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HomeMy WebLinkAbout0176 HIGH STREET - Health 176 High Street A = 10 West Barnstable I i I I C 1 (j` ,(/ e 3/f 0,9Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ca 176 High Street n Property Address Sigsbee Owner Owner's Name cr) information is 3> required for every West Barnstable MA 02668 11/21/2016 page. City/Town State Zip Code Date of Inspection I� PO N Inspection results must be submitted on this form. Inspection forms may not be altered in any dray. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to rrove your cursor-do not A.Riker/ use the return Name of Inspector key. Riker Land Construction � Company Name PO Box 726 Company Address r South Yarmouth MA 02664 Cityrrown State Zip Code 508-776-6460 S14590 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5.(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11/22/2016 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design,flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions'at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of�17 is J� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 176 High Street Property Address Sigsbee Owner Owner's Name iequiredifo is West Barnstable MA 02668 11/21/2016 required for every page. Cityfrown 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 ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °b 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and 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 '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 GPD t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage private well 9 ( Y 9 (gPd))� Detail: Private well/no meter readings avalible/homeowner to supply well test data' Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 176 High Street Property Address Sigsbee - Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 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: homeowner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: not required 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Installed 10/04/1983 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 30 feet Comments(on condition of joints, venting, evidence of leakage, etc.): Under slab and behind finished basement walls , no evidence of backup or leakage in basement were accesible Septic Tank(locate on site plan): Depth below grade: Tank#1 6"deep Tank#2 2"deep Tank#3 1'deep Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) The system has three precast concrete tanks If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 5'x5'x8'6" Sludge depth: #1=4"#2=4"#3=3" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Sigsbee Owner Owner's Name requir required is West Barnstable MA 02668 11/21/2016 required for every page. Cityrrown 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 #1=30"#2=30"#3=31" Scum thickness #1=3"#2=0"#3=3" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle #1=12"#2=14"#3=12" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): All tanks were at correct operating inverts with no obvious failures observed. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 176 High Street Property Address Sigsbee Owner Owner's Name requir required for is West Barnstable MA 02668 11/21/2016 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Equal to invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box has two inlets with single outlet, inlets were uneven with outlet invert at lowest elevation as designed. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 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 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2x 6'x6' Precast leach pits ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit# 1 had 12"standing water in base with stain line observed at 20" Leach pit#2 had 6" standing water in base with 24"Stain line . Failures were not observed in either leach pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer 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 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a. 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. Cityfrown 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 3 `'y .3 r� - 6q 16 I q t5ins.3f13 Title 5 Official Inspection Four:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. CityrTown 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: >30' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Rear of lot had standing water at bottom of steep slope approx 40'+ slope Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3112 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 176 High Street Property Address Sigsbee Owner Owner's Name information is required for every West Barnstable MA 02668 11/21/2016 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF P#RNr--rPPt - I DIV17SIOr oc JA II I N: - `l , - h Z ' I a e a 6l�PDFD-.k1P1iS�_'D -tom A7/] 88VI81ON8 BV .21 I e it I 11: - I r I I 1_ r.. 1 I I' - 3 .CIS. S.R._MICE-= e k 27218 Ps L 1 1'S486 a. 4 �a a —19-2a_a13 & 1±' i MASSACHUSETTS STATE EXCISE TAX BARNSTABLE COUNTY REGISTRY OF DEEDS Date: 03-19-2013 1 10:4Sam Ctlr• 366 Do1_Ti 16496 Fee. $1r3Q5.10 Cons: $405YO00-00 BARNSTABLE COUNTY EXCISE TA' BARNSTABLE COUNTY REGISTRY OF DEEDS Date= 03-151-2ii13 C:f Iyv 366 QUITCLAIM DEED Fee. .1?A?3.50 Con_. ..41iFCri 1, CONSTANCE LEE KAISER, an unmarried woman, of 790 Falmouth Road, Barnstable (Hyannis), Massachusetts 02601, -For consideration paid of FOUR HUNDRED FIVE THOUSAND DOLLARS ($405,000.00), Grant to CARL M.. SIGSBEE, individually, of 26 Chuckles Way, Marstons Mills, Massachusetts 02648, with QUITCLAIM COVENANTS The land, together with the buildings thereon, situated in Barnstable (West), Barnstable County, Massachusetts, on the easterly side of High Street, and more particularly being: Parcel B and Parcel C as shown on a plan :entitled."Plan,of land :.in .West.Barnstable !Mass. To be conveyed to James L. Kalweit & Karen J. Kalweit" dated June 22, 1970 by Lloyd C. Latimer, Civil Engineer an recorded at the Barnstable Registry of Deeds in Plan ,Book 239, page 29 and IParcel A as shown on a plan entitled "Plan of Land West Barnstable, Mass. For James IL. & Karen J. Kalweit" dated December 26, 1979 by Eldredge Engineering Co., Inc. and !recorded at the Barnstable.County Registry of Deeds in Plan Book 339, Page 35. Said premises are conveyed. subject to.and with the benefit of any and ail rights, rights of way, easements, appurtenances, reservations, restrictions or other conditions of record insofar as the same may be in force and applicable. Grantor hereby releases any and all homestead rights she may have in the subject ;property as defined by Massachusetts General Laws, Chapter 18,8. Property Address: 176 High�Streeti0est Barnstable, Massachusetts 02668 r DATE: January 2,2013 TO: Building File FROM: R. Anderson RE: Non-conforming status—Lot merger LOCUS: 164 & 176 High Street,WB I . Inquiry made from potential buyer's representative as to a developed parcel identified as 176 High Street(R134-003). A question of common ownership was noted as Constance Kaiser owns the dwelling in question as well as two-other undeveloped lots that touch the subject property. The parcels involved are 176, 164 and a narrow strip of land also identified as 164. All three have separate map &parcel numbers. Research resulted in a plan of property from 1970 as well as a subsequent plan from 1979 showing a 10' wide swathe of land running the entire length of the parcel R134-020-001. Said parcel is depicted as A2 on a plan recorded in Book 339 Page 35 on 12/31/1979 and identified as R134-020-002. There is a deed recorded for this 0.1 acre lot in Book 3042 Page 130. It is believed that the carving out of the 10' wide area was intended to serve as access and frontage requirements for the reserved rear Kaiser lot consisting of.95 acre and addressed as 164 High St(R134-019). The deeds and plans were reviewed with the BC on this date. An issue of common ownership was identified. Consequently,the BC determined that all three aforementioned lots merged under zoning. -31 pn� (ep - lam'` " � �,��P t'S�''�P ��) NeJ�►L C.�t•01�' 19� � . D f For Grantor's title see deed dated January 9, 1980 and recorded at Barnstable Registry of Deeds Book 3042, Page 130. Executed as a sealed instrument this 15' day of March 2013. P,_.��nsta_/n;ce Lee Kais Commonwealth of Massachusetts Barnstable, ss. On March 15, 2013, then personally appeared before .me the above-named . CONSTANCE LEE KAISER, who is both personally known to me and also proved to me through evidence of identification, which was her Massachusetts Driver's License, to be the person whose name appears on the foregoing instrument and acknowledged to me that she signed it voluntarily for its stated purpose. Laura M. Boucher, Notary Public My commission expires May 5, 2017 BARNSTABLE REGISTRY OF DEEDS i i i • nl. , • 1 A o u[ >U u v. D...1 N.I.e.. N�P4 LOCUS JI J� 1'.2000, SandWO Q..E. U.S.n5. 1057 Z N 10-5,50W 296,56 /Gq 's d i' ToWR way I I S 0/:3s;s; — s,on._Wall- ——_——— B8,00°e _ 1........ E q6 `S 168.9fi00 E 39.05' ZQ°B310c5•� 'n OI Iv....... N _ �D JAMES L. KALWEIT �S 14=57-0oE UK.1238 PG.49 =D �64SS m{4Y9' 69.os' pr.E 10 SC JOSEPH H. WITTENMEYER CATHY A. WITTENMEYER PARCEL PARCEL •�, �"�� ,R°' •Q-�' N c N-BK.1450 PG. 362 iD n °a °o 1.65 ACRES %tea. .55 ACRES Q m ^ a 3 1 IS>U0, y se'-,W I 0 m m n 'o m ,6: m 'o n m ! N P PARCEL .95 ACRES d C.B.In 8$.00' WILLIAM F. BODFISH N 6-09-3s°W 'Ti�27 MARTHA S.CARTER C,e.Ind I PROBATE W .0 1 in PHYLLIS A. BASSETT m�m BK.1461 PG.764 O a!l IH 15=48-45 W -- TAUNO LAMP[ EDITH LAAIPI BK.1105 PG.134 PLAN Rom-• LAND �pp� NOTE: P....1 'e B'c' v.1.5.....,.a P IL.A I V O L I"111 V D 11 V ,•••••Ill.l.an...n1..ml.y I.1. WEST BARNSTABLE MASS. TO BE CONVEYED TO I JAMES L_ KALWEIT a . KAREN J. KAILWEI T i LLOYD C. LATIMER t •���ci; SCALE I'=40 JUNE 22, 1970 FALMOUTH MASS. ,,r�... 44• ' �.c BtU1YvSTAf71s', = RPCIE OF DEEDS -JUL 24197 FECO EA M APPROVAL NOT REQUIRED q �J UHDER THE SUBOIVISION - CONTROL LAW BA N TRBLEPLANXINO BOARD - REOISTE EU....LA MD�9URVETOR �_.._ LAN 6:vvtZ—QO_._P.4C,r-o7 34.9 -3-5 BOOR PAGE i � PC Z 0 J LOCUS MAP s0AL0:: a000P-r, Y MAP/1 4 LOT PO ZONING R/: KAL/,yE/T 'W N,Jfo sP. /So'PLONTAO< .TAMES L"' ,gLYVE/T o W 0 KA Rev ✓ K c :o iJAME328 KA(-WE/'S 7'r /y 77-33'OOa��ppARCRA. Aa 4 eC 1 I 77.3.7 do i � /0•W/be ..$ 0 1� IW<1 n W31 a 1 -ARc&L. A I I of ,3 h W IZ�1•ti` n� h I , 37:.74 h Q 1 1 « � 1 I,h JOSHPH /�I. W/77-ENMEYER CATHY A. Gv/TTENMEYER /CYRT/PY TNAT.75f/J PLAN HA. BEENA eE REO/N G—po TMX NCc 7b THB,MN.I,/?76 RULE)ANP REGULAT/aN5 O^7N2 MRHJTA K COUNTY RCG/sTSRs aF L�OeOs. Pare: � LG,IT7y _ REJ/ eRCO NO JURVRYOR PLAN OF LA N0 ceW� IN e. K4ST -.4s-s. �^ NOTE: POR "LL PARCEL Ax IJNOTA BOILOAbLE ✓AMES L• A ICAREN ✓. I<ALWE/T 407 AND/s FOR CONVZYANC'/N4 -`� PURPoSFS ory<Y. ' ORAWN MA.AM. APPROVAL UNDER SUED/VISION CONTR04 LAW NOT REQU/REO "AI .I BARNS7A9LEPLANN/NGBDAROvJcrPL�A SND/vNON PItaN OF LAND BY LLOyD C.LAT/M6R, ELDREOGE ENG/NEER/NG /n��n n �yy� ,I "� .�— RCa.C/✓/L 6N6/NCSRe A suwvsYaRJ , DATE: /.2.$/-79 l T p(AM}{(p,/ OATED DUNE Z 1970,RELORpeO 7/2 N}'pIN 9T ]D Na MA/N 9T. A/ 9 9 /N PLAN BOOK 239,PAGE 29 NYANN/J,MA55 J0.YARMuuTH,M<SS. /Y P 7 O 6 339-35 . Commonwealth of Massachusetts rz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13, 2012 page. CityTrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, /1 use only the tab 1. Inspector: key to move your cursor-do not Edwin C. Gibbs Jr. use the return Name of Inspector key. Gibbs Septic Service Company Name 2 Oriole Lane �I Company Address Sandwich .MA 02563 CitylTown State Zip Code 508-888-5871 1750 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this ad"dr&ss and that theQ information reported below is true, accurate and complete as of the time of the inspection.-The Inspection was performed based on my training and experience in the proper function and maintenance of on>site sewage disposal systems. I am a DEP approved system inspector pursuantw.,'to Section 115.340�of Title 5(310 CMR 15.000). The system: Passes l ❑ Conditionally Passes ❑ Fa'ls ❑ Needs Further Evaluation by the Local Approving Authority Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins-1 Ill 0 Title 5 Official In e n Form:Subsurface Sewage Disposal System-Page 1 of W Commonwealth of Massachusetts a Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 176 High Street Property Address Kaiser Owner Owner's Name information is requi-ed for every West Barnstable MA 02668 November 13, 2012 page Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13, 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): `❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine,if the system is failing to protect public health, safety or the environment. I. .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 x 94 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is West Barnstable MA 02668 November 13, required for every 2012 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and 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 Y2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is West Barnstable MA 02668 November 13 2012 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (coot.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ (R 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. ❑ (K 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 Syste s: To be considered a large system the system must serve a facility with a design flow 10,000 gpd to 15,000 gpd. For large systems, y must indicate either"yes" or"no"to eac f the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is with' 400 fe of a surface drinking water supply ❑ ❑ the system is within 0 of a tributary to a surface drinking water supply El Area system is to ted in a nitrog sensitive area(interim Wellhead Protection EJ Area—IWP or a mapped Zone II public water supply well x t If you have answered "yes"t ny question in Section E the sys is considered a significant threat, or answered "yes" in Sec' n D above the large system has failed. T owner or operator of any large system considered a . nificant threat under Section E or failed under Se ' n D shall upgrade the system in accords a with 310 CMR 15.304. The system owner should conta the appropriate regional office of a Department. t5ins•11,/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13, 2012 page. Cityrrown 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 ❑ (3 Pumping information was provided by the owner, occupant, or Board of Health ❑ tA Were any of the system components pumped out in the previous two weeks? ❑ [A Has the system received normal flows in the previous two week period? ❑ Eg Have large volumes of water been introduced to the system recently or as part of this inspection? [S ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) 14 ❑ Was the facility or dwelling inspected for signs of sewage back up? 9 ❑ 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: ❑ [R, Existing information. For example, a plan at the Board of Health. 0 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: d Number of bedrooms (design): Number of bedrooms actual.: DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n f thins•11/1 0Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes EN No Is laundry on a separate.sewage system? [if yes separate inspection required] ❑ Yes R No Laundry system inspected? El Yes EX[ No Seasonal use? ❑ Yes 4 No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump. ❑ Yes ❑ No Last date of occup cy: Date Commercial/Industrial FI Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ ` No Industrial waste holding tank presents ❑ Yes ❑ No Non-sanitary waste discharge o the Title 5 system? ❑ Yes ❑ No Water meter readings, if vailable: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is West Barnstable MA 02668 November 13, 2012 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: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallonn s How was quantity pumped determined? Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ' ❑ Overflow cesspool ❑ r 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 I I " Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M, ,•�''� 176 High Street Property Address Kaiser Owner Owners Name information is required for every West Barnstable MA 02668 . November 13, 2012 s'' page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grader 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: Sludge depth: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °wM ,•''V 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13, 2012 page. Cityrrown 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 Scum thickness 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 as related to outlet invert, evidence of leakage, etc.): A 4— &IgA �� Grease Trap locate on site plan): Depth below grad f Material of construction: ❑ concrete ❑ meta ❑ fibergl ❑ polyethylene other{explain): Dimensions Scum thickness Distance from top of um to top of outlet tee or baffle Distance fro ottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11MO Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° M 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13, 2012 page. Cityffown 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 sit plan): Depth elow grade: Material of c struction: ❑ concrete metal ❑ fiberglass polyethylene El other(explain): } Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: Yes ❑ No Alarm level: Alarm in king order: ❑ Yes ❑ No Date of last pumping: Date Comments (condi "on of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is ,West Barnstable MA 02668 November 13 required for every 2012 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump hamber(locate on site plan): Pumps in rking order: ❑ Yes ❑ No Alarms in worki order: ❑ Yes No Comments(note con ition of pump chamber, condition of pumps and ap enances, etc.): Soil Absorption System (SA (locate on sit Ian, excavation not required): If SAS not located, ex to why: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage isposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13 2012 page. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Type: a leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ,❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Cesspools (cesspo ust be pumped as part of inspection cate on site plan): Number and configuration Depth—top of liquid to inlet inv Depth of solids layer Depth of scum layer i Dimensions of ce spool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form: bsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts r t . Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owners Name information is required for every West Barnstable MA 02668 November 13, 2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy locate ' . Y( one a plan): Materials of constructio Dimensions Depth of solids Comments(note condition of soil, si hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 176 High Street Property Address Kaiser Owner Owner's Name information is West Barnstable MA 02668 November 13, required for every 2012 page. Cityrrown 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 lie > =� i d t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 < ° Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. M 5•''� 176 High Street Property Address Kaiser Owner Owner's Name information is required for every West Barnstable MA 02668 November 13 2012 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Check Slope ❑ Surface water Check cellar ® Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained.from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Q Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11A0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 176 High Street _ Property Address Kaiser Owner Owner's Name information is West Barnstable MA 02668 November 13 2012 required for every , page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist [,3 Inspection Summary: A, B, C, D, or E checked [� Inspection Summary D (System Failure Criteria Applicable to All Systems)completed [&System Information—Estimated depth to high groundwater [ . Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/1 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No..l.1..3"3d.. pp� f Fxs.... l�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH \ 1�� ..........................................OF......................................I.-----.----..._.......--------.........._-------- i Appliration for Uiipusal arks Tonstrnrtinn Fumit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ° JSystem at:, -------------------------------------- L ion•Address or Lot No. ...................... ................... .................-•----.......................... ..............-•-•--............••..........•.................................................... W f / Owner Address...... Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers — a YP g ---------------•--•--------- P ( ) Cafeteria ( ) Q' Other fixtures ------------•-------------------- - - - W Design Flow............................................gallons per person per day. Total daily flow_..........................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.................... q. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 04 Percolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' --------------------•-••......-----................-----------•---........_........._..------............................................................... r 0 Description of Soil.................••--•--..........------........----.........--•----------•---...-•-•------------•-•--....-----------•-••--------.........---------........_............ W ..............--................................................................................................ -- .............................. S x ---� crv_-.�'141J. s...............................��'';` . U Plature of Repairs or Alterations—Answer when applicable........ . .. ..... --• -------------------•------•-............••-•------------------------------------......----..............------------..... f=. .. •� /f 1 9 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with fze provisions of TAITILZ 5 of the State Sanitary Code—The under ' ned further agrees not to place the system in operation until a Certificate of Compliance has en issued by e bo rd of health. a Signed• :G/,ffLv ...................•-------•• ?f.7....l .......... ate Application Approved BY ._...... .. ,d�....._.---•-- Date Application Disapproved for the following reasons:---------•--•-••-•----------•---------------•---•-•-•--•------•--•-••-•--.....-------------------.....---••---•- ••------••-•-----------------•--.---•----•--•--- -..- .-------•--------------••-•-•---•----•---------. -----•----------------- -.-------••----...---------------------.•-----•------------•- Date PermitNo......•-•.............................•-•-•----..._...... Issued....................................................... Date ��� No L1. .-3 z'm , FEIC .............. A ki THE COMMONWEALTH OF MASSACHUSETTS .A. BOARD OF HEALTH •` .. ....... ... ._........................OF............ .. Appliration for u �mal Workri Tomitrur#ion rrutit �7 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Ae.,W r L ion-Address or Lot No. �e- ......-------------•--- �17...�:Z.-;--C. .--------------------------------------........ .......--------.........................--- ----...........-----........L...------------... W `� rC�wner Address V. ........................A-••-._...fie ...................................._.... .................................................................................................. Installer Address Q Type of Building Size Lot............................Sq. feet V Dwelling=No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -•--- •---------------------•-•-•••----------••--••-••'----•.......--•-•-...--•-••.......--•-•••.........----------......---••-----•---...•---••...... Design..,Flow.........................................1.;_::gallons per person per day. Total daily flow...........................:................gallons. 04 W Wx Septic Tank—Liquid capacity............gallons . Length................ Width................ Diameter.............. Depth................ x Disposal Trench—No.................... Width...._........_...... Total Length.................... Total leaching area..... -t ..............sq. ft. Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) i a Percolation Test Results Perform`e'd'..bY .................... ---•..................... Date Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----••-----•-••-----••----••..................•••-•----••.......• "........ ----------- ODescription of Soil........................................................................................................................................................................ U UW .....::...................................................... -----------.-�_......... Nature of epairs or. Alterations—Answer when applicable ..... .:. .. ...... �_....�G:: �����C........--_•--__....... .? --------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LI.IL 5 of the State Sanitary Code.— The under ' ned further agrees not to place the system in operation until a Certificate of Compliance has tenissued by the bo rd Tof healig." Signed._ : ;tied i................................ . .. y Application Approved B - � �� -- Date '-Application Disapproved for the following reasons:............................................................................................................... ............................•----....-------•-----••-------------•---•---------------•-•--...------....--••----•--..........•-----------------•-••-•-----.............................................. Date Permit No.......................................... -------- .............. Issued............. --------•--......---•---•--••-------• '. Date THE COMMONWEALTH OF',-.MASSACHUSETTS .t BOARD OF HEALTH ..........................................O F..................................................................................... ' - Trrtilirtt#r of (I,autpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................ --•---•--..•--•..............•----•----- -•-... ..........--•--•-••--.._._..............--•--.._............•---........... scalier /..S`.c� ,. 1 � . le at �� `�` '''... ... - ------------------------------------------•--------•••......••...... h�_s been installed in accordance with the provisions of TITLE, 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__ _ '. ........... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE FF SYSTEM WIL NCTION SATISFACTORY. DATE....L� IY,t......_... Inspector. ...... ... c THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No... FEE..../............. �t��rtt,�tt1 u k,� �nttu�ttr�tuatt rrutit Permission is hereby granted............. ... ........... . ... --•j2...--------•----•-••.............•------•-••---•-•------.....--------..........•---...... to Construct ( or Repair ),an Individual Sera DisP System atNo...... ......... ----•--• `_..../..--_- '----------••--------------------•--•--------•-----------•------............. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ..�. ,. ...................................... Board of Health DATE................................................................................ FORM 1255 A. M. SULKIN, INC., BOSTON ' -7 No....................... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD 04� HEALTH - ----------- -----OF......... .. ........................................................... Appliratiou for Mipoiial Works Toutitrurtion Prrmit Application is hereby made for a Permit to Construct or Rep' (V-) an Individual Sewage Disposal Sy em at Location-Address or Lot No. %7. 'k................. .................................................................................................. ..... ................... JZ Owner Address .......... ....................................................... .................................................................................................. Installer Address Type.of Building Size Lot.................:..........Sq. feet U Dwelling—No. of Bedrooms......... :.:2___-------------_----------Expansion Attic Garbage Grinder ( Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( Otherfixtures ----------------------------------------------------------------------------------------------------------------------------------------------------- Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. P4 Y//w Septic Tank—Liquid capacit � ....gallons Length________________ Width______.._._._... Diameter___-____________ Depth__.___________-- W Disposal Trench—No_.................... Width__ . .. ........ Total Length. ... Total leaching area----------_-------sq. ft. Seepage Pit No.--/ ------- Diameter.....�e....... Depth below inlet_.....______________ Total leaching area._.2A.J..sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by......................................................................... Date.__________________________.___..___.... Test Pit No. I________________minutes per inch Depth of Test Pit___._______.__._____ Depth to ground water_________-___________-_. G%, Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water---------_------------ ---------------------------------------------------------------------------------------*-------------------------------------------------------- 0 Description of Soil....................... ................................................................................................................................... U ........................................................................................................................................................................................................ W .......................................................................................................... ----------- - ------- ----- ------c--- ----- -------------------- �ri U Nature of Repairs or A)tefations—Answer when applicable._______ '--____-- -- .......................... -------v1................................... ---- .......................... -----�---&" -- AgreEment: 7 The undersigned agreeg to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 of the State Sanitary Code— ndersigned Furth I- r rr agrees not to place the system in operation until a Certificate of Compliance has bee e oard ofni al, • Sigd . ...................... ..... ..... ....................... ................................ Date Application Approved By........ ..... ------- ................. Date Application Disapproved for the following reasons:.................. ........................................................................................... ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date No......................... Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O 1--1 EALTt-� t ..................OF......... .:: .. -........_. Appliration for DWpogFat"Workti Tonstriaduitn Prrutit Application is hereby'-made for a Permit to Construct ( ) or Rep 'r (1/ ) an Individual Sewage Disposal System at: f/- . Location.A�dress or Lot No. Owner Address 1 Installer Address = d Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.................................... .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building ............................ No. of persons------- Showers — � yp g p ( ) Cafeteria ( ) P4 Other fixtures .................................... d ------------------------------------------------------------------------------------------------------ WDesign Flow............................................gallons per person per day. Total daily flow----_:......................................gallons. WSeptic Tank—Liquid capacit��-----gallons Length--------_----- Width.........-_.._ Diarrieter-------_........ Depth................ x Disposal Trench—No. ........... ..... Width. ___..__._._._.._. Total Length lea________ Total leaching area....................sq. ft. Seepage Pit No._ -------- Diameter.._. _.___.._. Depth below inlet_................... Total leaching area...,2 a_.!...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------------------------. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch 'Depth of Test Pit.................... Depth to ground water........................ Pa' Don of Soil ---- ----- --•---------------------- -----•---•--•-----------------------•------------------•-------•--•-------------------.....-------_... x escripti W --------------------------------------- ----------------------------------------------------------------- txj Nature of :epa�rs o ?�At ions-Answer when applicable 4.. x-�✓' w ........................... !l �Vz -�` l Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iTTL p 5 of the State Sanitary Code— hm ndersigned furt :er agrees not to place the system in operation until a Certificate of Compliance has bee. e oard o iea 11. Sig> e ...•... ........... .--- ----------- .......................... Dat ' Application Approved By...... �.y----.` ... --•- --.. � ----- --- -- `5� 'Hate Application Disapproved for the following reasons----------------- ...................................-...............................-......................... ----------------------------- .--•-•------- ---------------------------------------- ------------.----------------------------------------_-------------------------------------------------------- Date PermitNo..............•--••------------------------......----•--- Issued....................................................... Date THE COMMONWEALTH"OF MASSACHUSETTS I BOARD F HEAL ........ . .........OF.... .......r................... Trrfifiratr of Tomphaurr THI T ERTI Y Tat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.`-=..---- -- L =. •. -- -------------- ` n ller ? has been installed in accordance with the provisions of TI > oThe State Sanitary Coe as descri in the application for Disposal Works Construction Permit No...`. ----. -: r ..._. dated_.-..�.._" �0 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........�.`.;�_'� ............................................. Inspector ...............------....................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH z S�. O F.. ........ -••-•........................................... F - No, .......,............... EE...... iurruVine/ rkutrun rrutit Permission is hereby grante '•. ------. e ---- -•----................................................. to Construct Ol) or Repair (' aal Sewa e ispd�al System / at No...............(}'..�i�Q,l�- . 4 ...._. _.....�.''.----'----------�-!....11.--'_��t''�'I!�".......................................... /oI yiH Street & v as shown on the application for Disposal Works Construction P No_______ _4Boad ated.__._........._....._..................... fF •...............•---...... / ealth !/J p-- r� DATE . ................................................. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS REVISIONS SV ------------ . . ..... ... 6.2 =_= = ek. � J i 'I r-I I � n u DUO - ___ Ej❑❑ _- •._'�i T7--`1 :-'T���I.I �1:.I '-� -r", �i�Y _ .I 'TI-T-T �-T- ___ - _ .T -T• __.___ -_.T-T-rT � .. •_. �_ ' �_ ---.: _ __ :.,--�--r:-;'-rrtf - I I':rT �IT- `r'-r--, __ _. f _ T 1 I I I I I I I I • I �i � I I � I 111 I I I I Q I -�ul�oJca .2a�.h"NW�r �LF_�/arioN. 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