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0204 CINDERELLA TERRACE - Health
4 Gin ere Terrace"'" Marstonns Mills 10 TOWN OF BARNSTABLE �1Cy LOCATION R,&C/ Cd n We f/4 SEWAGE#O?O i q s �d VILLAGE /t?asf+►,7s M,-I/S ASSESSOR'S MAP&PARCEL 0 Q INSTALLER'S NAME&PHONE NO. S"hh IylAepA T t- 15-v o 6 S SEPTIC TANK CAPACITY Co-1-it cT Sr o?'o� L i yz n r t%, LEACHING FACILITY: (type) G��°S 'To r iC s i sT sJ)SzP7Pc%Graff NO.OF BEDROOMS 1 OWNER h d/lea . C �► PERMIT DATE: 1I17 1 Cf 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 V ID�N ' "�/]e'" i L7 Gk",L 3 �3' le. ®CNN I TOWN OF BARNSTABLE q i LOCATION ROB{ &.v�/A T-r: SEWAGE#o�O�q- �a 1 VILLAGE Mft*ns M.'y/S ASSESSOR'S MAP&PARCEL (D Y 7-- //O INSTALLER'S NAME&PHONE NO. Sn M MarV-i T a '3y 6 -t4v m b b 13 SEPTIC TANK CAPACITY C 4 ol^r cT Sr oTc f'i tiz �- LEACHING FACILITY:(type) G o,-°5 Z To elf s i l�s�ri�T�� NO.OF BEDROOMS OWNER A h dr e M o to wic 4 PERMIT DATE: /I/7 /cf COMPLIANCE DATE: Separation Distance Between the: Maximum Ad,usted 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 V 0 I 6 1 � 3 D �. I' No. "Id ( C7 Ccfyl _ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application or Disposal *pstpm ConstCUttion Permit Application for a Permit to Construct( Repair( ) Upgrade( ) Abandon( ) ❑Complete System dividual Components Location Address or Lot No. a. r`fc4y4t� w�er''s Name,Address,and Tel.No. Assessor's Map/Parcel AA , ri'l r l(1 /)fD C��, h Ct./�!1'1Q .Q V!� Installer's Name,Address,and Tel.No.OC,ALID,0 U14 Designer's Name,Address,and Tel.No. John M&,rwr1 ® r Type of Building: .— Dwelling No.of Bedrooms �L�LoJ 3 d t Size sq.ft. Garbage Grinder 00) Other Type of Building GO.r 0 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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 'a'p-f licable) l C o n n r G l_ S-eya N E Linz r%o P" A�W _50.- O 'Cxs�sJ �hQ J'C(✓�r� '77G v Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Boak ofliealth. n Si Date AS a Application Approved by Date_?A, Application Disapproved by Date for the following reasons Permit No. �� -Y� Date Issued a rw'•r'•1'�rr"�JF�'�.'�,T'.F�tn...1]F:<It•�5.•°y"yrl���°(A!^"r�TY{ 'L1L�'..m rFY+«'(!ti.Y•..` wrJ+TSw aw+�:y"{T'i3`1iN`i�"T'F ..�{,, Pr+, .,k � _ to :W'.. � .�: �„� , {".'�'1�•� ,R�tJ`F' t'7/Vyr�„iT/S�f'lRa�'"rj� t} :.}. dy C7✓��/JVr � �R°1 J No. n�'� Fee. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:✓� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpphcation for Misposar *pstem Construction Vermit i Application for a Permit to Construct(-')/Repair( ) Upgrade( ) Abandon( ) ❑Complete System 0,I4-dii,idual Components Location Address or Lot No.01.0 44 Ci(1 4 ft 116% `I rr�C` wner's Name,Address,and Tel:No. I Assessor's Map/Parcel A • ✓h r (f f, toil d l4A- /n µ� 0 V i C-!1 Installer's Name,Address,and Tel.No.SUSS, ALJO,6(04 Designer's Name,Address,and Tel.No. n 1 CA.Y* n - -� � © r Type of Building: Dwelling No.of Bedrooms ! 'f Lot Size sq.ft. Garbage Grinder(+t 0) k Other Type of Building GO r G No.,of Persons Showers( ) CafeteriaCj ( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) /J✓�(11'C� S�e �t�' + ' r. � `"� n r w Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system m d` a accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of M Compliance has been;issued by this Boa d of ealth. w , Sig a Date Application Approved by ! Date Application Disapproved by v d Date r- for the following reasons Permit No. �"" /�`/ Date Issued c THE COMMONWEALTH OF MASSACHUSETTS V f BARNSTABLE,MASSACHUSETTS e �s�� 5 A .` Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned.( )by h - '�h. at has been constructed in accordance with the provisions oUfitle 5 and the for Disposal"System Construction Permit No. 2 P/6!' Y.Wed 1/ / N4 L S p Installer -� jV�G r7 j n: Designer r4,4 age.,' ��� #bedrooms 3 age., Approved design" flow d gpd r • The issuance of this pe it shall not be construed as a guarantee that the system will ifu�t`g a'designed. Date o2 1 0 Inspector t 1 ---------------- No. d SO Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS 33tsposal *pstrm Construction 3permit Permission is hereby granted to Construct`( Repair( ) Upgrade( ) Abandon System located at f Al ' Kr and.as described in the'above Applicat6'for Disposal System Construction Permit. The applicant recognized his/hertduty to comply:with Title 5 and the following local pro,tsions or special conditions. ;. AarT..f' Provided:Construction must be completed within three years of,the date of this permit. f Date /l 7 I >Y Approved by. ��� ' 1 No. d Fed / 6_0 0 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION o TOWN OF BARNSTABLE, MASSACHUSETTS 21pplicatlon for Disposal *pStem Construction permit Application for a Permit to Construct(Repair( ) Upgrade( ) Abandon( ) ❑Complete System ®drrdividual Components Location Address or Lot No. o,of/ 1AXLe/Li!�-:t✓L} Owner's Name,Address,and Tel.No. op Assessor's Map/Parcel — / '2 A Fi LDU/Ch Installer' N e Address and Tel.No. Designer's Name Address,and Tel.No. C [ W14P SC f n�►4 l.t��= Type of Building: DwellingNo.of Bedrooms r;3 —�� � i e sq.ft. Garbage Grinder W�0 Other Type of Building Ds-q 1r_A% L— No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) `IA f iU 1(%0 F )C2CeX e!:�,A.aA Jt57T Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si .-- --___._ .. . _ Date rr ry � za Application Approved by Date Application Disapproved by Date for the following reasons Permit No. r v( l '/ Date Issued 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS fh�� certificate of ComplianceTHIS IS O CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by r at C ujxo has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �c Y� 1 dated Installer Tt. } �. O ufl W ! Designer /� A #bedrooms Approved design flow�3 y i gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector _ f No. i 1 Fee d - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Disposal 6pstem Construction J)Prmit Application for a Permit to Construct V/ Repair( ) Upgrade( ) Abandon( ) ❑Complete System �tlividual Components Location Address or Lot No. �ph( � i�dE� L Owner's Name,Address,and Tel.No. Assessor's Map/Parcel _ sC�iLPK C Installer's Name,Address,and Tel.No. Designer's Name,A dress,and Tel.No. 1Z 42"r- �ij. c, j 2 5 GE tl 7'?GG-7 T7 L, !� 1 05 Type of Building: Dwelling No.of Bedrooms ? `� p� ,r'!VoSir sq.ft. Garbage Grinder(AO Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) - C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. SiglLed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued I -- '' - - - - - - ------------ - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE MASSACHUSETTS Certificate of Compliance � k HIS ISO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by at ` o L1 i has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit`No. °��"�, dated Installer"k "�,fn,+ -1�, rZ, ( 0 ,?sa e Designer #bedrooms _ Approved design flow T=y gpd The issuance of this permit shall,.ho be construed as a guarantee that the system will function as designed. Date Inspector ----------------------- ------ ------------------------ ----- ------------------------------------------------------------------ - No. G I I/ Fee o THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct(4,,� Repair( ) Upgrade( ) Abandon( ) System located at „ C/ r ,/„," /� �. _ , \and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided Construction m st be completed within three years of the date of this permit. Date ( Approved by t r Barns.ante tslclr.Kept � 180.00, S 35 44 22 W Leach Pit ® i�j Shed � / /septic A- I Tank _Y J 2 DECK O O 1 15' EXISTING HOUSE Setback 67.33' 3 Bedrooms 1 S 67 DO 34 E 125.00' N631437W a 1 — t1 Offset .FI I 1 i 1 e t -----30'Setback.------ P Off el R 66.59' b A 86.54' 123.10' N 38 3'I 40 E CINDERELLA TERRACE PLOT PLAN SCALE:1" =20' DERIVED FROM A SITE PLAN from j GARAGE-2602 Chris Ellis-3D Computer Home Design j ALL CAPE SEPTIC,LLC. 618 ROUTE 28, A—1 Plot Plan Andrei Yarmolovieh 276 Route 28,West Dennis,MA 02670 i. SOUTH YARMOUTH,MA02673 i 508-771-4200 204 Cinderella Terrace Marstons MA phone:774 212 6625 longpondl@mac.com >N0.!JWVICH,Mbai-Porrit-13.09.3919.CF ) _ Mills, „_ ..........:__ .___.__— _::-.........-_ LOCATION a'�� SEWAGE PERMIT NO'. T -4-- 11 C-,,Z&d&f LL4 r,&EWAc VILLAGE I N S T A LLER'S NAME i ADDRESS E. ,6,4,z/L,.5r��� R UILDE R 0 OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED Z tL � zi l �4 o� d� :�r Y _ .. ...... Fmc 14� ......... ............... THECOMMONWEALTH F ETYS BOARD OF HEALT 1 .n............OF..... .'n. ..........t"...�............................• Appliratinn for Uhipasal Workii Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ( t or Repair ( ) an Individual Sewage Disposal System at: �f a................................. ..... ... ..... i ..........gin .....Ni.��... ... o anon-Ad o Lo No. ...... ............... m:►. ............... f►!'.n .�1<-.. .................. Owner dd es� ...................................... Installer Address p c).Q d Type of Building Size Lot j..................Sq. feet U Dwelling—No. of Bedrooms.............3.__..........................Expansion Attic ( ) Garbage Grinder (J�,)6 pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ga Other fixtures -------------------------------• . W Design Flow......�v ............................gallons per person per day. Total daily flow......33.d........................gallons. WSeptic Tank—Liquid capacitvk00o..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area............:.....__sq. ft. Seepage Pit No---------------------- Diameter.................... Depth below*nl _..._....,.. .... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing t ( ) CC �v V `'' Percolation Test Results Performed bY___________ ____.........._..__...... ----••-•--=.__................... Date.... __J.` ......... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M --------------- ........................ ----•-...... ................ ... Description of Soil..... . / .........:....� ----------------------------------- ....... --�---------- ----------------------------. . . ----- ---.........----------------•--- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------••••-••----•-•--•-•--•--••••---•-•----•-----••-......._.........•-•-.....••-•-----•--•--•••-•--•---•-•-•-----•-•-•-_...._..••--•-•....-••••-•....-------•.•-•--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ed....._ to Application Approved By..... �'-c`'........... .. ....10 ._/ _...__ . I Date Application Disapproved e f ollowing reasons:----•...........................................................................................-•••-•-••••--_... ..........................................•-----.....-------------------------------•---.....---•--...------........------------•----------•--------------•---......----------------.............._..... Date PermitNo....................................................... Issued-....................................................... Date .. �,D. JA. �,l.. Fps...,... THE COMMONWEALTH OF MASSACHUSETTS / '�� BOARD OF HEALT `� ............................................................. Appliratiun for Biipuiittl arks Tonstrurtion Prrutit Application is hereby made for a Permit to Construct ( vYor Repair ( ) an Individual Sewage Disposal System at '� % I ...��\ S o at .7-a-W...4�� ....................... ................. .......... ion--Add ess a � 1 ddCe ss .Owner` � -•• .._... 5 .............. Installer Address 0 UType of Building �� Size Lot�_r...................Sq. feet Dwelling—No. of Bedrooms.............--_...........................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------------ ""-----------------------. W Design Flow.......�.U............................gallons per person per day. Total daily flow-----3 ly. Septic Tank—Liquid ca acitNk ...gallons Length................ Width................ Diameter................ �..�.�.- gallons. Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No---------------------- Diameter.................... Depth below inl Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) V G J _ C Percolation Test Results Performed by.......................... ..............___........ .......-......... Date...��.�._l _ .�....�... aTest 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........................ ------- - ---------------------------- C A . -• ....................................---•-•---•-•--•--------.........-- O Description of Soil.....0-` ......-��CJIM-------`C---. "' — JJ - -•-----------------•--------- U ------------------------------------ --.__6..-----Me..c- .......C.(t c:......S.an 6..... .....•CMO.1.0"N�-----......----••------...-----.....---- UW ----------------------------------- ------- .......... ----------------•----------•----•-----------------------........-------••-•------•-• Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------•-------------------------------------------------------...............-----•--•-------------------------•-----•-----------•---------•--•--...................•--...--...... Agreement: The undersigned agrees to install the aforede'scribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Application Approved BY ' : = :...........................••---•---•---•--...................... {� ...ff../ at - APplication Disapprove or a following reasons-------------------------•--•----...-•-------•-----•-•---------•------------...-•---------- •-••••••---..... .........................••--------------••-------•----------•••-•.........----------................-•••........-••---•••--•--------------------------------------------••--------------•---•-...._..... Date PermitNo......................................................... Issued-........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ... .�.. ..........OF..........� �1�6 .5. .. ............... .............. Trrtif iratr of Toutphatt r TIJIS IS TO CERTIFY, T. the Individual Sewage Disposal System constructed (44 or Repaired ( ) by - .---........-Vk ..-•--•--•........................•............. --. ------ InstaWe at.- ` '- -n- ..,........-.G-.....................�_____----..........................:.......'`.........------••. has been installed in accordance with the provisions of TITLE�55jf Mate Sanitary Code j s, g the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU ® AS A GUARANTEE THAT THE SYSTEM WI F NCTION SATISFACTORY. DATE../ ll..�.V.................................................... Inspector-- ......---•-•----•-•--------------------......---....----.•.....-----••-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHL f� / G \.L! OF.............. c' ... `�� '�.5�.............. L( No. .......-i1 ., .�f FEE........................ orku �un�trurtion rrutit Permission is hereby granted......v. -� �".... _.__ ........................................................................ Construct (✓) or Repair ( ) an Individual Sewag Disposal S gem at No........ ..........�S�............�-�!.n.C .-----am- ---- r ) b-•------ f M Street as shown on the application for Disposal Works Construction Permit No.._:iM.. ....... t....................................... ..............••.............•. -- ..............-------------------••--------••-•------.............. /�/ �3 Board of Health DATE-----------------•--- -----•-................................................... FORM 1255 A. M. SULKIN. INC.. BOSTON Log Number: 3162 Date: 10/28/83 sAR� BARNSTABLE COUNTY HEALTH DEPARTMENT SUPERIOR COURT HOUSE BARNSTABLE, MASSACHUSETTS 02630 o • A$ PHONE: 362.2511 DRINKING WATER LABORATORY ANALYSIS EXT. 331 . f t - Client: James K. Smith Collector: Fred Clifford Mailing Address: Rte. '132 Affiliation: C1 i fford WP1 1 nri 11 i ng Hyannis, MA 02601 Time& Date of Collection:• " 10/27183, 8*00 a_m_ Telephone: Type of Supply: we11 water Sample Location: T-o 19 Ci nd r 1 1 n Terrace Date of Analysis: 10/27/83 Marstons Mills Parameter Sample Result Recommended Limits Coliform bacteria (organisms/100 ml) 0 0 pH 5.7 Conductivity micromhos/cm 56. • 500.0 Iron (ppm) .12 0.3 Nitrate-Nitrogen (ppm) v.04 10.0 xx Water sample meets the recommended limits of all above tested parameters. Water sample is drinkable but has higher than average levels of This does not:represent a health hazard but future, monitoring is recommended (2-3 times per year). We will test for Sodium. Water sample is drinkable but may present aesthetic problems to users (staining, odor or taste). Water sample is of poor quality and is not recommended for human consumption. Resampling and retesting is suggested. c Results only. REMARKS: e Barnstabl Board of Health cc: ` cc: Clifford Well Drilling Analyst: 11/18/81 Nil Ilk Explanation of Test Results' Total Coliform Bacteria Coliform bacteria are an indicator of the sanitary quality of a water supply. Water supplies may become contaminated from malfunctioning septic systems, cesspools and surface runoff. A total coliform count of zero indicates that.your water supply is safe and approved for human consumption. A total coliform count of greater , than zero is most often the result of accidental contamination of the sample bottle through improper.sampling methods. For this reason,;it would be advisable to retest any well water that is not approved. pH pH is the measure of acidity or alkalinity of the water. On the pH scale, the number 7 is neutral, less than 7 is acidic and"more than 7 is alkaline. The pH of water on Cape Cod tends to be acidic in the range of 5.O to 6.5 Conductivity Conductivity is a measure of the dissolved salts in solution. Amounts in excess of.500 micromhos/cm are generally considered unacceptable and may have a laxative effect upon users. Iron The presence of iron in water in concentration of .3 ppm or greater may: give the water a bittersweet astringent taste, cause an unpleasant odor,.often gives the water a brownish color and cause staining of laundry and porcelain. The average concentration of iron in Cape Cod's water is .2 - .6 ppm. Although the presence of iron in water,.may cause the problems listed above, it is not considered deleterious to health. Iron may be removed by use of an iron removal system. Nitrate-nitrogen The Massachusetts Drinking Water Regulations have set a maximum contaminant level for nitrates at.,10 ppm. Excessive concentrations may cause methemoglobinemia (an infant disease) and have been suggested to form potentially carcinogenic nitrosamines. Contamination sources include fertilizers, cesspools and industrial wastes. Coppe f Due to the acidic nature of the water on Cape Cod, copper tends to leach from pipes. This normally does not present a health hazard; however, concentrations in excess of 1.0 ppm may cause a metallic taste and/or a bluish green stain on porcelain fixtures. Sodium - A concentration of sodium over 20 ppm.is only of concern to people who are on a low sodium diet. If the water supply has more than 20 ppm sodium, it is up to the people who are on such a diet to find another source of drinking water or contact their doctor to determine if.consuming the water is advisable. Concentrations . exceeding 50 ppm indicate that there may be ocean water or road salt runoff water getting into the well. \`ti 5'�►161Z7= •:FA/AIL-Y No �G'AQ-5AGE 6QAwt>EIz I� o�a►t_Y'F►.o; / -z 110 x II 5EPT%G TA►.1K = 330x150,V. =,495G.P. o 05C- %000 GAL. I0l',5Po5At_ P►'r u5E � 5.t= x .2.5 37 5 G.P© 0 'i 50TTOM AREA S.F. Q( I 50 s.� x t• o �o GPO. . . aAlo , 9 II -ToTA..I- II -TOTAL. DA I►-Y FL-0W - 330,6?t:> I Pap-COt_AT►ON GZATEt 1"IN ZMIN II /,• �"/ �O �% S.T. j+ `H OF)W s 4�, Ash' -r�i �•i II \�N OF A4As�, ALAN RiCHARD �„� 10NES A. { BAXTER V 251 Na 24048 G, T , �Q18T4�`�� ! Al i /Gi4/e I vN ,eF�1ot!E��L cos ,� _ �E•6c�v� S /rA3G� �"S f'ir �PEpt�C6' lt✓/c FAG'/f3"P.G.Gc►A/G.. - Z f-Si�f�79 � o oZ, d T O p FNt7 Z"Ty - Y,,, INV. 98.Z 1-0AA1,f loco tN1j- SUS 0uX ° IN�. Gee.SEPT►L / t000 tNY, 9T 6 TANK 7z ca s� LE AC u 9 PIT INV. INV. S ' IT p7 Q � ! J7G w u f� G wm-mr.D Cam-- 6Tvµ� Jz G.E2TIFtl=o PL.o-T Pt_A.W yo k/ar. PRUPi�>� � B7 Z L O G Q,-r'I o N /YfA2.STat/S /t'�/LL S NO 5GP.LE-. �jG_ ALa � ': t�/D DATE: 9//183 "�, .• . .. .c P L. t,4 R E F:SIZE W GE 1 LE:RttFY THAT 'f 1+f-- wN F{6,t2Eo N GOMFL%_ 5 VATN-THE S l o�t_IN E A►�G> SETeAcy. R.r.QuIQ6MEN'1'!5' oF -TµE- 7 TOWN O F I3 e.Q t�15-rA8t-E q nt v ►S IJ d'T' .�.C.C .3G 3D/ � L_OGp.T .WtTN11J TN'6 G1..OdD PL.A.tt� t VAT E --��`� a W`(E INC. K•.E615'T>r26V'I•.At1 C 5 u i�N EYof�S � Tu15 PL&KI t5 Ntrr 'BN561=) o►d AIJ OSTE2VILl.JE - N1i'``�5• IN•5T?-uMENT Sue'vey -THE ot=F.SET5 SuauLJ> NOT DE uSEDTo C�'t_TE'�/^1►�E L.oT -It-tE.�j i4PPLIGA►-IT A Doc:- 1r382r 199 11--01-2019 _lIZ49 BARNSTABLE LAND COURT REGISTRY DEED RESTRICTION WHEREAS, Andrei Yarmalovich and Anastasia Gleason, Husband and Wife, Tenants by the Entirety, of 204 Cinderella Terrace, Marstons Mills, Massachusetts 02648 are the owners of 204 Cinderella Terrace, Marstons Mills, (Barnstable County) Massachusetts 02648 (hereinafter referred to as "the Property") and being described as followshNo.arnstab County 363011 C (Sheet2)gistry with of Deeds Land Court Divisions as Lot 18 on Land Court Plan Certificate of Title No. 205853 and recorded as Document No. 1,265,974. WHEREAS,Andrei Yarmalovich and Anastasia Gleason,as the owners of said lot has agreed with the Town of Barnstable Board of Health to a restrictions as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environment Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environment Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction 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, Andrei Yarmalovich and Anastasia Gleason, do hereby place the following restriction this above referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 204 Cinderella Terrace, Marstons Mills, (Barnstable County), Massachusetts 02648 may have constructed upon the lot a house containing no more than three (3)bedrooms. Andrei Yarmalovich and Anastasia Gleason agrees that this shall be a permanent deed restriction affecting the Property located on 204 Cinderella Terrace, Marstons Mills, (Barnstable County),Massachusetts 02648 and recorded with the Barnstable County Registry of Deeds Land Court Divisions as Lot 18 on Land Court Plan No. 36301-C (Sheet 2)with Certificate of Title No. 205853. For title see Deed recorded with the Barnstable County Registry of Deeds Land Court Division with Certificate of Title No. 205853 and recorded as Document No. 1,265,974. Property Location: 204 Cinderella Terrace, Massachusetts 02648 N WITNESS my hand and seal this�_day of �C , 2019. And ei Yarm o is COMMONWEALTH OF MASSACHUSETTS Barnstable County, ss: On this 5 I2'day of [)CA-0 6za-,— ,2019,before me,the undersigned notary public, personally appeared Andrei Yarmalovich, proved to me through satisfactory evidence of identification, which were 1 j C-RaQ, , to be the persons whose names are signed on the preceding document, and acknowledged to me that he signed it voluntarily for its stated purpose. Notary Public My Commission Expires: !Z' Joanne C. Bresnan tr I Notary Public J(COMMONWEALTH OF MASSACHUSETTS My Commission Expires April 27,2023 t . 6 nns . K s r. 3 f � i r 0 i ' = �y �A-7 �� Commonwealth of Massachusetts R. Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills MA 02648 1-1-15 page. Cityrrown 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, use only the tab 1. Inspector: I key to move your cursor-do not Darrell Stone use the return Name of Inspector key. Cape Cod Septic Inspection Company Name P.O. Box 1466 Company Address fen Harwich MA 02645 Cityrrown State Zip Code 508-240-2500 S14995 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM .000).The system: ® Pa es ❑ ditionally Passes ❑ Fails ❑ N ds u her Ev ation by th r 1-2-15 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. I' �- IF t5ins-3/13 Title 5 Official Inspectio o : ub....Se ge Dis sal System-Page 1 of 17 .L Commonwealth of Massachusetts Title 5 Official Inspection Form - t: Subsurface Sewage Disposal System Form- Not for Voluntary Assessments t - w„ 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills, MA 02648 1-1-15 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) Y System Passes: ® 1 have not,found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 R Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is MArston Mills MA 02648 1-1-15 required for every page. Ci crown 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 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owners Name information is required for every MArston Mills, MA 02648 1-1-15 page. Citylrown 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 El ® 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•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M s 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kennewa Owner Owner's Name information is required for every MArston Mills, MA 02648 1-1-15 page. City/Town 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- 10jMgpd: ❑ ® 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 11 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 J 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills, MA 02648 1-1-15 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? 0 ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System_ (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills MA 02648 1-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 Bedroom residential dwelling 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts ° Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is MArston Mills, MA 02648 1-1-15 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: Pumped 2013 per Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 r Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owners Name information is required for every MArston Mills, MA 02648 1-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983 Per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 15 +/ feet Material of construction: ❑ cast iron ❑40 PVC ® other(explain): SCH 20 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): r_ Apparent good condition Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon Sludge depth: 4" t5ins-3/13 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 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills, MA 02648 1-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 1/2" 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 16" 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.): Normal liquid level No sign of leakage SCH 40 outlet tee Recommended next maintenance pumping within 2 years Recommended maintenance pumping every 2-3 years Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene y El 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 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills, MA 02648 1-1-15 page. Cityrrown 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 1 x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills MA 02648 1-1-15 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 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.): Grade to box 14" Good condition 1 Outlet Normal liquid level No sign of leakage No scum No sign of failure 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Y Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,N 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kennewa Owner Owners Name information isequiredorev every MArston Mills, MA 02648 1-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: El leaching trenches number, length: ❑ leaching fields number, dimensions.- El 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.): 1 (6x6') pit with 1'stone Grade to pit 24" Bottom 105" Ponding 38" Staining @ 3" higher No sign of hydraulic failure 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 L Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is MArston Mills required for every MA 02648 1-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction.- 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 M 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills MA 02648 1-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately r ` t I � t I 6 A B 2t- 23-10 2 26- 6 27- 3 3G- to b 5- 5 4 6 t5ins-3/13 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 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owners Name information is required for every MArston Mills MA 02648 1-1-15 page. CityrFown 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: >4 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: 1983 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Elevations from the design plan Bottom of SAS ELV. 91.2 Bottom of Test hole ELV. 87.2 NWE Separation >4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts _ Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 204 Cinderella Terrace Marston Mills, MA Property Address Joseph Kenneway Owner Owner's Name information is required for every MArston Mills MA 02648 1-1-15 page. Cityfrown 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 t t5ins•3/13 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System-Page 17 of 17 t Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form -Not For Voluntary Assessments _71 Subsurface Sewage Disposal System Form f =o; Part A t= Certification Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 L Owners Name:Jeff Keefe Owners Address:204 Cinderella Terrace Marstons Mills Ma.02648 Date of Inspection:9/21/2005 Name of Inspector(please print)Sean M.Jones Company Name: S.M.Jones Title V Septic Inspectors Mailing Address: 74 Beldan Ln. Centerville Ma.02632 Telephone Number:508-7784597 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CNM 15.000).The system: X Passes Conditionally Passes Needs further evaluation by the Local Approving Authority Fails Inspectors Signature Date: �otG jCUS 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. Notes and Comments: System is in excellent working condition at time of inspection. ****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. Page 1 I __ y . t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:Jeff Keefe Date of Inspection:9/21/2005 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B.System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please Explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally Unsound,exhibits substantial infiltration or exfiltration or the 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 structurally sound,not leaking and if a Certificate of Compliance Indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(S).The system will Pass inspection if(with approval of the Board of Health): broken Pe i (s)are replaced P obstruction is removed ND explain: . t OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:Jeff Keefe Date of Inspection:9/21/2005 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 310CMR 15.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform Bacteria and volatile organic compounds indicates that the well is free from pollution from that.facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other Failure criteria are triggered.A copy of the analysis must be attached to this form. 3.Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:Jeff Keefe Date of Inspection:9/21/2005 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface - water supply. X_ Any portion of cesspool or privy is within Zone 1 of a public well. ^_X_ Any portion of cesspool or privy is within 50 feet of a private water supply well. X_ Any portion of 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pp,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] X_ (Yes/No)The system fails.I have determined that one or more of the above 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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: 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 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 CM15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:-Jeff Keefe- hate of Inspection: 9/21/2005 Check if the following have been-done.You-must indicate"yes"or"no"as-to-each-of the following_ Yes No X _ Pumping information was-provided-by the owner-,occupant-,or Board-of Health X_ Were any of system-components-pumped-out in-the previous-two-weeks? _X _ Has-the system-received normal-flows-in-the previous-two week period? X_ _ Were as-built-plans-of the system-obtained-and-examined?(If they were not available note a&N/A)- _X _ Was-the facility or dwelling-inspected for signs-of sewage back up? _X_ _ Was-the site inspected-for-signs-of break out? X _ Were all system components,excluding SAS;located on site? _X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bares-or tee,material-of construction;dimensions;depth- of liquid;depth-of sludge and depth of scum? _X _ 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: Yes No- _X_ _ Existing information.For example,a plan-at the Board of Health. _X_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance- Is-unacceptable)[310-CM -15:302(3)(b)3 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:-Jeff Keefe Rate of Inspection-. 9/21/2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-3— Number of bedrooms(actual):_3_ DESIGN flow based on-310 CMR 15.203-(for example): 11-0 gpd x#o€bedrooms): 330- Number of current residents: 1 Does-residence have a garbage grinder-(yes-or-no)_NO Is laundry on a separate sewage system(yes or no): NO_[if yes separate report required] Laundry system inspected-(yes or no):—N/A Seasonal use:(yes or no) NO Water-meter-readings,if available(last 2 years usage(gpd)- 2003=25gpd/2004=30gpd/l"6-months 2005=28gpd Sump pump(yes or no): NO Last date of occupancy/use:_CURRENT COMMERCIAL/INDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design-flow(seats/persons/sgft-etc.): Grease trap present(yes or no): Industrial-waste holding tank present(yes-or no)- Non-sanitary waste discharged to the Title 5 system(yes or no): Water-meter-readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping records- Source of information: 2002 / OWNER Was system pumped as part of the inspection(yes-or no). NO- If yes,volume pumped: gallons--How was this quantity pumped determined? Reason-for-pumping: TYPE OF SYSTEM _I�_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-the system-owner-)- Tight tank Attach a copy of the DEP approval Other(describe),- Approximate age of all components,date installed(if known)and source of information: 1983 Were sewerage odors-detected when arriving at the site(yes-or no)_NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)- Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:Jeff Keefe- Date of Inspection:9/21/2005 BUILDING SEWER(locate on site plan)- Depth below grade:_32" Materials of construction-: cast iron_X_44 PVC other-(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): Building sewer-is in good condition no siyns of leakage. SEPTIC TANK: X_(locate on site plan) Depth below grade: 8" Material of construction:_X_concrete—metal—fiberglass__polyethylene other(explain) If tank is metal-list age: Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1000 GALLONS- Sludge depth: 10" Distance from top-of sludge to bottom-of outlet tee or baffle: 2 Scum thickness: 1" 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: 1246 How were dimensions determined: opened cover and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to,outlet invert,evidence of leakage,etc.): Inlet and outlet baffles intact,tank was structurally sound,liquid at correct level.No signs of water infiltration or exfiltration. GREASE TRAP:_N/A_(locate.on site plan) Depth-below grade: Material of construction: concrete metal fiberglasspolyethylene other-(explain) Dimensions: Scum thickness-: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels- As related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:204 Cinderella Terrace Marston Mills Ma.02648 Owner:Jeff Keefe Date of Inspection: 9/21/2005 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglasspolyethylene other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_X_(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.): 9 Box was level no signs of solids carryover box was not leaking. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes-or no)- Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:Jeff Keefe Date of Inspection: 9/21/2005 SOIL ABSORPTION SYSTEI%I(SAS):_X_(locate on site plan,excavation not required) If SAS not located explain why: Type _X_Leaching pits.Number:- 1-Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Soil was dry,no ponding around SAS no sign of hydraulic failure vegetation was normal.Leach pit had 4'6"of available leaching at time of inspection. CESSPOOLS: N/A (cesspools must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A_(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.): �I II OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:204 Cinderella Terrace Marstons Mills Ma.02648 Owner:Jeff Keefe Date of Inspection:9/21/2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 40'+/-from bottom of S.A.S.. Please indicate(check)methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: 9/1/1983 Observed site(abutting property/observation hole within 150 feet of SAS) X 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: Groundwater was determined by checking design plan on file at Town of Barnstable Board of Health,also by looking at Town of Barnstable Groundwater Contour Map online. I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:204 Cinderella Terrace Marstons Mills Ma.02649 Owner:Jeff Keefe Date of Inspection: 9/21/2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building BACK OF HOUSE r � I A g TANK 0 A-1=21'6" B-1=23'6" 0 D-BOX A-2=36'6" 8-2=59'6" S.A.S. A-3=48' �2 C-3=70'6" 3 _ w �w : i _ 9 t l i � •� W ' d . ' q