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HomeMy WebLinkAbout1596 MAIN ST./RTE 6A(W.BARN.) - Health 1596 Main Street/Rte 6A (W.Barn) W. Barnstable A = 197 022 I - Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i 1 u— 1596 Route 6A Property Address Joe Dellamorte r r, Owner Owner's Name information is West Barnstable ✓ Ma. 02668 02-11-2019 required for every page. City/Town State Zip Code Date of Inspection,-', Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S! 1 (oa.l on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road � Company Address Teaticket Ma. 02536 Cityrrown State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 9?�,' c� � ,.^-- 02-12-2019 Inspectors 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form 11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............ ,u 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This report is for the two structures on the property. They both have there own 1500 gallon H-10 septic tank and they share a leaching system. There are 4 bedrooms combined. The leaching was permited for the 4 bedrooms and there is a deed restriction limiting the land to 4 bedrooms. At the time of the inspection there were no visible signs of past hydraulic failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined"(Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. 1596 Route 6A V Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑, 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ........... ,. 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑l 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or``no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .......... 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 plus GPD Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y rY 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 L- - Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .� 1596 Route 6A u Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: 1999 and 2004 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 84" house 34"garage 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6 6" house 24" garage 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: Both stardard H-10 1500 gallon Sludge depth: 4" & 3" Distance from top of sludge to bottom of outlet tee or baffle 12" Scum thickness 3" & 2" Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 12" & 11" 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.): I recommend the new owner put the septic tanks on a maint. plan with a local septic pumping co. based on the future use of the home. The Barnstable Health Dept. has a list of local septic pumping co. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): At the time of the inspection both of the d-boxes had no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is West Barnstable Ma. 02668 02-11-2019 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp:doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is West Barnstable Ma. 02668 02-11-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of leakage. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 c� Commonwealth of Massachusetts IF Title 5 Official Inspection Form tilb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is West Barnstable Ma. 02668 02-11-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ® drawing attached separately I �0 G`j 4'lie ��a✓f �I e/1 c� d.•� 7'he t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 A - -. TOWN OF BARNSTABLE O d 0 6 o LOCATION SEWAGE # Gpp _ C< VILLAGE� S1f e,�n ASSESSOR'S MAP & LOT 'D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY . LEACHING FACILITY: (type) (size) x i�X NO. OF BEDROOMS BUILDER OR OWNS J PERMITDATE: fCOMPLIA�� b� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) - - Furnished by Feet . TOWN OF BARNSTABLE LOCATION �,,t1M IQr Q_ SEWAGE N Q '--!Q7 VILLAGE AQ?iV ASSESSOR'S MAP&LOT !l 7—& 2 INSTALLER'S NAME&PHONE NO. / SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 3 JSaw CAS' (size)131iC�4�X.?r NO.Of BEDROOMS_ BUIL6ER OR OWNER m:ra ( PERMITDATE:�/f-�-44 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (if any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by are r( JetV 6XS l <&* Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments u- 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet 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: I augered a hole. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1596 Route 6A Property Address Joe Dellamorte Owner Owner's Name information is required for every West Barnstable Ma. 02668 02-11-2019 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 'fwra`�`��` `rn�:asis-.#-���'aB�s�4n-v�m�..r- .�m�aa�tw�"�.' .��-."+ �?�'...s+d�,vu"".-.'��'x.a.bl.�s."�'e"Y.��=�...m- '�':"`-`�'���`m.�•'�'.s".>":air'..�.�a�.>...� . yy ++^�y• y 3 +y.��yy�y�n +y ii yy DEED RESTRICTION WHEREAS,Joseph V. Della Morte and JoselIe D. Della Morte of 1596 Main Street, West Barnstable, MA are the owners of 1596 Main Street,.West Barnstable, MA referred to as a certain parcel of cleared land situated in that part of Barnstable aforesaid, known as West Barnstable, adjoining the "Homelot" of Lucy E.Eldredge, together with the buildings thereon, and bounded as follows: Beginning at the Northwest corner of the land of said'-Eldredge, at a point on the northerly side of the State Highway; Thence running.Northwesterly by said highway, about seventy-five (75)feet to the land of Jose Duarte; Thence Northeasterly by said land of Duarte, about three hundred fifty (350) feet; CX Thence.Southeasterly by other land of said Lucy E. Eldredge about seventy-five (75) feet to a corner; Thence Southwesterly about three hundred sixty (360)feet to the first mentioned- bound or,place of beginning. Also a certain parcel of cleared land situated in Barnstable aforesaid, formerly a ----part-of the homeland of Lucy E.-Eldredge,bounded and described as follows: - Beginning at a stone post built of cobblestones at the Westerly side of the driveway on the Northerly side of the State Highway; Thence by said State Highway about thirty-eight(38) feet to land now or formerly of Alexander Michelson; Thence by said land now or formerly of said Michelson Northeasterly about seventy-six (76) feet six (6) inches to other land now or formerly of said Lucy E. Eldredge; Thence Southeasterly by said other land now or formerly of Lucy E. Eldredge about twenty-eight (28) feet to a stone wall built in the bank, this line running about two (2) feet from the barn now or formerly of said Lucy E. Eldredge; r. Thence Southwesterly said stone wall about eighty-four (84) feet five (5) inched to the first mentioned bound or place of beginning. WHEREAS,Joseph V. Della Morte and Joselle D. Della Morte as the owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot, WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to authorizing the issuance of a building permit for the construction of a single family home and/or appurtenant structures on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house .constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE, Joseph.V. Della Morte and Joselle A. Della Morte do hereby place the following restriction on their above-reference land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors.in title: 1. 1596 Main Street, West Barnstable, MA may have constructed upon the lot a house together with appurtenant structures containing no more than four (4) bedrooms. Joseph V.Della Morte and Joselle D. Della Morte agree that this shall be a permanent deed restriction affected property located at 1596 Main Street, West Barnstable, MA as previously described above. Executed as a sealed instrument this day of December, 2003. �- Y ose V. Della Morte oselle D. De orte ; COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. December., / . 2003 Then personally appeared the above-named Joseph V. Della Morte and Joselle D. Della Morte and acknowledged the foregoing instrument to be their free acts and deeds,before me. Notary P lic My Commission Expires: j$ p/ 41 TOWN OF BARNSTABLE V LOCATION T'r �,/A _ SEWAGE # Q* --<�z VILLAGE ASSESSOR'S MAP& LOT 117 - 0 2 INSTALLER'S NAME&PHONE NO.-� SEPTIC TANK CAPACITY Z'W LEACHING FACILITY: (type) 3"Z!Pv (size) NO.OF BEDROOMS BUILDER OR OWNER � � PERMITDATE: ho=C-aq COMPLIANCE DATE: /®�7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Sy ,� fill M 0-'QiAP%6075 +746 No. — S-d / Fee /00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZippYication for 33i5po5ar *pgtem Cougtruction 3dermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System I �7 d�z /❑Individual Components Location Address or Lot No. 15% g' �A f a Owner's Name,Address and Tel.No. _1d6 Assessor's Map/Parcel `9 ISO � , CIQ` Installer's Name,Address,and Tel.No. OPM A/i0� Designer's Name,Address and Tel.No. 0q0�.� CA i�`1 MG Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type.of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable). 61 0/Y Zft YK 6410 L- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ntal Co and not to place the system in operation until a Certifi- cate of Compliance has been issued ayo� of ea Signed Date /0_ O! Application Approved by Date Application Disapproved for the Mlowing reasons Permit No. of yU q—S J 7 Date Issued / /n, /00 ' ,-W , `.No'► (,' 5d / Fee THE COMMONWEALTH OF MASSACHUSETTS ( � Entered in computer: +✓i..' ol Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS 01ppYication for Miquaf *p!tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components � n Location Address or Lot No. S/1 (�/� Owner's Name,Address and Tel.No. Assessor's Map/Parcel ( q 7 ^ 0�Z IS ` r e,`7 I' 6t4 Installer's Name,Address,and Tel.No. 6 LYi0-r,/ Designer's Name,Address and Tel.No. MILLS' Type of Building: Dwelling No. of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date - Title Size of Septic Tank Od CAZWIV Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)__T 1 I1 ,6!9 Cit ela l TR/64 Date last last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Enviro ntal Co and not to place the system in operation until a Certifi- cate of Compliance has been issued byeiseoarof/.ea Signed r l Date Application Approved by Date — —U Application Disapproved for the Mowing reasons a t Permit No. U0 — S oZ 1 Date Issued /y Lo- U --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTWY that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded_(X ) Abandoned( ),,b,,�� Li,�& Rio rTl at /53; W7 44 (ti /?/W/ has been constructed i/n a co dance with the provisions of Title 5 and the for Disposal System Construction Permit No. o� G Ll "S-2 7dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the s s e w function as lesigned.,�j Date �� � Inspector ��!�1 S, --------------------------------------- No. D o o Li` <_a 7 Fee nJa THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS lwigozar *potem Con.5truchon Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at !o- Po ux &wy and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pe . i;. t `� Date: I b -6 D Approved by r ='r i TOWN OF BARNSTABLE LOCATION SEWAGE# - ASSESSOR'S MAP & LOT 1 - 2 � ASSESSO � � VII.LAGE �d � - INSTALLER S NAME&PHON E NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (site) 19t3 I NO.OF BEDROOMS jBUILDER OR OWNER PERMITDATE: ho= -a _COMPLIANCE DATE: /Q:Z I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by /%O-Q CW +946 t s�•rr� Y Y r y Ps 1-36 0142172 DEED RESTRICTION WHEREAS,Joseph V. Della Morte and Joselle D. Della Morte of 1596 Main Street,West Barnstable, MA are the owners of 1596 Main Street, West Barnstable, MA referred to as a certain parcel of cleared land situated in that art of P P Barnstable aforesaid, known as West Barnstable, adjoining the "Homelot" of Lucy E. Eldredge, together with the buildings thereon, and bounded as follows: M Beginning at the Northwest corner of the land of said Eldredge, at a point on the northerly side of the State Highway; LU Thence running Northwesterly by said highway, about seventy-five (75) feet to the land of Jose Duarte; Thence Northeasterly by said land of Duarte, about three hundred fifty (350) feet; Thence.Southeasterly by other land of said Lucy E. Eldredge about seventy-five (75) feet to a corner; Thence Southwesterly about three hundred sixty (360)feet to the first mentioned bound or.place of beginning. Also a certain parcel of cleared land situated in Barnstable aforesaid, formerly Y a part of the homeland of Lucy E. Eldredge,bounded and described as follows: Beginning at a stone post built of cobblestones at the Westerly side of the driveway on the Northerly side of the State Highway; Thence by said State Highway about-thirty-eight (38) feet to land now or formerly of Alexander Michelson; Thence by said land now or formerly of said Michelson Northeasterly about seventy-six (76) feet six (6) inches to other land now or formerly of said Lucy E. Eldredge; Thence Southeasterly by said other land now or formerly of Lucy E. Eldredge about twenty-eight (28) feet to a stone wall built in the bank, this line running about two (2) feet from the barn now or formerly of said Lucy E. Eldredge; i Thence Southwesterly said stone wall about eighty-four (84) feet five (5) inched to the first mentioned bound or place of beginning. WHEREAS, Joseph V. Della Morte and Joselle D. Della Morte as the owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to authorizing the issuance of a building permit for the construction of a single family home and/or appurtenant structures on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE, Joseph V. Della Morte and Joselle A. Della Morte do hereby place the following restriction on their above-reference land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 1596 Main Street, West Barnstable, MA may have constructed upon the lot a house together with appurtenant structures containing no more than four (4) bedrooms. Joseph V. Della Morte and Joselle D. Della Morte agree that this shall be a permanent deed restriction affected property located at 1596 Main Street, West Barnstable, MA.as previously described above. Executed as a sealed instrument this day of December, 2003. ose V. Della Morte oselle D. De orte f COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. December 152,, 2003 Then personally appeared the above-named Joseph V. Della Morte and Joselle D. Della Morte and acknowledged the foregoing instrument to be their free acts and deeds,before me. Notary Pd6lic My Commission Expires: ���Q TOWN OF BARNSTABLE LOCATION SEWAGE # 0 _ LP VII.LAGE � ��( . —� GLLV ASSESSOR'S MAP & LOT �© INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l rpp LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNS �J _ PERMTTDATE: COMPLIANCE DATE J b� Separation Distance etween the: Maximum Adjusted Groundwater Table to the Bottom of Leachin g 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) Furnished by Feet . .... i a y V ' TOWN OF BARNSTABLE LOCATION ���i� Q �Q Lu'. ( ./4/.. SEWAGE # -ZOOO — VILLAGE JII �ASSESSOR'S MAP & LOT 'D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITYfi�o LEACHING FACILITY: (type) (size) 13 oe qx 4 NO. OF BEDROOMS BUILDER OR OWNER �T PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by E 60 153 3n &A I V No.----_-----.-- - Fee---- .-------------- BOARD OF HEALTH TOWN OF BARNSTABLE ZppCicat ion fforVeri Con5truction30ermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (#*1an individual Well at: Location — Address Assessors Map and Parcel /� (� / Owner �+ Address (J A at"f'e f 1 Pv e .+fit u s 4� cAe.w C., c - — --- Installer — Driller ^— Address Type of Building Dwelling Na" Q Other - Type of Building-- ------ No. of Persons-- —_______—__ Type of Well 41 A� c Capacity -------------- Purpose of Well---Qt'k-V f,C. Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certific a of Compliance has been issued by the Board of Health. Signed — _— l d I6 oa — d to — Application Approved By ----- � da Application Disapproved for the following reasons: --------- --;----------- date Permit No. — Issued -_— ------- date BOARD OF HEALTH TOWN OF BARNSTABLE iCertificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired by— Q l�.�ea Installer at has been installed in accordance with the provisions of the Town of Barnstable Boar50--�a7td h P ' Well Protection Regulation as described in the application for Well Construction Permit No. -------THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--— Inspector---------- --- —_ —____ No.--=-------=---- r Fee------------------- �O 99 � BOARD OF HEALTH TOWN O`F BARNSTABLE IV P�r0 Ion,farVefr Con!5tructionPermit Application is hereby made fo'r a permit to Construct ( ), Alter ( ), or Repair.(Ian individual Well at: Location — Address Assessors Map and Parcel ----- - I Owner— ---_____---_------Address -"--- -____�--- �A �o. �� G� d C </ — _----------- ---- ------------—------- - - -——— — _— - — Installer — Driller Address Type of Building Dwelling -------- Other - Type of Building-------------- No. of Persons.----____--__ ------ Type of Well �t /)J C Capacity- Purpose of Well-mac-` Agreement: i The undersigned agrees to install the aforedesc�ribed individual well in accordance with the provisions of The Town-of-Barnstable-Board-of-�lealth Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certific to of Compliance-has_.been.issued by the Board of Health. �� / G/oo Signed d f- - - ----- r A ApplicationApproved By -------�---- ----'"` Application Disapproved for the following reasons: -------- --- -- date -- Permit No. -- Issued — ----- -- — ---- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (`�) uI Installer I at � � r[� 1., P1"` h has been installed in accordance with the provisions of the Town of Barnstable Board of Health P ')�a Well Protection n�i Regulation as described in the application for Well Construction Permit No.U)0k� a d---- --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE Ansp&tor ___-- x o° ` S L 1 I �fi BOARD OF HEALTH TOWN OF BARNSTABLE loeCC Construct ion permit Fee---yw -- Permission is hereby granted to Construct ( ), Alter ( ), or Repair ( '-'an Individual Well at: No. /'y6 GA t,� . 1/111i Street as shown on the application for a Well Construction Permit No.- — -- Dated A_111A,A /1 _--�_------------------- — Boa4, f Health DATE—' — I` Tyr No.. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application for ioizpaar *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. /5'5I,6 AT,!' �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel / _0 ! 06 Installer's Name,Address,and Tel.No. 49 /NITU6 Designer's Name,Address and Tel.No. !�J ogGT�ea0 614 020- Type of Building: Dwelling No.of Bedrooms t' Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /22O Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)A CM t X Z'�O QYZ0 -1 l�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of itl 5 of the vironme tal de and not to place the system in operation until a Certifi- cate of Compliance has been issue his BDI f Hea Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued r 1Vw Fee 30 THE COMMONWEAL-TH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION -TMWN OF BARNSTABLE., MASSACHUSETTS Yes 01ppYication for ;Digpoga[ *proem Congtructfon Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. /�C/6 Q7!1!d/' CMOwner's Name,Address and Tel.No. Assessor's Map/Parcel / / �6) O6— _ _ OG�3�5af5_ y� O 'Installer's Name,Address,and Tel.No. �� � dT/C Designer's Name,Address and Tel.No. ape of Building: Dwelling No.of Bedrooms 1, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) r .Other Fixtures Design.Flow gallons per day. Calculated daily flow gallons. Plan Date. Number of sheets Revision Date Title Size of Septic Tank .&22 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable), L Z5o ( Zi( aAl /,!�K Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of the 5 of the vironme al erode and not to place the system in operation until a Certifi- cate of Compliance has been issue 4 his r d f Hea ------ Signed Date Applicadon'Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ----------------------------------- ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS 6 Certificate of Compliance THIS IS TO CERT Y,that the On-site Sewage Disposal System Constructed( )Repaired (//Upgraded( ) Abandoned( )by /t / 77,4 at_TI�TQK RT ZEf(.W,/. 2A/ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.� 3 Cl dated Installer Designer The issuance o•thi permit hall not be construed as a guarantee that the system will function as designed �.V� i� �.J Date ., ( / Y� 1 Inspector N Iy i!` 1, a ` f\ --------------------------------- No. 2.ew v —31' l Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS 'wi!5po!5a[ *p! tem Construction Permit Permission is hereby granted to Construct( )Repair(Lej Upgrade( )Abandon( ) System located at 4wz as 4 4 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: by - � �✓ L� f U6i99 NOTICE: This Form Is Zo .BetUsed For the Repair Of Failed Septic Systems Only. CER=CATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, )di' A y — herebyce. that the au lication for din w '�Y P disposal or's construction permit sinned by.me dated concerning the property located at r�j��14 FA meets all of the followina criteria: Ir �• The failed system is tonne✓ed to a residential dwelling only. There are no commercial or business uses associated with the dweilins. l• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inca. 1• There are no wetlands within 100 fe`t of the proposed septic system �• There are no;private wells within 1f0 fee;of the proposed septic system There is no increase in flow and/or change in use proposed There are no variant= requested or needed. The bottom of the proposed leacaing faclity-will not be located less than five feet above the maximum adjusted undwater table elevation. (?adjust the Groundwater table using, the Frimpior method when applicable] If the S.A.S. will be located with '_f0 fee;of any vegetated wetlands. the bloom of the proposed leaching facility will not be located!ess than ,ourezn (1 Y) fey;above the mLcimum adjured Q*oundwater table e!evadon, Please complete the following: A) Top of Ground Surface =iciation(using,GIS information) B) G.W. Elevation -the N .,.-K ,'--i;h G.W. AdjuTcment . _ D[ E'RE`+CE B E-P�Vp -.' a,and 3 SIGNED : DATE. (Sketch proposed plan of s✓s oac:cl. q:4caith toidcr.:-t r r� mou( !� �o u Danlel J. Naznialc OfLhi♦,BLWf01!On/IC09 n0lCbOfO TO!lOG�DOCC! clot?C'(J�S+�.pDy 1mu I�Ya-nl.vm+n.Ai14 Q�LOIr O�.r drwa a�r�u`1,u`6 ,•�}• 1 rENERAL NOTES: eve• '' --�---i ' ....._•..� i r r�r°wcrca ro veuvr iao coGrmewre //��,�,� ��!a>•e ran rm. .r� •(y�12.NSr 2 rpOglGrnF i0 K)°rf MD ::-T'.•ST' �aa^^VV11 i wwuwre.0 oewnov�wc hTM ``44''"-�n m�xri ro�eersray.�am w m�srn m. _ q !:LnE-rn YfLIP!P NiU.4 M¢:J I AI I I STN0. 4}V°1 Q 7yyyyDINI 1 •,14L w�woo DENS/rO FI.1 azu ro,* r_�• LL— i II ! .,,ir-oF PgRGH I L—�w II I i FIR5T FLOOR I `l2.0—� � PLAN wa I PROPOSED R= OVATIONS FIRST FLOOR PLAN DAL A Hp¢T=_ResIDENCE u.•.ro' '996 MAIN 5 'HEST BApN5TA2L=,MA 0:660 ;f.-96-%N CIS-�999 03/]l/00 Q➢ we=nlaic �a or Dan;el .1. Neznlak u•cF.itec'xal seMces weatbOr� mpSeGGhVeBLte A aCMT3LTM&r GENERAL NOTES: �,conwcroa io vEvvr.ro ccD�mNAre ALL OrBHP6 M M r•gp M. r_ __________ CULT N SCAT ].COM�KiDR iD�Fl-ue _ LOpCYINiC••Ll C@CL111P1 YOdC Y111� OIrHt GvrlR TD 5r6urY NIY A9rA5 CQ ]-w rose I osrsn rD 5E savAa®09 r�rm. A 3.dr6t i0°3FLfY V EASiOIf wax 5TAQ1 w0 9�YYOrG NLL.9 AiP iD ROOF DECK ASTER PROOM ua sa aw rosi A lrulm c6eoe 5a yLTpx A-A i ' , ,i'i w0L91 LMl 9®9CBrt ' � AaeAs a Deumon a ' I; �wnnwl rrxAt s'-r• ITINO u _ ;� ar•x b-0• y M I I � 11viceMwl�lcAnon • < _ .j l.. i.I'Cr-r x PO T �aw.,n.u�c'e�i+M.M+ i�I' ---�. � -TI 0 •eAve sro9.ee �I I 4 y 3 S' I '� - — SECOND'LOOR -- `--- PLAN SECOND FLOOR PLAN CELLAAYCRrE R SIVENCE IH••I'-0 1596 MAN STCE°-i reST SARY5TAME.MA.0--666 1596-PLN OI'1-1999 oeavco PD .. y TOWN OF BARNSTABLE LOCATION AT, 612 SEWAGE # �T7� VILLAGE t.UL-S% ASSESSOR'S MAP & LOT Ll INSTALLER'S NAME&PHONE NO. SA7�i-� !�,21-2-' : SEPTIC TANK CAPACITY - LEACHNG FACELITY: (type) �` 610 iflOV2 L`p� (size) 13.x 3�, i-S—ic,YC NO. OF BEDROOMS BUILDER OR OWNER - PERMIT DATE: �( �) - Y 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 �t Pin kt G - - - TOWN OF BARNSTABLE C LOCATr`ON �� 0 61� SEWAGE # �_ VILLAGE (AZ , f, - ASSESSOR'S MAP & LOT 11 INSTALLER'S NAME&PHONE NO. A , qJQ-5T�f� SEPTIC TANK CAPACITY 15O LEACHING FACILITY: (type) , 0/6" ® 441170 S (size) L�ex 3� NO. OF BEDROOMS `BUILDER OR OWNER PERMIT DATE: r - Q Y 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 k i , l RALK i O'box e 3Soom, �6qcA CAI"&A5L-4 i No. Fee V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Miopoal *pgtem Construction permit Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) EJ Complete System ❑Individual Components Location Address or Lot No./ � Owner's Name,Address and Tel.No. Assessor's Map/Parcel / <°� � O�� e� .S Installer's Name,Address,and Tel.No. � � Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size gko hCAS&.ft. Garbage Grinder( ) Other Type of Building r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4,40 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. J. Description of Soil f—�, �O/�/�2 �-�.� .�'f� Ce—Acy /X WW Nature of Repairs or Alterations(Answer when appl' able) -7 ��� C.��C tom, o. G 11 " _ G Date last inspected: Agreement: The undersigned agrees to ensure the construc ' and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of T' of t E ronn Code and not to place the system in operation until a Certifi- cate of Compliance has been issued is ar H Q Signed Date G`� Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued /� y r Fee d _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: a Yes ;• PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ' rication for ig osial *pgtem Congtruction PC�ntit Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No., Owner's Name,Address and Tel.No. Assessor's Map/Parcel e"ftvu.�4 /q 7 — Installer's Name,Address,and Tel.No. � ! 'rfQ Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size .ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets t f 7 Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil -�. (Jf f/�') +-�.� Sli135 1.3 —7 V Nature of Repairs or Alterations(Answer when applicable) i N Date last inspected: r Agreement: The undersigned agrees to ensure the construc ' and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti of t n onm Code and not to place the system in operation until a Certifi- cate of Compliance has been issued is and H x, Signed - Date - t Application Approved b Date Application Disapproved for a following reasons Permit No. Date Issued ——————————— ———— ------- —————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( C.,,rUpgraded( ) Abandoned( )by at has been constructed in accordance with the provi oo�ns of Title 5 and the for Disposal System Construction Permit No. dated Installer KlY G046T"r Designer The issuance of this emit shall not be construed as a guarantee that the system will function as designed. Dater! 9� Inspector�V r- -!� --------------------- ------ No. Feet, THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Miopogal Opgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( ' Upgrade( )Abandon( ) System located at- ,(& 5-1 l yL-Sr LLA,QrY and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of thisRt. Date: ��' � Approved b r� 116199 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, 1!zYhereby certify that the application for disposal works construction permit signed by me dated concerning the property located at �. (� j" }�jy !� meets all of the following cntena: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. t • There are no wetlands within 100 feet of the proposed septic I system • There are no private wells within 150 feet of the proposed septic system Lu'6u- ON �► There is no increase in flow and/or change in use proposed • There are no variances requested or needed. �• The bottom of the proposed leaching facility will not be located less than five feet above the ma.dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the NUuX. High G.W. Adjustment . DIFFERENCE BETWEEN A and By J SIGNED : DATE: [Sketch proposed plaff�system on back]. q:health folder:cen ��. ' . � 4, �- � � � �,/y� ��-!` � ` i r '?i ��Po G�� �.�� ���S �� � ,�-` - — .. _. ¢ ' I fi ! VAr-TErzs - sEcol�t� t-L�orL. ">t-r>,�+ li�c'•- I'-�,.. 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