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HomeMy WebLinkAbout0310 RACE LANE - Health 310 Race Lane Marstons Mills A = 126 009 001 J I I r 02-07-2007 & 10 = 2 cA DEED RESTRICTION WHEREAS, Eric W. Drifineyer and Gretchen J. Drifineyer, husband and wife, as tenants by the entirety, both of 310 Race Lane, Barnstable (Marstons Mills), Barnstable County, Massachusetts, are the owners of the land, with the buildings thereon, situated at said 310 Race Lane, Barnstable (Marstons Mills), Barnstable County, Massachusetts, and being shown as LOT 3 on a plan of land recorded with the Barnstable County Registry of Deeds in Plan Book 364, Page 98, containing about 51,395 square feet of land according to said plan, and more fully described in a deed recorded with said Deeds in Book 16705, Page 143 (hereinafter referred to as the"Premises"); and WHEREAS, the said Eric W. Drifineyer and Gretchen J. Drifineyer as the owners of said Premises have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in the single-family residence on said Premises as a pre-condition to maintaining an existing septic disposal system in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; and WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to approving the subsurface sewage disposal system in compliance with 310 CMR 15.000 State Environmental. Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for renovations to the single-family residence located on said Premises, is requiring that the agreement for the restriction on the number of bedrooms in said residence be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE, we, Eric W. Drifineyer and Gretchen J. Drifineyer as the owners of said Premises, do hereby place the following restriction on their Premises in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and shall be binding upon all successors in title: There shall be no more than three (3) bedrooms as defined by 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage located on the Premises, and we agree that this restriction shall be a permanent restriction affecting the Premises as described above. For title see deed recorded with said Deeds in Book 16705,Page 143. Property Address: 310 Race Lane Barnstable (Marstons Mills),Mass. i Executed as a sealed instrument this. day of Eric W. ri e r Gret h J ri mey COMMONWEALTH OF MASSACHUSETTS Barnstable County, ss. On thi% day of_ al& ,2007, before me, the undersigned Notary Public, personally appeared the above-named Fri W. Drifineyer amd Gretchen J. Drifineyer, proved to me by satisfactory evidence of identification, being (check whichever applies): [ giver's license or other state or federal governmental document bearing a photographic image, [ ] oath or affirmation of a credible witness known to me who knows the above signatory, or [ L,,-rm-y own personal knowledge of the identity of the signatory, to be the person whose name is signed above, and acknowledged to me that they signed the foregoing instrument voluntarily as their free act and deed, and for its stated purpose. Notary Public �— Print Name: .,j /T��/ 0010 I My Commission Expires: �� Qualified in the Commonwealth of assachusetts , a°'•'....... s, its skj . ...�•'••(�� '•. 00 t -2- TOWN OF BARNSTABLE LOCATION —?ZJ 0�//it Ia 6lA-E- SEWAGE # 2bl VILI;AGE � r�IS ASSESSOR'S MAP ,&,)LOT ,?�- �; INSTALLER'S NAME&PHONE NO. 1 SEPTIC TANK CAPACITY V COJr �di� LEACHING FACILITY: (type) �� /e�� (size) o NO.OF BEDROOMS 3 BUILDER OR OWNER -o 0 .rl.t/lyt �e t PERMTTDATE: aC OMPLIANCE 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 acility) Furnished by Feet � 1 !�p 0�1 co" _ ASSESSORS M&N(k /�Z? � Y No. l PARCO.N� '7 r - Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippliCation for ioiopooal *pztem ConotrUCtion Verna Application is hereby made for a Permit,to Construct( )or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. 1/v/ / Owner's Name,Address and Tel.No. Assessor's Map,/Parcel eoC.E 4e �"'C f/f Installer's Name,Address,and Tel.No. � , ?! Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of.Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow Z-70 gallons per day. Calculated daily flow 7�G gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by oard o Signed Date d6 19pi5- Application Approved by Date Application Disapproved for the.following reasons Permit No. _pig( Date Issued I No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE, MASSACHUSETTS PUBLIC HEALTH DIVISION 0 Y. 01ppYication for ;D gpogal *pgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at: i' Location Address or Lot No. \j U Owner's Name,Address and Tel.No. Assessor's Map/Parcel �P®Cc L/pB14_ ^�/, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms I Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow _I G gallons. Plan Date Number of sheets Revision Date Title Description of Soil . `Nature of Repairs or Alterations(Answer when applicable) -Date last inspected: `Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this'Board of Health: Signed - Date /P� Application'Approved byP Date t Application Disapproved for the following reasons Permit No. Date Issued 3 —— ————————————————— ———— —-——————— . THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance TUIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced(�on by '`;;0)'1's ' Installer at Jrlo has been constructed in accor ce/.-- with the provisions of Title 5 and the for Disposal System Construc 'o e t No. dat 4 '' �' C) Date �� Inspect _ v THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THA THE SYS- TEM WILL FUNCTION SATISFACTORY. — I No. ��� ��� -------------- f----------Fee THE COMMONWEALTH OF MASSACHUSETTS'_� PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 33iopogar bpgtem Congtruction Permit Permission is hereby granted to to construct( )re air(�an On-site Sewage System located at No.# �1O 10C� -�� i1�` Street E w. and as described in the above Application for Disposal System Construction Permit. No. Da V-, The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions,- ` All construction must be completed wi/thin three years of the date below. Date: ' �� Z!51 Approved b Board of Health CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS hereby certify that the application for disposal works construction permit signed by me dated c)-d 199 6 concerning the property located at ,�/G �/o��z �� • meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. i SIGNED: DATE: . �q96 LICEN C SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. o f6 60 r� c� a ' e�- i Town of Barnstable P# c�-3 Department.of Regulatory Services i Public:,Health Division Date A?h tnJg �� 200 Main Street,Hyannis MA 02601 fotiva�' - i `r 1 Date Scheduled fi / Time /( Fee Pd. Soil Suitability Assessment for ewage Dis osal Performed By: witnessed By: LOCATION& GENERAL INFORMATION Location Address 10 h,&C E L P9 AI r Owner's Name G pl G l, ► ✓�1��� 1 YV�i412s7DN5 rvi���5 >b1►4 ©.�7 6,yg Address 310 gY Assessor's Map/Parcel: O p / Engineer's Napr0�� m 1 L L O�?Lo�f me NEW CONSTRUCTION REPAIR Telephone# , 08--77,5— 1 11 Land Use /''>Cs- Slopes(9b) / — Surface Stones ILM Distances from: Open Water Body NA ft Possible Wet Area 46t ft Drinking Water Well 10 ft Drainage Way !V& ft Property Line G�d ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands i`n proximity to holes) �0_.3 ou - - - f P G- Parent material(geologic) V✓�.�✓aS�'1 Depth to Bedrock / /0 S 1 Depth to Groundwater. Standing Water in Hole: NO Weeping from Pit Face 14/0 Esdmated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE . Method Used: Depth Observed standing in obs.hole: __ in. Depth to soil mottles: Depth to weeping from side of obs.hole: in. Groundwater Adjustmenk f. -___. _ Index Well# Reading Date: Index Well level Adj,&etor Adj.Groundwater level..,n PERCOLATION TEST Bete Time //'W Observation Hole# Z a Ilme at 4" Depth of Perc (7oP) Z _ Time at 6" �V`°t'�► 1;� l�S" Start Pre-soak Time @ D' ' y a 'Time 01-6") End Pre-soak Rate MinJlnch Site Suitability Assessment: Site Passed X— Site Failed: Additional Testing Needed(Y/N) . Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100'of wetland,you must first notify the. Barnstable Consei vation Division at least one(1)week prior to beginning. Q:\SEPTICVERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones;Boulders. istenc %Gravel) SRAID. D ,►_ 32'' 2 � 5PfAl0 0 1/l7 �/ DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) b-A, G Ste/- 0 112 VA 514A)0 c v 2 s DEEP OBSERVATION HOLE LOG Hole# _ Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) /0 V& DEEP OBSERVATION HOLE LOG Hole# Lo'. Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. on t45 N0 10YX'31- 6`(-7Zit 7z`�— l3L" 2 �5✓ VO /v YA7 Flood Insurance Rate May: Above 500 year flood boundary No— Yes Within 500 year boundary No= ' Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery.ous material exist in all areas observed throughout the ro osed for the soil absorption system? Y area! )? If not,what is the depth of naturally occurring pervious material? Certification I certify that or Z (date);I have passed the soil evaluator examination approved by the Department of Envir nmental Protection and that the above analysis was performed by me consistent with . the required training expertise and exnerience described in 310 CMR 15.017. Signature Date �� Z Q:\.SBPTICVERCFORM.DOC sz a5-4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—.NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PARTA CERTIFICATION Property Address: :3/0 '&Ce �cQ" RECEIVED Owner's Name: C/i:,y L Xnn Lac w.4 JAN 2 8 200Z Owner's Address:-- 3/0 1?a cr w h /Nl+is vs s M:is /NN TOWN OF BARNSTABLE Date of Inspection: HEALTH DEPT. Name of Inspector: (please print) U0411 1171a//v Company Name: off+ /Y doe rv�P Mailing Address: /B�2 !� Ht'St /V/q/ S/O/7s 'k a Os 6 yy Telephone Number: S_09-'12 8- 7779' CERTIFICATION STATEMENT 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 oaf on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Tii 5(310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: L Date: The system inspector shall su mit 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I F. Page 2 of 11 OFFICIAL INSPECTION FORM-NC'tOOR'VOLUNTARY-ASSESSM ,.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued):' a ' _ Property Address: 10 RAC—S 4,4AIe kS o Owner: ` Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete~ II otSsC P-D A. System Passes: �::: •; `'- I have not found any information which indicates.that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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. . Answer yes,no or not determined(Y,N,ND)in the 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 fa'hare 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. ND explain: Observation of sewage backup or breakout or higb 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 obstruction is removed distribution box is leveled or replaced . ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPO5AL.SYSTEM INSPECTION FORM PART k , . CERTIFICATION;(continued) Property Address: 370 Rae_ Ah Nr ARsro,r�s AXI sl Q owner: 1.i Date of Inspection: >-.I;1-e a . 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 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 , OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSEC SYSTEM:INSPFMJONYORNI PARTA ` CERTIFICATON.-`(coatmued M .� Property Address:31O VQAG ,4A•A1,C Owner: n4%u 7" Date of Inspection:-/', 4 -8,2., D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all in ` Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool if Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool V 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''/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 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 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'30Tdet1 om-wprivate water supply well with no acceptable water quality analysis. [This systerirpassea if thew g water analysis, performed at a DEP certified laboratory,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,provided that no other fsibum criteria are triggered.A copy of the.analysis must be attached to this form.] Ai'D (Yes/No)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• , You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the arteria above) 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(Intcrirn Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large.system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION,FORM NOT FOR�VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL':SYSTEM INSPECTION FORM PART B 'CHECKLIST Property Address: 3,1a' �Ac Owner: rYAIAZ Ly`wl9 Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping informatioiwas provided by the owner,occupant,or Board of Health V- 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 art of this inspection? g Y Y .P P ✓ _ 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? AOPI*'_ Was the site inspected for signs of break out? y Were all system components,excluding the SAS,located on site? ' Were the septic uncovered, e d and the interior of the tank inspected for the condition _ s tank manholesopened,P P � P of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? tl _ 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 jSAS)on the site has been determined based on: Yes no V _ 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(3)(b)] 5 Page 1I I I Ir OFFICIAL INSPECTION-FORM NOT FOR�bE64tAI�CASSESSNI N"fiS SAL.-SYST'EM INSPECTION FORM SUB. URFAC SEWAGE°D APO PA IT.0 STEM;.--.gNFORMATION � t Frtpaty Ad3rmm 10 17c'C LVAIX owner: C410 Date of Inspections - 1 x�dpX CONl�)1TT.ON9 _... ... RESIDENTIAL Number of bedrooms(ddsi.p) ;3 Number of bedrdbras(actual):,. DESIGN flow based on 31"CIS 15.263(for examplei'110'gpd z'1 of bedrooms) 5- D Number of current residerIt : r�-1 Does residence:have a garbi ge Finder(yes or no) Alo t , Is laundry on a separate stwa e s stem es or no , �Y11 inspected' P P (y,g Y ) (Y ... ) � [if yes separate inspection requu'edJ� Laundry s stem ins ected' es or no Seasonal use.(yes or no) All 9p0� p� t •' T .::'mot •,•y�f`95•#x f ae' ' 3•r .y' S ,3. ... .. ._ ,., Water meter readings,�f available last 2 ears usa a do+�p_ yam' 1t�0� �6/ '�bSyf_r/rr.k�et�yf � g ( Y g (gP )) C Sump Pump(Yes or no): fl�D :' '► !: ,.�b.,f:. ,;; , :�"?. I�, � ,� . t�; :� , a _e s F Last date of occupancy 4PTa.Ifz.:'� S.. 4 E..�f...C{nl,1 t :.* <PU 1' ,I f, - COMMERCIAL/INDUSTRIAL Type of establishment Design flow(Based on 310 CMR 15.203):+ a� ssr.f �,� ,t�.', �� Y�i; rt1 :;�; ta, `zr,, . Basis of design flow(seats/persons/sgft;etc.):. Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no)- Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL•INFORMATION t , Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped:_gallons-•How was quantity pumped determined? . Reason for Pumping:. TYI'E OF SYSTEM ►/Septic tank,distribution box,soil absorption system f _.Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any)`4 _Innovative/Alternative technology.Atta:ch'a copy of the curr=t operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy of the DEP approval _Other(describe): Aa s i.aa&4 .o ory r at/� o o l i flow /�a a 7v,-&�, Approximate age of all components,date installed(if,yknown) d source of information: Were sewage odors detected when arriving at the site(yes or no): Alo 6 Page 7 of 11 #t;3 z4:a. "OFFICIAL INSPECTION FORM NOT FORWOLUNTARY•ASSESSMENTS 3 ` f SUBSURFACE SEWAGE DISPOSAUSYSTEM INSPECTION;FORM r ;PART C ;'SYSTEM INFORMATION(con"timed) Property Address: 3/O NfJC z/!il/� . Owner: (-,'LiR��`r �y.�r//1 1,da�Wlq / Date of Inspection: 1-� /-O2 / _ __ _...__ M. 'xsz t`,;"► it i BUILDING SEWER(locate onsite plan) 't. x ` t ,P,r . rb'i = s x,.'xw _ ,.t . Depth below grade: z . Y :>itF<3 ;c �'s ; {i`J' Materials of construction: cast iron 0 PVC ''"`other(explain):, I s �' I _ 3 > ` Distance from private water:supply well or.suc ion Ime:.' Comments(on condition of joints,venting,evidence of leakage,etc.): r ' ; SEPTIC TANK: (locate on site plan) W. g�t }+) ? Igisof:i:; ,= !� cr4 w: �s;r±=„:A. Depth below grade: Material of construction:.., oncrete metal fiberglass, Dolyethylene.,__.•.. .,v._, ,., ,, _, other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /,Piss `� :e'I ,t#_.?i:r.v r,.?iiFi4 t,,.,°il7,lil a Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle ScumthlCkrieSS: ;'4� il,;i°.,r5. ?d,+,✓ri3Y ,z;:tCter�:t! i .>i ,r�;' :f ti% ztr1t2,Sfv fIr{te'c.1 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:.. How were.dimensions'determined: .Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels Is_. as related to outlet invert,evidence of.leakage,etc.): AIANG r h/N .ih ri ljr;I _. GREASE TRAP:_(locate on site plan) Y below grade:Depth^ µ P i 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:. Comments(on pumping recommendations,inlet and.'outlet tee or baffle condition,structural integrity,liquid levels t as related to outlet invert,evidence of leakage,etc.): 'O 7 _ - , Page 8 of 11 t OFFICIAL'INSPECTION.FORM NOr PA VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE.DISPQSAL.SYSTEM-INSPECTiON:FORM `:.pAR't'C . : c <SYSTEM INFORMATION(continued) Property Address: Owner: G r,tey` bP/ Date of Inspection: TIGHT or HOLDING TANK: tank must be pump6d at time of'. 76n siteplan) Depth below grade: :..r Material of construction: concrete metal,; -fiberglass polyethylene ry' other (explain): Dimensions: Capacity: gallons Design Flow: gallons%day' Alarm present(yes or no): Alarm level: Alarm in working order(yes or no).' Date of last pumping: Comments(condition of alarm and float switches,,etc.): 'V� .y:„3Y a rRn a'%�i ... - ': , •rt:,.F .}.[,. y i [ F .,. .t.x..,,.,t t -'.f , ,. ^ia .. ., .....r i DISTRIBUTION BOX: (if present must be opened)(locate on site plan) ; 3 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.): r ���dX live' -li(i(iFh^C/I.DH/h Aa!� 6� ,. i..k i•,.J .e_, 3. •- t:e } ., r' ., ,_,.. ... 7 ..,J ...f�.-.:2..,P i....}} i t' .. s . PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): .. z Comments(note condition of pump chamber,condttitm ofptmmps and.appmtenances; y V01 r . —'i.i.- . . n,..I 8 I Page 9 of 14 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 0 &96T o A. Owner: Wiq Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type y leaching pits,number: leaching chambers,number leaching galleries,number. V leaching trenches,number,length: / = 6 0 ` X If` n 2 0rtj� leaching fields,number,dimensions: overflow cesspool,number innovadve/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): c 1, J., fir, 4 � s o C ey - �otv 14 ?r,' / /II00 u ` TO h c r o a r R c Au to :t.,e 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 or no): 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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NO'FOR VOL'UlV' XIY ASSESSMENTS SUBSURFACE SEWAGE DISPOSA'[ SYS'FENi INSPECTION FORM PART C . t. SYSTEM INFOPMATION(continued) Property Address: 310 Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM 4 Provide a sketch 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. �QCL �t�h2 � D 3� 30 ' � 1 6 6 , /$„ _. 3 .2� ` �i•8 6,, o pox y /� �/•o o yQ/ :. Love '�. 60 10' f Page 11 of 11 , • _ _ OFFICIAI,INSPECTION.FORM—'NOT.FOR.VOLUNTARY ASSESSMENTS ` SUBS,IJRFACE.3, WAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address: L 7 1op Owner: Cj, :. l. .1 UO�dv�cy :; Date of Inspection: -2 . .Q / SITE EXAM Slope. Surface water Check cellar Shallow wells Estimated depth to ground water!S"S'• feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: :Nuns °4t Tom,. la Checked with local excavators,installers-(attach documentation) ✓ Accessed USGS database-explain: You must describe how you`established the high ground water elevation: 7 coh 5,4, i 4/0 ire41' 1, A yteo 'u l y � oss, o �.tc% 7a. ad veY' 11 . TOWN OF BARNSTABLE / LOCATION �l �L'�'t-�- SEWAGE# b VILLAGE .T_ r�� C ASSESSOR'S MAP& LOTI2G"0�� INSTALLER'S NAME&PHONE N0. dEF 2 —L/ dcr`f SEPTIC TANK CAPACITY LEACHING FACII,ITY: (type) /e`�C (size) NO.-OF BEDROOMS 3 BUILDER OR OWNER �o h ..j"t�► fie, PERMITDATE: a COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Fee Private.Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Fee I Edge of Wetland and Leaching Facility(If any wetlands exist Fee within 300 n ac Furnished by g ) feet of leachi ihty I. i k �0 sr - Commonweafh Of Massachusetts - � John Graci. - EXecutIve Office of Environmental Aff®rs D.E.P. Title V Septic Inspector bepartment of - P.O. Sax 2119 _ `I aticket' A.O25 - Environmental Protedlon (508)Te �6�4`6813 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM — e) - - PART A _- CERTIFICATION ``yvb' Property Address: 310 Race Lane Marston Mills Address of Owner: Y Date of Inspection:7116196 _ - (If different) Name of Inspector:John Graci Swanbeck:lolworcesterct. '1 _ _ a Company Name,Address and Telephone Number: ASSWORSW MCI K(k CERTIFICATION STATEMENT y� if that I have personally inspected the sewage disposal system at this address.and that the information repo below is true. accurate I certify P Y P and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Furth r Ev ation By the Local Approving Authority x Fails Inspector's Signature: t Date: 7116196 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B,C, or D: A] SYSTEM PASSES: _I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: ~ _One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.) r _ The septic tank is metal, cracked, structurally unsound,shows substantial infiltration or exfiltration,or tank failure is tt/ imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. { (revised 11115195) One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 - - I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION(continued) - Property Address: 310 Race Lane Marston Mills OWnef: Swanbeck:101 Worcester Ct. Date of Inspection:7116196 Sewage backup or breakout-:or high static water level observed in the distribution-box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced - obstruction is removed - distribution box is leveled or replaced _The system required pumping more than four 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 - obstruction is removed j 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 the public health, safety and the environment. 1) SYSTEM 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: 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. 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: x I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 11116195) 2: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ _ - CERTIFICATION (continued) Property Add-fess: 910 Race Lane Marston Mills . Ownec swanbeck:1o1 Worcester ct Date of Inspection:7116196 _D] SYSTEM FAILS(continued) -- v,- 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. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). - Numbers 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 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ 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: 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 information. (revised 11115195) 3 F•s.. £. aF. .�!. :��st.J.3,��.ry'"� '3�fi�.,.. _ d.r��_�a . .. . .. ,..c .._. _ .. �.���.���.c1�9�1Y��.2..:�'ti_�. - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - PART B _ CHECLIST - -- - Property Address:-310 Race Lane Marston Mills - - Owner: _ swanbeck:101 WorcesterCL Date of Inspection:7110196 Check if the following have been done: _ - - X Pumping information was requested of the owner, occupant, and Board:of Health. _ X None of the system components have been pumped for at-least two weeks and the 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: X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System, have been located on the site. X 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. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 -` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART,C SYSTEM-INFORMATION. Property Address: 310 Race Lane Marston Mills _ Owner: Swanbeck:101 Worcester LY - Date of Inspection:7116196 - FLOW CONDITIONS RESIDENTIAL: _. Design flow: 33.0 gallons - - - Number of bedrooms: 3- Number of current residents:4 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No - - - Water meter readings,if available: nda Last date of occupancy: n1a _ COMMERCIAL/INDUSTRIAL: Type of establishment: n1a Design flow:0 . gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No - Water meter readings,if available: nla Last date of occupancy: n1a OTHER: (Describe) nla Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped in 1995 by Acme System pumped as part of inspection: (yes or no)No If yes,volume pumped: gallons Reason for pumping: n1a TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1987 Sewage odors detected when arriving at the site:(yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART C - SYSTEM INFORMATION(continued) Property Address: 310 Race Lane Marston Mills Owner: swanbeck:1o1 WorcesterCL Date of ln.spection:7116196 SEPTIC TANK: X (locate on site plan) Depth below grade: 1'6'* - - Material of construction:X concreate_metal---FR_P- other(explain) _ Dimensions: LS'6•H5'7'W4'10" _ Sludge depth:6' _ Distance from top of sludge to bottom of outlet tee or baffle: 21' I Scum thickness:3' Distance from top of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 15" 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.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: nla Material of construction:X concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:nta Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a 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.) Na (revised 11115195) wg. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - - PART C - SYSTEM INFORMATION(continued)- Property Address: 310 Race Lane Marston Mills _- _ 1 Owner: Slvanbeck:101 Worcester Ct. - Date of Inspection:7116196 TIGHT OR HOLDING TANK: (locate on siteplan) _ - _ t: Depth-below-grade: Na Material of construction:X concrete_metal_FRP_other(explain) - Dimensions: n1a - __Capacity: rda gallons Design flow: n1a gallons/day Alarm level: n1a Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Na DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) n1a PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) nla (revised 11115195) T SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '• SYSTEM INFORMATION(continued) _ Property Address: 310 Race Lane Marston Mills -- - - Owner: Slwanbeck:.101 Worcester Ct Date of Inspection:7110196 - SOIL ABSORPTION SYSTEM (SAS):x - (locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: _ Na - - _ Type: leaching pits, number: 1_000 Galion leach pit leaching_chambers,number:nfa - leaching galleries, number: n/a leaching trenches,number, length: nla leaching fields, number, dimensions:n/a overflow cesspool, number:n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) The leach pit in hydraulic failure. CESSPOOLS:_ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: nfa Depth of scum layer: n/a Dimensions of cesspool: nra Materials of construction: n/a Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n/a PRIVY:_ (locate on site plan) Materials of construction: n/a Dimensions: nfa Depth of solids: n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) nla (revised 11115195) 8 Fi,.'* •at.��. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .. PART C r SYSTEM INFORMATION(continued) Property Address: 310 Race Lane Manton Mills Owner., Swanbeck:101 Worcester Ct. - - Date of Inspection:7116196 - SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate-all wells within 100' — - o A AA IS A B Ac.3g` o � ,y DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS MAPS AND CHARTS (revised 11115/95) 9 ,"�t�",�'�3�!' ��..*-x'i`#.+iy`t�,'e���''`" 5��se.__,. ¢v+�, _ _t . � .,� �k. _ 3+�`` ���� -...��taE��::-I . .� •-� -. TOWN OF BARN STABLE ► �'&'�� LCji_-ATIUN� _ �\CccQ_ \-.ikv3.� . SEWAGE 1J VILLAGE 1M_ M'I�S, ASSESSOR'S MAP & LOTIA(a- 0oQ 00/ r INSTALLER'S NAME & PHONE NO.Carlko_� SEPTIC TANK CAPACITY 1 LEACHING FACILITY:(ty ) L . �° _ (size) tDDo ��, . NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER _ BUILDER OR OWNER_ `�o�a•� -- "� C, °`��� DATE PERMIT ISSUED:_ DATE COMPLIANCE ISSUEDY � '1 �S;7_, _. VARIANCE GRANTED: Yes No���.��. �_ ® _ ��� a id � 3� �s, No.-- � Fxs..... D, Q 0 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........................................OF............................-............................................................. Appliratilan for Dispatiai Workii Tnnstxnrtiun ramit Application is here i a e for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - Location dress CK U �CA .... or Lot No. !!�d ........................ ••---• •----............ ._........------.....--------.................-•---- \ PJ� t jLA . .......�_.n....s Tess �(�(\ S a -•-^......---••••--•.........`.'... 5------------------- ............................t '1 f'4.._. .J ... Installer Address i dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) ►-+ pa-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures --------------•-••----------•--• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No...............:..... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by................................................................------•-• Date........................................ � Test Pit No. 1................minutes per inch Depth of Test Pit.__.__._............ Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ O Description of Soil................ x U --------------------- --------------------------------------------------------------------------------------------------------•---------•---------------•----........................... .......... W •••--------------------------------------•-•--••-•--•--•-•-----------------------------•............---•-••. ............................................. U Nature of Repair or Alterations—Answer when applicable.-------- ___________. ©ice Less 2 at Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TA!;%L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha �en,�isssued by the board of health. / Signed. ` � _ �l !Q. A �4 Kc ---- ......^..-------- Date Application Approved By.......... I . ... -- --------------------------------- --------- � - Date Application Disapproved for the following reasons----------------•----•-•------------••-----------------•......-------------------------------•--••......--•..._.. -----------------------------•--.....----••-----....-----•----•-------------------------....----------------------------------------------------------------------------•-----------------------•------- Date - 'S---------------------- Issued.....___ `•3. �� fvop - 0 0 9 t Apr No.. .... f�. t} F�s....0..........�. ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F........................................... Appliration for Disposal Works Tonstrur#ion Vrrmit Application is her yZLO r a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � 0 ` i3 ................. ....C�.. -• -=�..... ------------=-------- ------------------------------------------- ----------------..........---------------- `Locatio dress or Lot No. ......... ... ••••.. .... ................... ..... -----••--•-...-•-•-•---•-...--------•---...............•-----......--•-••............-- i Own' Address (� Cti � r.1% s "a � Gt `f�l )c_ ..��.. 30 i YY Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__________13__________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria P 1 Other fixtures ------------------------•--••••. . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Ix Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No----_-------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_-_____--__-____---_----. fTq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ _ ------------------- •-•------------------------------ --------------------- --------------------------------------------------------- .--�- '`O Description of Soil............... W (---------------------- U Nature of_Repair or Alterations—answer when applicable______'_ __---------- ______________ z_k ' 1�: . R -------------------••-.----- •--•....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TILE y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance heen issued by the board of health. , Signed. au-u j ti a ........ ............................................................ Date Application Approved By......... ^^`'-)---- `." ^-- ---------------------------------- --•---.... 3- ----- Date Application Disapproved for the following reasons-----------------------------------------------•-....---•------------------------•------------------------•-•---- •----••.....................•---••-•---•..............-•-•-•-•----•-•••-•----------..........•--•-•-•--•-•••--•-•...-----••-•--•-•-••-••-----••---•---------•-••••••••-••-•-••--••--•---••••------------ -_--.�._�._.__Date------ Permit No._--••-•g - Ql --------------•------- Issued------�'---- --3 Dau THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .r.`:�z. :........OF..........fir.:._�.... ..--�yx....,r^ Trdifiratr of TompliFanrr �9 IS TO ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by. _.,�.. ` ------ ----•................. -- -------------------------------•----••-----------•---------- 1 G� < Insta f r i ! r N at............................................................................... . ......--•......•---•-•••--•._...---•---------••-•-•••------•--•-•-------•-----•••••-•-••-•. has been installed in accordance with the provisions of TITIEi 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.......B-: _.._ __ ..... dated_............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................•-- 3_nl•g.--•--••--•--•---•--•-•---- Inspector.............. -- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (J Cf f air ........OF............N•�'.-�v.... s�.....`{........................... NO.-U--------------5 FEE........................ Disposal Fo . p Tonstrwtion Prrmit Permission is hereby granted............ to Construct ) or Repair ( ) an Individual Sewage Disposal System at No................ Street as shown on the application for Disposal Works Construction Permit No �._�Jam_ Dated.......................................... �� j p� Board of Health DATE............................----.......(Jo FORM 1255 HOBBS & WARREN. INC., PUBLISHERS t 2B'-(r NEW P.T.6x 6 POSTS W/ (ADDITION) (ADDITION) c� 1 x 7/1 x e CASING 4'-0' NOTES:12'-0' 4•-0" 1.) CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS UJ C] `r A A &DIMENSIONS IN THE FIELD Q Q N ————— — 2.) CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, o�O v - DETAILS,&FINISHES IN THE FIELD WITH OWNER m I 3.) ROUGH OPENING HEAD HEIGHT OF WINDOWS AT F-. c:7 fii 4 ' NEW �° FIRST FLOOR TO BE V-10'.'ABOVE SUBFLOOR �w o io I 4.) ALL CONSTRUCTION TO CONFORM TO 780 CMR MASSACHUSETTS E• c� COVERED' PORCH STATE BUILDING CODE 0 m m<a I A A 5.) CONTRACTOR TO REMOVE EXISTING DOORS,WINDOWS, WALLS,&ROOFING AS REQUIRED FOR NEW CONSTRUCTION. A6 I A6 E s I i NEW a E FAMILY A ROOM I NEW PATIO I (c 4'-2 3'-10' ANDERSEN !e FWH 6068 APLR TEMPERED 30'x 6'B° E A b^o 15 LITE FRENCH B 4 DOOR A6 ® v 1 6-(r BENCH EXISTING CHIMNEY 2'-0' &HOOKS m MULTI LVL BEAM — TO REMAIN - w ———— —— ALIGN WINDOW 0' � ul W/NEW DOOR ° JEJ D TEMPERED ° - 0 w O KITCHEN BATH. O• f M+•�L� C� EXIST. B Q r---i Z p � � DINING As • � do 1 w ,- FIRST FLOOR PLAN �' 0,6 EXISTING FIRST FLOOR =1008 S.F. 6a — y EXISTING SECOND FLOOR =455 S.F. Q NEW FIRST FLOOR =608 S.F. — NEW SECOND FLOOR =732 S.F. LEGEND: L), EXIST. O EXISTING-WALLS W w LIVING _ aa NEW C= CONSTRUCTION TO BE REMOVED _--- STUDY NEW CONSTRUCTION EXIST. `�I` (FORMER BEDROOM CHANGED I^Ij �I PER DEED RESTRICTION) OS SCALE: SMOKE DETECTOR_--deemed ©CARBON MONOXIDE DETECTOR I/4 I�= -U --� EXIST. EXIST. HALL - DATE: �� THE DESIGNER SHALL BE NOTIFIED IFANY 9/27/2006 c=d ERRORS OR OMISSIONS ARE FOUND ON THESE DRAWINGS PRIOR TO START OF CONEXIST. THE EXIST. WILLS BE RESPONSIBLE ORITHECONT NTTOR IST. EXIST. DRAWINGNo.: EX IN THESE DRAWINGS IF CONSTRUCTION COMMENCES WITHOUT NOTIFYING THE DESIGNER OF ANY ERRORS OR OMISSIONS.. THESE DRAWINGS ARE SOLELY FOR THE USE ON THE PROPERTY NOTED.ANY OTHER USE OF I' THESE DRAWINGS REQUIRES THE WRITTEN �ISTIN64r* REVISED: 4/I I/200( CONSENT THE DESIGNER.THESE DRAWINGS (EXISTING) ECCOPYRIGHT PROTECTION ACT OF 19M ARCHITECTURAL z - - -(ADDITION) 00 I I I �N00 k a o I JVMDOWS �C..) cr.,:E � I I LINE OF WALL LOW C BELOW UNDEFOR M N C I C N U LOW DOORS UNDER WINDOWS I �4 A FOR STORAGE I As a H As c NEW c MASTER aF N c BEDROOM ILE NF a - I L DOORS UNDER WINDOWS FOR STORAGE II Tor B'-te1 4'$ 8'-S'3 3'-0' I,1 I to to s n� c N I SHOW O c i/i I B'.Ir NEW j B y W.I.C. I As NEW 7� >� I a BATH 0: W ------ - ————----4- --- - -- ------ --- -c-- II PANELS I J 2W.x S'B' NEW rcxse I I ST �z.. CLOS. STOR. C� 4A6 --------------- -- w EXPAN Q� °d EXIST. HALL EXIST. F EXIST. © EXIST. BEDROOM#2 BEDROOM#3 5 T -DN. `J N tr � EXIST. CLOS. CLOS. EXIST. V co I SCALE: 1/4' = 1'_0„ DATE: 9/30/2006 DRAWING NO.: I �= SECOND FLOOR PLANA2 I. I I C/ c EXTEND EXISTING i Q Q O N CHIMNEY TO D'WRI m W ABOVE NEW RIDGE I a. ,z ,z 00 A 2 .4 NEW RAKE&TRIM BOARDS [a]= TO MATCH EXIST. C"' X eDF PLATE OU c a r¢ N L.ECOND 1zMATCHEXIST.FLOOR @FLOOR TOP OF PLATE I FIRS FLOLOOR R i V! REAR ELEVATION w � � z 0 CONT.RIDGE VENT NEW ASPHALT SHINGLES 12 TO MATCH EXISTING Z r NEW DFASCIA MATCH E EXIST. � BOARDS TO MATCH EXIST. eOF PLATE r f<Z '. NEW CORNER BOARDS ® //►��"�� J(n TO MATCH EXIST. ( v N NEW W.C.SHINGLE SIDING m TO MATCH EXISTING F�1 SECOND FLOOR TOP OF PLATE P.T.6 x 6 POSTS W/ 1 x 7!i x 8 CASING rm [E y SCALE: 1/4" = F-0° DATE: 9/30/2006 DRAWING NO.: LEFT SIDE ELEVATION z EXTEND EXISTING CONT.RIDGE VENT CHIMNEY TO T(r ABOVE NEW RIDGE 0 Np CV 12 NEW ASPHALT SHINGLES TO MATCH EXISTING L W 12 NEW FASCIA 6 FRIEZE �^ EXIST. 00 BOARDS TO MATCH EXIST. W C`p TOP nG �Uc � MF u SECOND FLOOR SUSFLOOR TOP OF BA ® ® ® ® FMNEW CORNER BOARDS. TO MATCH EXIST. NEW W.C.SHINGLE SIDING TO MATCH EXISTING F FIRST FLOOR 1 SUBFLOOR RIGHT SIDE ELEVATION cf) 28'4r 5� 2('-D' (ADDITION) (ADDITION) A A O U W O Z .� f F ►�1 [� W 1 m w o NOTE: lyl B 1.VERIFY ALL FRAMING DETAILS W/ENGINEERED T►t I A6 JOIST2.USE S MPSON OISTIOHANGER ON ALLOISTSR TO START OF UCTION ILI `.J 3.FOLLOW ENGINEERED JOIST MANUFACTURERS SCALE: FASTENING REQUIREMENTS F DATE: s _ - — - 9/30/2006 DRAWING NO.: MULTI L BEAM ---- -- B SECOND FLOOR FRAMING PLAN A6 A A I z 28'-D' G) 0 Q N 2014r h.., p N P.T.2 x 10 LEDGER BOARD LAG BOLTED TO ( DI ION) (ADDITION) NOTE:DROP TOP OF NEW FOUNDATION r � ql SOLID BLOCKING W/(2)LEDGERLOK BOLTS TO MATCH NEW SUBFLOOR W/THE Q� f� ¢— 1Go.o.w/Jolsrs GERS AT BOTH ENDS Ems, B'-o, s.p EXISTING SUBFLOOR.(VERIFYINFIELD 28'DIA.'BIGFoor FOOTING IF REQUIRED). t` UNDER tY DU\.SONOTUSES AT BASEMENT BASEMENT pW:„00 00 PORCH 4'0'DEEP \ WINDOW W O ------ -------- �' ---- F. x�Lo I I I I I F I I I I I I M I U o I I I A6 I po F. o a a NEW j I ° I CRAWLSPACE I I F'j NEW S'CONC. 12'DIA CONC.SONOTUBES I (7 CONC.SLAB) I I FOUND.WALLS TO 4'0'BELOW GRADE I I I I-�—NEW S'x 18' CONC.FOOTINGS B I r------- A6 0-4INSTALL NEW CONC. I I F[�]� 0o " BASEMENT m BEAM UNDER EXISTING t) WINDOW I I PKT. CHIMNEY Oa I J 2'-0' F—I L-------� --- — --J L--- ACCESS—J L—I-I r---------- —ram----------------- r1-1--- O NEW V CONC.WALL i I 3'-0' 3'-0" a I I I I W/B'x 18"CONC. l i FOOTING i I I I �j Q �I EXIST. F—� ' BASEMENT �+ BASEMENT EXISTING.STONE FOUND. B EXIST.. WALL TO REMAIN.TIE IN O ( W As CRAWLSPACE WITH NEW WALL USING r(...y REINFORCING STEEL BARS l W ` O'6 EXISTING STONE WALLS TO NOTE:UNDERPIN REMAIN.TIE IN WITH NEW WALL EXIST.FOUNDATION NOTE: USING REINFORCING STEEL BARS WALLS AS REQUIRED 1.VERIFY ALL FRAMING DETAILS W/ENGINEERED /1 VERIFY IN FIELD JOIST SUPPLIER PRIOR TO START OF CONSTRUCTION FOUNDATION PLAN 2.USE SIMPSO I JOIST HANGERS N FACTUALL ER U TS 3.FOLLOW ENGINEERED JOIST MANUFACTURERS FASTENING REQUIREMENTS WINDOW SCHEDULE 7w TYP MANUFACTURER'S UNIT ROUGH OPENING REMARKS cy) A ANDERSEN WDH 2646 2'-8 1/8" x 4'-9 1/4" WOODWRIGHT DOUBLEHUNG B ANDERSEN WDH 2642 2'-8 1/8"x 4'-5 1/4" WOODWRIGHT DOUBLEHUNG SCALE: C ANDERSEN C 12 2'-0 518"x 2'-0 5/8" CASEMENT 1/4" 1.CONTRACTOR TO VERIFY ALL WINDOWS WITH OWNER AND ROUGH OPENINGS DATE: j WITH WINDOW MANUFACTURER PRIOR TO ORDERING OF WINDOWS 9/30/2006 2.ANDERSEN WOODWRIGHT WINDOWS WHITE HP LOW E4 GLASS FULL DIVIDED LITES,TRUSCENE SCREENS,&6/6 GRILLE PATTERN ~ DRAWING NO. 3.ANDERSEN CASEMENT WINDOWS ARE WHITE HP LOW E4 GLASS FULL DIVIDED LITES,TRUSCENE SCREENS,&4 LITE GRILLE PATTERN A5 REVISED: 4/11/2007 CONT.RIDGE VENT C7 ,) NEW ROOF CONST. -2 x 10 ROOF RAFTERS®16'o.c. Q N C li D •1!2 COX PLYWOOD ROOF SHEATHING 12 — .ASPHALT ROOF SHINGLES 2x8'e®t6'o.c. .15LB:FELTPAPER Lc7 /� -6'HI•R BATT INSULATION ®SLOPED CEILINGS(R-M E- W N •9'BATT INSULATION 1 ~ L�00 C 2 x 10 CEILING JOISTS®16°o.c. @ FLAT CEILINGS(R� (,T] a, -2 x 12 RIDGE BOARD(UNLESS OTHERWISE NOTED) C� W 1�X 17 GYP.BOARD \ \ -SIMPSON H 2.5 HURRICANE CUPS / \ \ CONT.ALUMINUM AT ALL RAFTER ENDS O M ¢x NEW WALL CONST. / // ON 1 x 3 STRAPPING \ \ SOFFIT VENTS ICE/WATER SHIELD AT BOTTOM V _ In.L , / ®16'c.m \ \ 37 OF ROOF 1.1x6 STUDS®16'o.c. / // NEW \ -PROP-A VENT BETWEEN RAFTERS 2.1r2 PLYWOOD SHEATHING / / MASTER 3.6'(R-19)BATT.INSULATION 12 / F 4.trr GYPSUM BOARD BEDROOM S.W.C.SHINGLE SIDING MATC MM EXIST. IJ 6.TYVEK VAPOR BARRIER 4 T&G BLOCKING UNDER LYWOOD SUBFLOOR, SECOND FLOOR DORMER WALLS GLUED 8 NAILED SUBFLOOR 9 V7 ENGINEERED JOISTS @ 16'o.c. MULTI LVL BEAM 1/7 GYP.BOARD BEAD BOARD ON 1 x 3 STRAPPING O LL NEW @,6•0.�. Z FAMILY o P.T.2 x 10 LEDGER BOARD LAG BOLTED TO COVERED ROOM n SOLID BLOCKING W/(2)LEDGERLOK BOLTS = 16"o.e.Wl JOISTS HANGERS AT BOTH ENDS PORCH 4'T8G � PLYWOOD SUBFLOOR, FIRST FLOOR P.T.6 x 6 POSTS Wl GLUED 8 NAILED SUBFLOOR 1x7/1xSCASING - 2 x s @ 1 o.c. 886 9 11r ENGINEERED JOISTS®16"O.C. 00 2.P.T.2x 1Ds 9'BATT.INSULATION(R-lq 1I2 DW ANCHOR -114 BOLTS®4W o.c. NOTE:DROP TOP OF NEW FOUNDATION NEW TO MATCH NEW SUBFLOOR W/THE 5" NEW 2r DIA"BIGFOOr FOOTING CRAWLS PACE NEW r CONC.SLAB NEW 8'CONC. a EXISTING SUBFLOOR,(VERIFY IN FIELD UNDER 17 DIA.SONOTUBES AT § FOUND.WALLS IF REQUIRED).. ,^ PORCH 47 DEEP v CONC. x1FOOTINGS NEWB' ' I A BUILDING SECTION NEW FAMILY ROOM w wz POST UP TO _ RIDGE O ' ) i EXISTING ROOF STRUCTURE LLL TO REMAIN(VERIFY CONDITION IN THE FIELD) O Y_Iv =11EWULTI LVL HEADER � w I i EXPAND. N F HALL Q w W ' x EXISTING FLOOR JOISTS 9 1(2 ENGI EERED JOISTS 16'o.c. NEW MULTI LVL HEADER W Z O NEW EXIST. z C-5 m F FAMILY DINING SCALE ROOM ROOM 1/4" = F-0° 9 lr2 ENGINEERED JOISTS®16'o.c. EXISTING FLOOR JOISTS =J—EXIST. DATE: NEW CRAWLSPACE 9/30/2006 CRAWLSPACE DRAWING NO. I NEW 6"CONC.WALL WllrxllrSEW4'CONC. FOOTING CONG B BUILDING SECTION NEW FAMILY ROOM (ADDITION) N a 3-0' I 30• 4 a ¢�� r 3 pwDo00 E- w cn e X I C)UQ�ax.,c¢ A w A6 A6 S W 40 4 F f NN 2 N F rvQa I Z o � I w ------------ w N I. I I ) I 1� B _` 4 x 6 WOOD POST UP TO RIDGE 76 1 7-0' _NEW MULTI LVL BEAM US C IL G NEW 4 x 4 POSTS I WALLS Q w O T. NEW DORMER WALLS TOP BLEND INTO EXIST. ROOF,(FLASH ACCORDINGLY) MULL LVL FLUSH BEAM RAFTERS O ~•/ �x H 0-4 W �-1 � Z EXISTING RIDGE_�_�_ e LlW w o C-5 cy-) I 1111-1 F IV-7 NOTES: SCALE: 1 ) ALL ROOF FTERS TO BE 2 UNLESS OTERWI E NOTED x 10's 1/4" = 1''0° 2.) USE SIMPSON H 2.5 HURRICANE CLIPS 1 AT ALL RAFTERS ENDS DATE: 3.)VERIFY GUTTER TYPE/LAYOUT 9/30/2006 W/OWNERS DRAWING NO.: ROOF FRAMING PLANA7 ` j S� �i }