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HomeMy WebLinkAbout0017 SEA ROBIN ROAD - Health "i7 Sea Robin Road Marstons Mills A.= 122 036 -— --- - - Commonwealth of Massachusetts /off o? -03�0 a: W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments n`4^ 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfo ram_ use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich_ Ma 02563 City/Town State Zip Code (508)477-0653 SI 13640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-21-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or Y p 9 P Y Y has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road M Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. 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 ❑ NO (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is Marstons Mills Ma 02648 6-21-16 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 FIND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form sI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road M Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for ever) Marstons Mills Ma 02648 6-21-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _) Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 17 Sea Robin Road _ Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 --Number of bedrooms (Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage See below 9 ( y 9 (gpd))� Detail: 2014-42,000gallons 2015-99,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road _ ,M ad Property Address Janet Favreau _ Owner Owner's Name information is Marstons Mills Ma 02648 6-21-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner- last pump unknown Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is Marstons Mills Ma 02648 6-21-16 required for every _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'10" feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallon Sludge depth: 8 t5ins•3/13 Title 5 Ins Inspection Form: Official p Subsurface Sewage Disposal System•Page 9 of 17 it Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road M Property Address Janet Favreau Owner Owner's Name information is Marstons Mills Ma 02648 6-21-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 11" 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 6 How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17 Sea Robin Road _ Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: - gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up or carry over. 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 Gallon ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Chambers were dry when inspected. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions — Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately GARAGE DRIVE WAY t1 2 Al-24T Tg49F-11'5" A3.311" A4.327' A5.3T' 1-2W 100 3 B2.16'8t1 8�g3�a»25'11" N.197" 85-32i7" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. CutylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW 120" 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: 9-7-01 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Sea Robin Road Property Address Janet Favreau Owner Owner's Name information is required for every Marstons Mills Ma 02648 6-21-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 6, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TIOWN OF BAR'vSTA,$LE LOCATION SEWAGE #a00 1-4 I2 VILLAGE i0stow ASSESSOR'S MAP &LOT' 13` INSTALLER'S NAME&PHONE NO. S®V • 83-6 - P �a SEPTIC TANK CAPAC (' LEACHING FACILITY: (type) (size) NO.OF BEDROOMS j- BUILDER OR OWNED PERMTTDATEZ g ®2 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by le 6 - 0 S '37` 3 9'7 " y3 . d s ,a ]545DH SIBDM , (0 $OeDM MASTER BDRM DECK OFFICE `m sate sate ,- sore iv CL05ET 3668 ltte � 90� CLOSET ssnesm 1yte MASTER BATH GREAT ROONEr m HALL BATH =m � `� ,ave B019]Y9 w J m _ � q� wte T � B e�a e 5TAIRFmNELL i m r— ------------------- �� BEDROOM n I 23'-4 3/16" - i � I 4 13'-9 1/4" I a I 41/1'' 21'_2" m $ I 1 B1BR�pe,8� Bit ales DWva�u B360] I N rn 359BDN I - ,zte �Dte ,ate (V m GARAGE I B,D3,TG n DECK �, �...,�,,,..,.-..�,.�;,..-�•..-;�,.�_:,_ .., I�--------7 r——— � —_ I — — — — — — jJ Ms. Myriam L. Cimbrel0 17 Sea Robin Rd `" I I Osterville, MA 02655 2 II 23'-4 3/16" II i I 1'-1 13/16" 9, I7 m� aoeD ' r 60'-1 1/4" 6-2" 15'-11" 23'-8" 14'-4 1/4" 2614R5 I 1 2614R — ——— — — U coI I -- I TOOL 5140P 1 r BATHRO M I I I I : L---- --------- -- I 1 1 " 1 I ° 25' I I m I 2'-?1/4" 1 o m rylry N in r IrzI ANTEROOM I I 5t rage I . I & tility m I ry GAME ROOM I : I I =�. I - - :;= 1 IN E IN $ 1 1 LnIN —————— — ---- I m 1T-103/4' 1 I 3T-3 1/4" 14' :> I J I 23'-3 1/4" _ — —— r; ---------------- - ��Ms Mynam L. Cimbr•elo� 17 Sea Robin Rd 15'-4" 24'--►1/4" 14' Osterville,•MA;02655 53'-11 1/4" T WIv'OF BARNSTABLE a e LOCATION _ e- SEWAGE #` 00 / �� VILLAGE I��— ASSESSOR'S MAP & LOT �3f INSTALLER'S NAME&PHONE NO.c5o l _ gffSEPTIC TANK CAP AC 00', 0 6 LEACHING FACILITY: (type) NO.OF BEDROOMS 3l BUILDER OR OWNER' PERMIT DATE - 0 2— COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � I nn r • v3 I�S rr Z 3-31 . S P 3 7' d 39,, NO. J`J`-'�% 1��1 c7�y THE COMMONWEALTH OF MASSACHUSETTS t FEE7D y OARD OF HEALTH ,_ W of (�,�2 �d Ss,C� C�� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct (/Repair ( ) Upgrade ( ) Abandon ( ) - Complete System ❑Individual Components , r. -s 9? L 7V)-J //DMf_S" Location ®� 177 4ner's Name /3 g / A ap/Parcel# �/V J 0 9 7 / l eS/ I s e & 146 / q Desi ner's�am�Ve� Telephone# Telephone# Type of Building: ke—S I,OW I l AYL< OW EL L/A)a Lot Size o oo o Sq.feet Dwelling—No.of Bedrooms 3 Garbage Grinder (APO) Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. equ'red) ® gpd Calculated design flow gpd�kDesign flow provided 330gpd Plan: Date ® Number of sheets Revision Date Title A AL4m1 PAQ P't S" 00 v S 46- 4-- �v�fAl2 SewA-&-r_ ©/,S®os�-�- �✓.1; p ( ) a s .o4 n� o Z •� s oy a y�-/2lj"p��0.f -�R /�L C— Descri lion of Soils ®`'� LOA4+1 � - Ld�A,+a e Soil Evaluator Form No. 5 Name of Soil Evaluator S. k'14 SO AI Date of Evaluation/ — 9 DESCRIPTION OF REPAIRS OR ALTERATIONS IJ G't�LS?7Z1/GTi- The undersigned agrees to install the above described Individual Sewage Dispoial System in accordance with the provisions of TITLE 5 aner agrees not to place the system in operation until of Compliance has been issued by the Board of Health. Signed V D FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 Ii _ �.- I,M t� M , ,... Y`• � f r.TA�-,,r,'• ,r•�.�y ,...... .. ..*r.F'. r ,. . � .. �Y .t,. �. .. .. - . ? , F, yHECMMONWEALTHOF MASSACHUSETTS EEN �' a BOARD OF HEALTH L�t,,/ �r OF aAad S77� LI APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT !y ' Application for a Permit to Construct Re air U rade Abandon. �,+�. pp (� p ( ) pg �( ),Abandon� (" ) - Complete System ;,;(]Individual Components #3 + At17 Sep goer l AD, M��,�s � /G rO^/ &A4,V S t e Location ner's Name / Z 2 36 po Qox /Z Z - �` 3 ap/Parcel# _5"©8 77 3"V7 ^ a. Lot#a. M I �J S ���'��1e/j, In t 's me Designers ame dtp r*c ma,'*. 6 � q 09� a S-4 0 V Q 9+Q t'd�dd_ gs 1 1 Teleph o ne# Telephone# Type of Building: , �S/��+✓i I A L �W C /h�� Lot Size © Oo d Sq.feet Dwelling—No.of Bedrooms }� Garbage Grinder WC) _Other Other—Type of Building No.of persons Showers ( ), Cafeteria ( ) Other fixtures Design Flow(min. equ' ed) 310 0 gpd Calculated design flow gpd,4kDesign flow provided-3 3-Dgpd Plan: Date 7D Number of sheets _� Revision Date Title Aam Ot a,.J Piza Qds"&aS g- -A- ue 6►-t d' S Description of Soil(s) 8 N Ln�t OVA d^Z 4 ry L Aaw*',0y Q . Z'¢"�2 d����S�1r► G QA�`Z: G Soil Evaluator Form No.249-L Name of Soil Evaluator s. hell-SO AJ Date of Evaluation —9 j DESCRIPTION OF REPAIRS OR ALTERATIONS NCIAl CO3JJ778 cJcT10 The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and'�jHher agrees not to place the system in operation until jZeLMate of Compliance has been issued by the Board of Health. Signed V D (C.� .4nspoCtion9' n A I ` FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. -C) T Er COMMONWEALTH OF MASSACHUSETTS FEE Iyo- - '" BOARD OF HEALTH CERTIFICATE OF COMPLIANCE t Description of Work: ❑ Individual Component(s) [Complete System The undersigned hereby certify that the Sewage Disposal System;Constructed(-W.-K5paired( ),Upgraded( ),Abandoned( ) by: has been installed in accordance with the p ions of 31Q CMR 15.00 (Title 5) and the approved 'design plans/as-built plans relating to application No,r)( -Lo( dated qla I I-) Approved Design Flow (gpd) Installer Designer: Inspector t� t. Date 1. The issuance of this certificate shall not be construed as a guarantee that the system will function as dAA gned. ` FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 I I No, ,- ' ---. THE COMMONWEALTH OF MASSACHUSETTS FEE 3��s\CAIZ�_BOARD OF HEALTH i DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is her bW a.t¢d tot Co true ( i epa'r ( ) Upgrade ( ) Abandon ( ) an individual sewage Permission is heZRZ, j disposal system at 1/ as described }} in the application for Disposal System Construction Permit No. to dated q 1 !I I I-) �. Provided: Constr tioll 6a e pleted within three years of the date of this per. 't.All�'caLridnditions,mI �b-omet. ` Date Board of Health ` FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 (REV 5/96) H&W Homs&WARRENrnn PUBLISHERS- BOSTON 4 f( 2.k 3a+6s='7 F'Ep 122 -33464 0 7—!_Iti3-201 7 & 93 1 e c9R DEED RESTRICTION I, Myriam L. Cimbrelo, do hereby agree that the following Deed Restrictions shall be incorporated into the Deed to the property situated at 17 Sea Robin Rd., Osterville, Barnstable, Massachusetts, being more particularly described in a deed duly recorded with the Barnstable Registry of Deeds in Book 29950 at Page 271. The buildings and improvements presently existing and hereafter constructed on the property situated at 17 Sea Robin Rd., Osterville, Barnstable, Massachusetts, which is described in the deed referenced above shall not contain in excess of three (3) bedrooms per the Barnstable Board of Health regulations, until such time as approval is obtained from the said Barnstable Board of Health for expansion of the septic system capacity in order to meet the design flow requirements under Title 5 (310 CMR 15.290 et seq) for additional bedrooms. For my title.see deed from 13 14 244/89 dated 9/22/2016 and duly recorded with the Barnstable Registry of Deeds in Book 29950 at Page 271. Executed as a sealed instrument 3.rd day of July, 2017 Owner's signature COMMONWEALTH OF MASSACHUSETTS 'tea-r�sc�..b1P_ , ss 20 l 7 Then personally appeared the above-named known to me to be the person who executed the foregoing instrument and acknowledged the same to M t} 5+a+e free act and deed, before me, `SE.FF REv A , ?�)oLj_F'1,S5 Notary Public My commission expires: as{ ,4o ay date " JEFFREY A. DOLLEUSS = AV ° Notary Public Commonwealth of Massachusetts �.W'•si�%� ''�:�+�":j�;+uJ� My.Commission Expires ian.25.2p2�: ; ''"ti'• �j! ' ;'.3�: BARNSTABLE REGISTRY OF DEEDS J� 15 .i�1i111111111N John R Meade, Register BSS D E S I G N April 9, 2002 LAND SURVEYING CIVIL ENGINEERING Barnstable Health Department LANDSCAPE ARCHITECTURE 367 Main Street" BSS Design,Incorporated Hyannis, MA 02601 164 Katharine Lee Bates Road Falmouth,Massachusetts 02540 RE: SSDS Inspection 508.540.8805 Fax 508.548.8313 #17 (Lots 13 & 14) Sea Robin Road, Marstons Mills, MA To whom it may concern: On April 9, 2002, BSS Design inspected the subsurface sewage disposal system at the above tCi ..oficeu 1wat1v1I. The Jystclll VJCLJ 1Q'Lllfi.t to 1iav:+bec-11 SiiJCQ11eU JiivJt3l:tiai1y"ai+livluilig tV plan. One change was the SAS location-( in relation to the tank and house foundation)which was installed a few feet south from the proposed plan location. The other noticeable change was the material used for risers on the septic.tank, d-box, and chambers. Black corrugated plastic pipe (CPP)was used instead of"concrete"'risers. The covers to go on the risers were standard H-10 concrete as per plan. If you have any questions please call me at 508-540-8805. Sincerely, BSS DESIGN, Inc Lawrence Perry, R.S., C.S.E. ru'�, APR 1 2 2002 LHEAL N OF't/ifitdfi'%nBLE •-. .DripT: l I - t k j --- _�_EETFf�V ---- --- . I 508-428-6191 I - �_� lf 5ev1 i n r :r -tZ :o a54�F�� _ - - @UStOM -- — o esigns served 999 Al Rights® Rel f p _ Tlo.—r.-e�fir-rr- _. _n•-a-r--gene _ : ��:.EYOC11Ei.T_escE - ' LT'!' 2a_xZ9.leisw. a JA- . _ w 4i lirtte(ure-M H cz ssie� - Q (roR DETNt t- - r �J Preliminary plans and layouts"by D.C.D.afe for the use of their customers only.Any other use is strictly prohibite i r J L. _1 _ t i I I ! A� I a y rot F-k o. - N - I 0 r 4'±TNK.CMM sI.AS a i b I .o 4— - - — - 2"X 26Xt*THK fTG. o FOA91/2`• � � _ . 4 CONC.FILLED ULLLY COL .. p -CM_23-370-'?. /.:K7 PLY. 508.428.6191 i dev*in .,�•.�••... j'fTCS7—CdST��-A-FF-1T CIYt=.-1:0) _ N .I �B'TiDL,1RIALI3.OM T-4'X8' � � I I ...'4=amass-tr,.tsEn)—� C§�1s 01'1'f !cFnv�c i I D esigns. N I .; -- - .•1 i .I r4cLFsw7� Copyright®2001. i N' 8•DIA,C01.C.FlCCm All Rights Y! .�covlancr,[P'cc::" __ ON2°X2°X to Tlpf,Q�IOTDDEg Reserves 1, 1 19 of i - - e! 9 Ye to-=QF- 11*4j:_:. _9:t'e t0'.TJiL1V'. 1:9 9:0'" .._._._..—_...�_p_ .. ._.._1ram13.0� a g �T1 Preliminary plans and layouts by QC.D.are for the use Of their customers only Any Other use is Strictly PrOhi Di[e f j I? I _ 7T7 o; �Ip —/K13�iZF�_v�rr�= I'• ��CTt-c��l"-q_4- -------'- ._. .. —_4.:0" ..r 4:tc'..._._4:4e"... 1 S:a ... .. 4:4i• `` SECT10_�s�� t3 i i n —1 I� - lz -vFJ,it— :' _ri/_P3y2 II T j �ry 14 �..t�UL, {t Of �f 5(:ALE DA 01 508.428.6191cri— , i o eviin IT Custom �x �J?CX A — COpyflQht®2�1' All Rights i O - _ Reserved `.W/CX6�X o'6d.W.M." -� __F(7t:-CH-_. m -- �i I •. ! 1 SECT10_ �-C i F a _�.�'"--:.'.:.- .----.It;o_..�::_.:__-...-. �:�^. _.. e-o lo•.o^" �•:o:.::-".:."I_.__-t._o•-- -'-- •� -"— � Y e l g 11 �} A3 B �PeST.-Et1]Q2._E�G4C�------ -.. Preliminary plans and layouts by (1CD.are for the use of their customers only.Any other use is strictly prohi bite