHWG WATE;Z PROPOSED ELEVA TION ��ACILrTY TO BE RE140 VED rAN AM,' 47EPLACED YX TH CL EXISTING CONTOUR 50 SINGLE FA MIL Y PESIDENCE OBSER VA TION PIT A 0 ' DISTRIBUTION BOX YSTEM SERA PROPOSED- GE 'DISPOSAL _ S_ D FOR RE PREPA _Lr -A6rPiKlCj' PI T CAMME. ONS_TPUC TUON fo o SEPTIC ', TANK TT,', C T, J I qESER.VE 4, RP L SS MIL L MA BA NS TA BL E �ELEVA TION,.. PIPE INV897 ,CA PE ISLANDS SURVEYING, INC, DA TE.*,M W &OT A F'l PLOT.-PLA N SCALE �ASr NOTED' :P. :0 �� -BOX-�334 SCA LE.* 1 -T EA TICKET MASS PAP - SEC 'PCL , LOT. :HSE"