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3715 MAIN ST./RTE 6A(BARN.) - Health
3715 Mani Sfreet A 317 081 g c-S ' Town oI _8,at nstatb1c P# Department of Health,Safety,and Environmental Services �1HE Public Health Division Date L1, 367 Main Street,Hyannis MA 02601 RARNSTABLF- �'°rEaneo�" Date Scheduled u Time Fee:Pd. Soil Suitability Assessment for•Sewa e Disposal r �S•Performed By: l'}Z?'-� FN1^04N% v Witnessed By: k LOCATION.&GENERALINFORMATION '' Location Address ?� H ' 5�CRC &a, Owner's Name S-T p&TL^+- t< t L4e 1—"9T Address 311 S as�'' 5`r Assessor's Map/Parcel: -61-1 14D,,8 1 Engineer's Name NEW CONSTRUCTION REPAIR Telephone H So3 3W I( 1Q I Land Use :7 A"Z Slopes(%) SSurface Stories R�U Distances from: Open Water Body ft Possible Wet Area -ft Drinking Water Well ft Drainage Way ft Property Line /o ft Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) �tA Y Parent material(geologic) Depth to Bedrock Depth to Groundwater: Standing Water in Hole: `oe�J Weeping from Pit Face Estimaied Seasuaal High Groundwater .3 S ` .. DETERMINATION FOR;SEAS,0 L HIGH i�VATER T. BLE ... Method Used: r Depth Observed standing in obs.hole: /d. t in. Depth to soil mottles: in. Depth to weeping from side of obi.hole: in. Groundwater.Adjustment , ( ft. -tr Index Well#/41 _. Reading Date:./Z. Index Well level Z L_ Add factor_3. r Adj.Groundwater Level & Z ;PERCOLATION TEST' mate Timelj°_¢`� Observation Hole# Time at 9" Depth of Perc `7�i t Time at 6" U; Start Pre-soak Time @ 07- Time( '-6" End Pre-soak Rate Min./Inch LZ + b Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back j Copy: Applicant DEEP OBSERVATION HOLE LOG Hole # _ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency.° i 2/t v DEEP.OBSERVATION HOLE LOG Hole#: 2 ` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistent Gravel) /ZC' " C F�l S f 0 tt 64. .DEEP OBSERVATION HOLE LOG Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel DEEP OBSERVATION HOLE LOG Ivle#' Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. Consistency,%Gravel Flood Insurance Rate Map: Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material`?_ Certification I certify that on /t l¢ !-% (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis 1�vas performed by me consistent with —� the required training, a rtise and experience described in 310 CM 15.017. Signature Date, I - r. r \\ \ 155. 16 \\\ \\ 111 4 TREE 24' REE 'T EEi� \ SM. CORNER S\rEP \3 1 TP*2 TfoI \\ EL-104.02 \ \ (3 q-Box .. .... . .... 4 3 \ 1500 G4LLON I \ \ o FRONT l O \ N/ •:. � SEPTIC TANK I ROO - I \ \ m SEENOTE l.!. CESS DOLS W I \ \ \\ b in \\ OFFI 36 \ \ - LIVING � \ \ ROOM \ O \ BA IN \ +.101.3 PORCH _-_ \' \ X I rCNEN \ \\ 12' R E 3 APLF \ PLE \\ / i COIDH FND \ ' 1 \ \ EX1Sr1NG \ GARAGE \ I \ 01 \ I L 0 T l 42. 869+ S.F. { 12IV.03' N 87°24'40"W I0' 20 40 ' LOCUS MAP SCALE I"=2000' 1909 LO, ASSESSORS MAP 317 STATE HIGHWAY ,PARCEL 81 r ROU: E 6A I S 82' 192.16 MF{g9p'WIDE - 155.I6 94 '3700-. �. 4 o !�9 i t a ., � { . N vt S _ Co. QD 3 a il4 LETA L.FULGINITI V Z n E t ALBERT R. 1 BK.8216 PG.27, t c HIV LAMB Z LOT I )•E LCA5659A I to N 5 PL.BK.282 PG.28 .e.t<e S m — Y + exist. CB - I trD gar. ® v 2I .i 3 .�� N3°44'3!,'E a o0 45AC I O w S85°32'40"E P` III. 3 3• 'Q 40.00 I h , 'P.. N 87°24'40"N 121.03% i r o' ROMANIE C iASE. I Z N o o o� :p 3 BK.3101 P,i 339 _ o E U __DH t'I Q,M.x w w ' zin �___g n eatstinq dwa ling 1 n N 85°32'40 tV ° a' 40.00 >-� �T THIS PLAN CONFORMS WITH THE ,� , tyr t:, ?GULATIONS OF THE REGISTER Z 91,93 106.4 _ 52.99 SB I OH. . -- — — !' N 87624'30"W 19_8.3f S85°39 50"'N �r > REG.PROF.LAND SURVEYOR COUNTY OF BARNSTABLE l PL.BK.53 PG. 137 CL� i HEREBY CERTIFY_THAT THE PROPERTY LINES 0-1 ;. SHCWN ON THIS PLAN ,ARE THE LINES DIVIDING. I i - - EXISTING OWNERSHIPS, AND THE LINES OF 't_„ I I STREETS AND WAYS SHOWN ARE THOSE OF 1 •PU8_1C OR PRIVATE STREETS OR WAYS ALREADY ESTABLISHED,AND THAT NO NEW LINES FOR DIVISION OF EXISTING OWNERSHIP OR FOR NEW. EASEMENT PLAN . IN BARNSTABLE , MASS. WAYS ARE SHOWN. FO R JULY 7, 1995 REG..PROF. LAND SURVEYOR STANLEY E. AND FRANCES H. ST. PETER 4- JULY 7, 1995 O 40 80 120ve SCALE IN FEET 1"°40' cv•-rv, - t EDWARD E KELLEY �°00 REG. PROF LAND SURVEYOR CUMMAOU If). ►re �s0 BP•0981 9=018S 95-08-�9 • 2:4 3 404:32 SEPTIC SYSTEM EASEMENT iu AGREEMENT made-. this day of 1v , 1995 by and between m STANLEY E.. ST. PETER-and FRANCES H. ST. PETER, hereinafter referred to as "GRANTORS" and ROMANIE . CHASE, hereinafter referred to as "GRANTEE" f3 i. IN S?, � MAIS l of,,C e. I`��6- (/A G�G ro WHEREAS, the GRANTORS and GRANTEE are the owners of adjoining parcels of land with buildings thereon situated .in Barnstable, Barnstable County, Massachusetts as shown on a plan of land hereinafter referred to; and � . WHEREAS, the Septic System that services the buildings on the tu. land of. the GRANTEE is presently located on the land of the ! a GRANTORS; and WHEREAS, the .GRANTEE and GRANTORS now desire to formalize the location of that Septic System and show the location of that Septic System on .a plan; and it i WHEREAS, the GRANTORS have . caused a plan. to be prepared it showing the location of the Septic System. N� NOW, THEREFORE,.. it is agreed by and between the parties , hereafter that in consideration of the payment of $1. 00 from the w GRANTEE to .the GRANTORS•,. the: GRANTORS hereby grant and convey to CL the GRANTEE woman1.: An. easement to install, repair, maintain, alter and operate a Septic System .under the land of the GRANTORS within the confines of the "Sewage Easement" as shown on said- plan and as hereinafter described. z _ BP:ID981;9'0186 95 i I;,_`9 2:43 #LIB 17 2. The easement granted in this instrument shall be appurtenant to the dominate estate. 3. BY acceptance of this easement and the execution of this document, the :GRANTEE agrees that it shall be the GRANTEE responsibility to maintain. the' Septic System in gogdcondition. The GRANTEE shall also be responsible to maintain the surface area of the granted easement in such a condition that it blends with and is indistinguishable from the other land of the GRANTORS. The GRANTEE agrees that it shall be .kept as open lawn area . and be . maintained in the same condition as the remainder of the GRANTORS land. 4. The parties agree. that in. the event that it becomes necessary to excavate the land to repair or alter the Septic System, it shall. be the responsibility of the. GRANTEE to restore the land to its previous condition fully equal to that'. existing . before the land was. excavated. , I 5. The GRANTEE agrees that following' any repair or ._ c.onstruction . operations on the site, the land will be resurfaced and the contours made neat and in agreement with the remaining land of the GRANTORS. 6. The GRANTORS hereby reserve to themselves, their heirs, successors and assigns, the right to cross and recross over the . surface. Gf the sewage .,easement area. They reserve to themselves the' right to use that land as part of their lawn or garden butthey agree that they shall not place any .objects, of any kind, on the Surface of the sewage easement area. t I�f 7. The .ease ment : rights and. privile instrument shall cease ges granted under this and terminate if and is no longer necessa when the Septic System rY for the use and en on Lot 02. J°Yment 'of the buildings. 8 . # The easement:.rights and and if the pr1 li,. . . s shall` t'ermitate when house on Lot 02 becomes seaward septic _System is or when and- located or on if a new a Portion of Lot #2 in th place of existing. 'Septic System now located e area. . ., within.. the. granted easement , 9• The GRANTORS agree that this With * the land and grant of easement shall. run shall be binding on and shall benefit of the parties to this a re inure to the g ement, their respective heirs, successors and' .assgns. The .parties g a ree that the, sewage easement described as follows area is Beginning at a" point of land at a . ii side line between. the d lan of the Grantor and the Grantee• , I de rees thence ..North 85 t 1 32- minutes, 40 second a to s. West al distance of 40 ' by. .land of. the Grantor to a Po degrees r.ees P lnt, thence . North 4 . g 27 minutes, 20 seconds. East b Grantor 401Y other land .of the to. .a point;,.. thence .South 85 de fi1nutes, 4.0 seconds.East, grees., 32 y oth er land. of the' Grantor 40 to a point and the' side line 'betty een the. land . of Grantor and the Grantee; the thence South 4 de minutes, y land,2b seconds West b degrees 27 of the Grantee a to distance of 40 , to tal the point of be . . 3 BP ' t i it rl �',-_- 'ji- i .-i;�-3 This area, is more _ particul.arly,,shown on a plan of land entitled "Easement Plan .in. Barnstable, Mass. for Stanley r E.. and Frances H. St.. Peter; July 7, 1995 ' scale:. 1" _ 401_, Edward E. Kelley, Registered Professional Land Surveyor, Cummaquid, MA" and is shown on said - Plan as' . "Sewage. Easement" . Said . plan is to be recorded at the Barnstable County Registry. of Deeds. 13 CG 1 S'1 P CZ IN. WITNESS WHEREOF, we have set our hands and. seals this day of , 1995. yA ( . / Romanie Chase, now ]mown as Stanley IFI. St. Peter Romanie Abraham Frances H. St. Peter COMMONWEALTH OF MASSACHUSETTS Barnstable, ss: Date: 4 Then personally appeared before me.the above-named Stanley E St. Peter and Frances H. St. Peter, who separately acknowledged the foregoing to be their free act id;deed Nota Public ' My commission e pires:, ,at STATE OF MASSACHUSE7fS ... County of Barnstable Dater a S * Then personally appeared before me the above-named'Romanie Chase, who acknowledged the foregoing to be her free act and deed. *now known. as Romanie . i sham. Nota Public _ " My commission q�; ires: ���� T -W- 60 LQC QT 1.0-N- N.C.�E---PERMIT--U 0 ,/-1 L-L p G►E �-AL5i D�►TE_-P E-R-NA1T-I 5 SU E D '-- I D AT_E-C.OIL/-RL-1-h,�1-CE--1-SSlI-E-D-:--==3� -� -- J l .20 37 TOWN OF BARNSTABLE LOCATION 37 S AAC.,a S+ TLf- SEWAGE#90 13 - VILLAGE�ctlN�fG�'�' ASSESSOR'S MAP&PARCEL '10-1 INSTALLER'S NAME&PHONE NO.�O\) as A �► sc,v:rs Z�vc SoR--'f9-0-YS3'f SEPTIC TANK CAPACITY /SOQ N Cu) LEACHING FACILITY(type) 14 1 Itra Q�f �q 05 (size) 3900 o-S S�r oa L,P C rfs y Rows Ok b . - NO.OF BEDROOMS y OWNER PERMIT DATE: - - I3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Jr 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 BYcI �vc`�g lei�c�.►:s� i,.�e 1 o j- � 1 0 U'Y--.2S'3'' .D 37' 3 g ' Li - Gl' No. Q ' / Fee U V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS es Rppl LAtion for Vsposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(V<Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 37/5 Ma'5 ;e}G,A Owner's Name,Address,and Tel.No. 3�raSFc b�t� TCA4A)-5' O-j Assessor's Map/Parcel 3/-7/oRl Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. `t7c ieg A FaFen,�.) 7 N,, 5i-r p A 5- 15. Type of Building: Dwelling No.of Bedrooms 'I Lot Size 4 z r 60!! sq.ft. Garbage Grinder( ) Other Type of Building to e3,/S No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) q qO gpd Design flow provided i to gpd Plan Date b]ab i 12- Number of sheets Revision Date Title Size of Septic Tank 1 S(�)Q Type of S.A.S. j A,' t I cf&fc7f 3'L Description of Soil Nature of Repairs or Alterations(Answer when applicable) j N}-c t 1i I-Vj 1 y t(e 5 Scy 1-14n 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. Sign Date 7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. o Date Issued Ag //'' / No. f 1 f � u _ _ y III . Fee U 0 t z � • THE COMM01�1LEALTHgOF MASSACHUSETTS Entered in computer: t es PUBLIC HEALTH DIVISION -TOWWOF BARNSTABLE, MASSACHUSETTS 2pplication for Disposal *, pstrm Construction Permit Application for a Permit to Construct Repair w<up grade( Abandon Complete System El Individual Components Location Address or Lot No. 31/5 Mo rj )2}GA Owner's Name,Address,and Tel.No. ,�- 3otpSFab r jC7 Assessor's Map/Parcel 3 /?. ©p3 1 V1�J�a©tV : Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size h 2 foGj sq.ft. Garbage Grinder( ) Other Type of Building V\o og No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) PJ H 0 - gpd Design flow provided H10$ Igpd Plan Date f31 se)I I'Z- i Number of sheets Revision Date Title Size of Septic Tank 1 s©® Type of S.A.S. l to t l t lo/ QvtcIC ld VAIYS 32- - Description of Soil i 1 Nature of Repairs or Alterations(Answer when applicable) 1 or k c.t 1 Ai P w —1 'k! #/C i 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. Sign 1d f�/ .— Date /, n Application Approved by o� Yl Date Application Disapproved by Date for the following reasons Permit No. C) > 's Date Issued / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of (Compliance 'THIS IS TO CERTIFY that the On=site Sewage Disposal system Constructed Repaired Upgraded > g P Y ( ) P l' ) ( ) Abandoned( )by ,J 1 C4 C at 3 7).2� A.t L;-ry" G+ .12+ A1 r has been constructed in 1accordance with the provisions of Title 5 and th_e for Disposal System Construction Permit No.?"/ '! dated / Installer ''' �.,31,_� A l�rn..I,.1TtrC' Designer esi.r A N uc'�, #bedrooms L/ a Approved design flow gpd The issuance of this permit sha ot&cons ed as a guarantee that the system wil function as designed.(14r Date — �� ®� Inspectors ti No. U j —.2kb Fee 161d THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon System located at 3'7/-S AA, ,,3 5.r ?T 5 4 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 b completed within three years of the Idate of this permit. bu/. Date / Approved-by- tL S : ToWn of Barnstable FINE tn.- a • . G Regulatory Services Thomas F. Geiler, Director * BARNMBLE • - 9 '""9•s639• Public Health Division �0 .. , ATED""p�A Thomas McKean,Director 200.Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form z Date: Sewage Permit# 90 j 3 v Assessor's Map\Parcel 3 f 1 C>e° Desig ner: A l-W S Installer: � N.._. � Address: q2 3 C P& Address: y�d.41C�iC ) i. t On g-(/ � , was issued a permit to install a (date) (installer) septic system at-3-7 I i tJ S 1 `Z �A based-on a design drawn by (address) . f dated 3fl 26 I z- iz-C__0(sL� �� 1 2 u 1� ` (designer) 11 ,. o/ I certifythat the septic system rue . p y m of renced above was installed substantially according to • ' the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component , of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. staller's Signature) esigner's Signature) (Affix Ddsign.erls Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF. COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH. THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. ' THANK YOU. Q:\Septic\Designer Certification Form k6vised.doc 044532 are?-31—`013 a 08 ® 25d Notice of Alternative Sewage Disposal System M.G.L. c. 21A, § 13 and 31.0 CMR 15.0287(10) This Notice to be recorded and/or filed for registration in the chain of title of the Property served by an Alternative ewage Disposal System("Alternative System").] NAME(S) OF OWNER OF PROPERTY SERVED BY ALTERNATIVE SYSTEM: ADDRESS OF PROPERTY SERVED BY ALTERNATIVE.SYSTEM: Z>71 C AA.C""o I TZ r G A 13c rtig k"�c9 TITLE REFERENCE FOR PROPERTY SERVED BY ALTERNATIVE SYSTEMS [check and complete each that applies]: Deed recorded with the J;-_-;eW'e Registry of Deeds in Book Page Certificate of Title No. issued by the Land Registration Office of the Registry District _Source of title other than by deed [If Alternative System Owners) is other than Property.Owne(s), complete the following:]. Alternative System Owner Name: 1 r,)rA A A.C_ Alternative System Owner Address: --�,-T1 G..& a rtJSkc,TpT WHEREAS, Section 15.280 of Title 5 of the State Environmental Code("Approval of Alternative Systems"), provides for the Massachusetts Department of Environmental Protection (the "Department") to approve or certify, as appropriate, all proposals to construct,upgrade or replace on-site sewage disposal systems using alternative systems; WHEREAS, owners and/or operators of approved or certified alternative systems are subject to general conditions, as specified in Section 15.287 of Title 5 of the State Environmental Code, 310 CNa 15.287, and may be subject to special conditions, as specified in the Department's approvals or certifications; such general and special conditions potentially including, without limitation, requirements relating to the use of trained operators, periodic inspections,.maintenance, sampling, reporting and/or recordkeeping; WHEREAS, Section 15.287(10) of Title 5 of the State Environmental Code, 310 CNa 15.287(i 0), requires that"prior to obtaining a Certif cate of Compliance for installation of a new or upgraded system, the system owner shall record in the chain of title for the property served by the alternative system in the Registry of Deeds and/or Land Registration Office, as applicable, a Notice disclosing both the existence of the alternative on-site system and the Department's approval of the system. The system owner shall also provide evidence of such recording to the local Approving Authority [;]" and WI=REAS, the Property is served by an alternative sewage disposal system. NOW, THEREFORE, Notice of an alternative sewage disposal system is hereby given for the above-referenced Property, as follows: 1. Existence. An alternative system has been installed as a new or upgraded alternative sewage disposal system, on or adjacent to the Property, and serves the Property. The trade name and model number(s) of the alternative system are as follows: i , Trade name of technology: (Lo ilk,. y Manufacturer Name: SWc,, I Model number(s): Lk 'fib$)s t'/ Page 1 of 2 I 2. ApprovaUCertification. OnJoN4 3,aOt3 [date], the Department, pursuant to its authority under the section of Title 5 as specified below, approved or certified the technology used in the above- referenced alternative system; under MassDEP Transmittal Number.X a 8n'12- [Transmittal Number of approval or certification]. [Check one of the following, as appiicable:] Approved for remedial use under 310 CMR 15.284 Approved for piloting under 310 CMR 15.285 Provisionally approved under 310 CMR 15.286 Certified for general use under 310 CMR 15.288 A copy of the Department's Approval/Certification is available from the Department in person or on- line at the Department's website: http://www.mass.gov/de-c . WITNESS the execution hereof under seal this ,? �h day of T 1y 20L_3_, made by the above-named Alternative System 0wner(s) [Alternative System QWner(s)] 2 Print Name(s): f 4 COMMONWEALTH OF MASSACHUSETTS I ssy \'ou�uaaa;@�aW On this 2G day of j 20 (4 before me, the undersigned notary pub, cW) appeared ,,, trX an%t ", (name of ument signer proved to me through s i"s cto a •`�N�� evidence of identification, which were to be do the person whom signed on the preceding or attached.document, ac o e d t e that(he) (sue) sib . �t Cy, . :at- voluntarily for its stated purpose. =. y'•.•Z co ZAA (offs ial signature and al of notary) ++na++uR�ii��``� ---------------------------- -- -- . .�M ----------------------- ---------------- [Complete the following Property Owner(s) Consent if Alternative System Owners)is other than the Property Owner(s): CONSENTED TO: [F operty O ner(s)j t N e(s): d� D COMMONWEALTH OF MASSACHUSETTS � ss On this 2G+_�ay of 1��. 201`3, before me, the undersigned notary public,personally,,:�,,,,,,s appeared Qw'i{s\ R) (name of doc mgnt signer), proved to me through satisfactory f,•*``'\` LY ``''��;'� I evidence of identification, which were to be the person whose name is�� signed on the preceding or attached document, an acknow g o e that (he) (she) signed it voluntarily for its stated purpose. Lai ;o s a(Are 0 of notary) '�• R ••''•0� '� Upon recording, re to: ',y °••....• S�":�°° ice#i [Name and address of Property Owner(s)] '�f�,„`"•r���eA�``!��\`'t �r Page 2 of 2 SMSTWE REGISTRY OF DSWI S� p � �� o �^�� Sta;iddrd Conditions for Alternative Soil Absorption Systems Page 8 of 15 General Use and Remedial Use Approvals Revised Date: June 6,2013 16. Any System structures with exterior piping connections located within 12 inches of or lower than the Estimated Seasonal High Groundwater elevation shall have the connections made watertight with neoprene seals or.equivalent. 17. In compliance with 310 CMR 15.240(13), a minimum of one (1) inspection port shall be provided within the SAS consisting of a perforated four inch pipe placed vertically down to the elevation of the SAS interface with the underlying unsaturated pervious soils to enable monitoring for ponding. The pipe shall be capped with a screw type cap and accessible to within three inches of finish grade. (A locking cap at-grade is preferred) Facilities with multiple SAS's shall have an inspection port in each. 18. Upon submission of an application for a Disposal System Construction Permit (DSCP), the Designer shall provide to the Local Approving Authority: a) proof that the Designer has satisfactorily completed any required training by the Company for the design and installation of the Technology; b) certification of the design by the Company for any residential system with a design of 2,000 gpd or more or for any proposed non-residential system or if required by the Special Conditions for an approved Technology; c) certification by the Designer that the design conforms to the Approval, any Company Design Guidance, and 310 CMR 15.000; and --d) a certification, signed by the Owner of record for the property to be served by the Technology, stating that the property Owner: i. has'been provided a copy of the Title 5 I/A technology Approval, the Owner's Manual, and the Operation and Maintenance Manual, and the Owner agrees to comply with all terms and conditions; ii. for Systems installed under a Remedial Use Approval, the owner agrees to fulfill his responsibilities to provide a Deed Notice as required by 310 CMR 15.287(10) and the Approval; iii. for Systems installed under a Remedial Use Approval, the owner agrees to fulfill his responsibilities to provide written,notification of the Approval to any new Owner, as required by 310 CMR 15.287(5); . iv. if the design does not provide for the use of garbage grinders, the restriction is understood and accepted; and v. whether or not covered by a warranty, the System Owner understands the requirement to repair, replace, modify or take any other action as required by the Department or the LAA, if the Department or the LAA determines the System to be failing to protect public health and safety and the environment, as defined in 310 CMR 15.303. 19. The System Owner and the Designer shall not submit to the LAA a DSCP application for the use of a Technology under this Approval if the Approval has been revised, reissued, suspended, or revoked by the Department prior to the date of application. The Approval continues in effect until the Department revises, reissues, suspends, or revokes the Approval. THE t � Barnstable o� Town of Barnstable .: Nfti lcacito . antuvstn�t.r;. t � � r ;q. Board of Health t6 �0 a '°rFn-max° 200 Main Street,Hyannis MA 02601 2007 Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,D.M.D. Junichi Sawayanagi November 26, 2012. Ms. Jeni A. Landers Wynn & Wynn, P.C. 300 Barnstable Road Hyannis, MA 02601 RE ° St Peter Family Trust/3715 Mam Street;Barnstable, Iv1A r ` s_ t y Dear Ms..Landers, You are granted a six month extension qon behalf of your client,the St. Peter Family Trust, to repair or replace the failed onsite sewage disposal system components.located.at 3715 Main Street, Barnstable, MA. This extension is granted until March 31, 2013 with the following conditions: • The premises shall remain vacant until such time the septic system is repaired or replaced. The septic system was deemed"failed" on May 4, 2012 during an'inspection conducted by Mark ' Polselli. The cesspool was."structurally unsourid"according to the report. The,owner was ordered to replace the failed.septic system within sixty days. However according to your letter, -the property is unoccupied and will remain unoccupied until it is sold. The Trust has no assets, other than this property, and,no financial resources to complete the repair at this,time. Once the property is sold, you indicated arrangements will be made to bring the system into compliance: ' The extension is granted because the Board is of the opinion that there is little to no risk to anyone at this time, due to the fact that the property is unoccupied: Sincerel yours; Wayne Mi r, M.D., Chairman BOAV HEALTH - Q:1 WPFILES\ExtensionStPeterFamilyTrustMainStreetbamstable2012.doc • AT TO RNE_YS • 300 Bamstable Road Hyannis,MA 02601 (508) 775-3665 June 19, 2012 Fax(508) 775-1244 1 (800)899.3003 http://www.w,ymnwynn.com Town of Barnstable Jeni A.Landers Board of Health Jeffrey L.Madison 200 Main Street Richard A.Martone Kevin P.McRoy** Hyannis' MA 02601 Seth D.Miller*** Robert F.Mills Charles D.Mulcahy John J.O'Day,Jr. RE: St. Peter Family Trust Kevin J. T.Panebianco 3715 Main Street, arns Btable> MA AnthonyAntho Raymond C.Pelote* Thomas E.Pontes Michael J. het Ryan E.Propophett y To Whom It May Concern: Rebecca C.Richardson Janice E.Robbins William Rosa* Dina M.Swanson Please be advised that this office represents the St. Peter Family Trust, owner Andrew A.Toldo of the property located at 3715 Main St., Barnstable, MA. The property has recently Paul F Wynn Thomas J.Wynn been listed for sale and as part of that process, an inspection of the septic system was completed. Of Counsel Hon.Robert L.Steadman(Ret.) Hon.James F.McGillen,11(Ret.) . We received-your notice by mail,today stating that-the system failed and must Keough&Sweeney William E.O'Keefe be repaired or replaced within 60 days from the date of your letter. Edward F.O'Brien,Jr. I am writing to formally request a six-month extension after the 60 day period Admitted: for this repair. The property is unoccupied and will remain unoccupied until it is sold *Massachusetts and Rhode Island at which time, of course, arrangements will be made for the system to be brought into **Massachusetts and New Hampshire ***Massachusetts and Connecticut compliance in order for the sale to take place. The Trust which owns this property has no assets other than t property'.-"-and no financial resources to complete the repair at this time. The repair QI either be completed with proceeds from the sale or by the new owner, but in either case,the trust requires additional time as a buyer is sought. Because the property is unoccupied and the system is not in use,Ithere is n'o 41 risk or haza y - time and the Trust respectfully requests that this ,Q Board ant a 6 month tensfoA after the 60 day pexiod'has run. Affiliate Office: Raynham 90 New State Highway•Raynham,MA 02767 • (508)823.4567 Please contact my office with any questions or concerns or if any other documentation is needed. Very truly yours, WYNN & WYNN, P.C. Jeni A. Landers AL:alu I i Town of Barnstable Regulatory Services 9 ' ABM MAss Thomas F. Geiler, Director qj s639. �m f Ma+" Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 5/2/11 Mr. Stanley St Peter Barnstable, MA. 02630 Dear Mr. St Peter, I responded to a complaint on 4/25/11 about an open sewer cover at your property. I would like you to call me to discuss this. My office hours are 8 — 9:30 AM and 3:30 4:30 PM. Thank you, D ald Desmarais RS Health Inspector Town of Barnstable 508-862-4740 QAOrder letters\Septic\339 Pitchers Way.doc r Town of Barnstable Barnstable �pF tHf� P� 1°, BOARD OF HEALTH m"a�y nA MASS..LE,1• 200 Main Street Hyannis MA 02601 - 9 MASS., � - � ,1 �Al039 A�0 2007 Fb MAt ' Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 Paul Canniff,'D.M. Junichi Sawauanagi CERTIFIED MAIL# 7011 0470 0001 4525 7154 June 6,2012 St. Peter Trust 3715 Main Street Barnstable,MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 • The septic system located 3715 Main Street,Barnstaple,MA was last inspected on 5/4!2012, by Mark Poselli, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of the 1995 TITLE 5(310 CMR 15.00) DUE TO THE FOLLOWING: • The cesspool is structurally unsound. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system with the deadline period will result in future enforcement action , PER ORDER OF THE OARD OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health . Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\Regulatory Authority.doc _ 4 a Commonwealth of Massachusetts f:= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is /��v//¢ va`-70 required for every 61e--/h s� page. City/Town State Zip Code Date of I pedio 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 v key to move your 1• Inspector l cursor- notuse CA key.the return - �/q Name of Inspector Company Name Company Address Citylrown State p Zi Code --1 o Telepho Number License Number -r ,,_ B. Certification z M 1 certify that I have personally inspected the sewage disposal system at this address and that the• information reported below is true, accurate and complete as of the time of the inspection. The inspection, was performed based on my training and experience in the proper function and mainteiiance of on�site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000). The system.- ❑ Passes ❑ Conditionally Passes Failsr ed urther Evaluation by the Local Approving Authority Ins�0, Signature Date Thy tern in 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 now 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. Isms•1 f/10 Tif1e 5 Official Inspection Forth:Subsurface a Dis posal sposalSystem•Page t of 17 .<� Commonwealth of Massachusetts =` -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' YC4� ✓ /� ��� ✓, Property Address S-4 Owner Owner's Name 1 information is G/h S T,41,E required for every page. Citylrown State Zip Code Date of inspecti n B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/ahvays complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: i 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): 15ins•11110 'title 5 Official Inspection Form:Subsurface Sevrage Disposal Systom-Page 2 of 11, Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name l information is G �j�` �a 4 �C required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipes) 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 belowj: 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 +h: 15ins•11/10 Title 5 Qlficial Inspection Form:Subsurface Sewage Disposal`System•Page 3 of 17 r • I Commonwealth of Massachusetts E= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form —NNot for Voluntary Assessments / C1 I ✓7 Property Address Owner Owner's Name ST- information is _ required for every G� �l e / Doi G,�To / page. City/Town State Zip Code Date of I pe on B. Certification (coot.) 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 DE 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: a. You!us Icate"Yes" or"No" to each of the following for all inspectlons:, Yes No a/ S41-(,f GT fit/ U 41 SU 14 ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ❑/ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•11/10 Ttle 5 OfricW Inspection Form:Subsurface e ,Sevrag Disposal System•Page of 17 Commonwealth of Massachusetts Title 5 official Inspection Form l - Subsurface Sewage Disposal System Form- Not for Voluntary Assessments F Property Address l Owner Owners Name information is �', required for every ) page. Citylrown State Zip Code Date of I p c on E3. 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. ❑ L3' 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 collfonn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, p vided that no other failure criteria are triggered.A copy-of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. . Yes No ❑ ❑ the system is within 400feet of a surface drinking water supply ❑ . ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I5ins•11I10 - rifle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 ' Commonwealth of Massachusetts i - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form �- Not for Voluntary Assessments Property Address Owner Owner's Name U information is 1 / required for every G✓✓1 j l G �t il,, Uo� (,�Q J / //pt 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 ❑ ;Z�HWas ere any of the system components pumped out in the previous two weeks? 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 his inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ L�' Was the facility or dwelling inspected for signs of sewage back.up? . Was the site inspected for signs of break out? ❑ ere all system components, excluding the SAS, located on site? Cpss 'on �S ❑ 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, ensions, 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 jbeen determined based on: ❑ (2� 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 de'si ` Number of b _ ( 9n) - bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#ofbedrooms); 15ins•1 V 70 • Palle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 - { r Commonwealth of Massachusetts =-. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address �� ,p , Owner .J / C. Owner's Name information is L „ /� required for every G -✓?S 1 G l f, aot(�3� / page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: y Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? El Yesa No Seasonal use? ❑ Yes U-N—o_ — Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ ,No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Sins•17/10 - Ttle 5 Official Inspection Form:Subsurface a• _Seweg Disposal System•Page 7 0(17 - Commonwealth of Massachusetts r`ST Title 5 Official Inspection Form Subsurface Se wa a Disposal System Form-Not for Voluntary Assessments } Property Address Owner Owners Name A)"information isryG✓ l y � required for eve i // page. Cityffown State Zip Code Date of Inspedion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: /V 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: ❑ Se ank, 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): 15ins•11110 Title 5 Official Inspedion Form:Subsurface Sev age Disposal System•Page 8 of 17 Commonwealth of Massachusetts -: Title 5 Official Inspection Form lY =_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments hT ( ��� j ���G/ ✓I S� j Property Address Owner Owner's Name information is required for every page. Cltyfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all component s, ate installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes o Building Sewer(locate on site plan): Depth below grade: feet Material of i construction: ast iron �PV they(ex I in) "Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: i5ins•11/10 - Title 5 Official Inspeclion Foim:Subsurface sevrage oisposal system 7Page 9 of 17 Commonwealth of Massachusetts -_ Title 5 Official Inspection Fora - !.: _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address _ Owner Ownefs Name information is G/ S /� 9 v�6�D / required for every / ��r page. City[Town State Zip Code Date of In ection D. System Information (cont.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑polyethylene 0 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•11/10 - ritle 5 Official Inspection Forth:Subsurface Sevrage Disposal System•Page 10 or 17 Commonwealth of Massachusetts m=-=- Title 5 Official Inspection Form b ` -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address _ r � - P �Own l� e Owner's Name information is /N j�a OP C .3o required for every_ T � '// page. City/Town State Zip Code Date of rlsp lion 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 15ins-11/10 - - y Ttle 5 Official Inspection Form:Subsurface Sevrage Disposal System-Page 11 of 17, - Commonwealth of Massachusetts Title a Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is Oo required for every G/✓►•f�� �22 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ISins•11/10 - Title 5 Official Inspection Foim:Subsurface Sevmge Disposal System•Page 1201 17 Commonwealth of Massachusetts � i`- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is 6� d 5 T required for every � '�l page. CityRown State Zip Code Date of In'spectfort D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. Cl innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): �SS o G — ► B 4 �t c' UC 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 7Ei1015ins•.11110 - Ttkf 5 Official Inspedion Form:Subsul System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of I pecti In 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.): (Sins•11/10 _ The 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts � _- Title 5 Official Inspection i=orrn _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - �91r '-WG h S',L Property Address 'P f� Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 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 p lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately -114 c , l lid 15ins•11/10 Title 5 Official inspection Form:Subsurface Sevmge Disposal system-page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments rv7 ST-- Property Address Owner Owner's Name / information is �-� lO v 30 SAC required for every 'c[C page. Citylrown State Zip Code Date of Inspection D. System Information (coot.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ bserved site(abutting property/observation hole within 150 feet of SAS) Checked witbjgccal Board of Health- plain ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: G 0 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 - Title 5 Official Inspection form:Subsurface SevQge Disposal System•Page 16 of 17 Commonwealth of Massachusetts, Title 5 official Inspection Form t. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 22 \ Property Address Owner Owner's Name ) �` information is J�403 a /�� [/d 6 u /�' required for every J 7 1 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 Eg"System Information-Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file (Sins•11l10 - Title 5 Official Inspection Form:Subsurface Savage Disposal System•Page 17 or 17 ACCESS COVERS MUST BE WITHIN INSPECTION 9" MINIMUM. INVERT ELEVATIONS : DESIGN CR I TER I A : GENERAL NOTES : 6' OF FINISH GRADE PORT 3. MAXIMUM COVER FIRST 2' TO INVERT AT BUILDING: l0/.3 DESIGN FLOW: BE LEVEL INVERT IN SEPTIC TANK: 100.55 4 BEDROOMS AT 1/0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION INVERT OUT SEPTIC TANK: 100.33 BEDROOM EQUALS 440 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY. 4- D/AM P PE CLEAN SAND BACKFILL INVERT IN DIST. BOX: 100•22 NO GARBAGE GRINDER 2• VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS 101.3 100.3 /00.0 3.3' AND 2" OVER CHAMBERS INVERT OUT DIST. BOX: I00.05SET. SEE 5!TE PLAN. 100.55 * 6A$ 100.22 �u 99,98 9-AROUND INVERT IN LEACH CHAMBER: 99.98 BAFFLE SEPTIC TANK REQUIRED: 6 OUTLET 32 INF/TRATOR QUICK 4 PLUS BOTTOM QE LEACH CHAMBER: 99.7"mull 440 G.P.D. X 2QOx - 880 GAL. J. ALL CONSTRUCT/ON METHODS AND MATERIALS AND STANDARD LP CHAMBERS IN BED FORMATION ADJUSTED GROUND WATER: 94.7 l500 GAL D-BOX � SEPTIC TANK PROVIDED: 1500 GAL, MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL OBSERVED GROUND WATER: 90.8 CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6` CRUSHED STONE OR BOTTOM OF TEST HOLE #I; 89.8 BOARD OF HEALTH REGULATIONS. GQMPACTED BASE � SOIL ABSORPTION SYSTEM REQUIRED: ADJUSTED INDEX WELL A I W 247. ZONE B DES I GN PERC RATE r 5 M/N/I NCH PROF i LE : NETT To SCALE = GROUNDWATER. EL-94.7 JULY 2012 READING-24.56 '. ADJ-3.9• SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFLUENT LOADING RATE - 0.74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER MEMO 440 GPD / 0.74 GPD/SF - 595 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- GROUNDWATER. 4-90.8 STANDING H-20 WHEEL LOADS. PROVIDED: 32 INFILTRATOR QUICK 4 PLUS UP/3/I89 STANDARD LP CHAMBERS. 128•x 4.73 SF/FT 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 605 S.F. x 0.74 - 448 GPD APPROVED EQUAL. 'ROJ ,�+ n 6. SEPTIC TANK AND D-80X SHALL BE REINFORCED '"' L�, SO I L TES T R I T DA TA & PRECAST CONCRETE OR APPROVED POLYETHYLENE. �j pm !NDICATES _� INDICATES BOTH SHALL BE WATERTIGHT, D-BOX SHALL BE WATER M PERCOLATION -- OBSERVED TESTED FOR LEVEL WHEN THERE IS MORE THAN ONE j 199 TEST GROUNDWATER OUTLET. ` \ S 82°51 - l ,�.I s Tp #I P#!37/9 TP #2 \ \ � 40 f 100.2 7. BEFORE CONSTRUCTION CALL 'D l G-SAFE`. 55• !6" l-888-DIG-SAFE AND THE LOCAL WATER DEPT. ____,__ 0« H0R l ZON TEXTURE COLOR 99 8 0. HOR J ZON TEXTURE COLOR 99.8 i j FOR LOCATION OF UNDERGROUND UTILITIES. 24-TREE A LOAMY IOYR A LOAMY IOYR u SAND 2/2 SAND 2/2 24 REE T EE;. - "" - 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE 20)- REE f 22--- - - - - - - - - - - - - - - - - - - - - - 98.0 20" - - - - - - - - - - - - - - - - - - - - 98. 1 � BM CORE rP:z R o- RE E / LOAMY IOYR LOAMY IOYR DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION \ ,�� B B OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE EL /04.02 S IL RfMOYA ,�„ SAND 6/4 SAND 6/4 \ - \ \ t r:':•� • 5• tIL ` 36" - - - - - - - - - - - - - - - - - - - - 96.8 40" - - - - - - - - - - - - - - - - - - - - 96.5 CONSTRUCTION INSPECTIONS. � \ q sox �.:: -.� . :;::• sfk NOTE Iv. +'io !o MED/UM IOYR MEDIUM IOYR\ t C 9. EXISTING CESSPOOLS TO BE PUMPED DRY, REMOVED SAND fi/fi SAND 6/6 Too. j 48• IN THE AREA OF THE NEW SYSTEM AND BACKFILLED \ _ t f 32 INFILTRATOR OMICK 4 \ 0 :1 : / \ \ ' �-• aw PLUS STAWARD LP iCHAMSERS W I TH SAND. ` \ FRONT :::.�:: I500 GALLON i \\ \ ROOK/ SEPTIC YANK l . . \ w \ SEEti PTE P . t cEssTboocs + /0. ALL UNSUITABLE MATERIAL !A 3 B HORIZONS) � ENCOUNTERED BELOW THE INVERT OF THE L EACH/NG `\ p \\ OFFICr 136 A t i� , t2 TN7 FACILITY TO BE REMOVED FOR A DISTANCE OF 5' 10 " 90.8 /08" 90.8 AROUND AND REPLACED_W l TH SAND IN ACCORDANCE RooU WITH TlrLES. \� \ BATH \ , a / l 0 .6 \\ \ a PORCH --� ;o/.3 120' 89.8 i 24' 89.8 /I. SEWER L l NE TO BE SLEEVED /D FEET FROM WATER ` _ LINE WITH A LARGER DIAMETER PIPE. ` s DATE: AUGUST 20. 2012 TEST BY. STEPHEN HAAS APL`6 �\ l2 R E 12. ALL SEWER LINES ARE TO BE VERIFIED. EXISTING 1 o y- - - - \ J / WITNESSED BY: DONAL D DESMARA/S 1 NVER TS MA Y NEED TO BE RA I$ED TO MEET THE r/ PERC RATE: ! 2 MIN/INCH NrR\ PROPOSED INVERT ELEVATION AT THE DWELLING. SEWER OUTLET AND CESSPOOL FOR THE KITCHEN-AND SHOWER ARE UNKNOWN AND MUST BE LOCATED. PUMP \LE \ " AND FILL CESSPOOL. REROUTE SEWER LINE TO THE PROPOSED SEPTIC TANK. B Locus w �3 o � C8/0H FND \ t 14 S E- P T C SYSTEM DES I CN exisriNG GARAGE t 371 S MA / N STREET . MAP 3 1 7 , PARCEL 08 1 ----- '� L OCUS MA P BARNS TABL E7 . MA . 8A PREPARE© FOR : L EGEMD L O T I T ' P E7 T E7 R )= A M / L Y T R US T BEDROOM 42. 869+ S.F. °R° ■ GB CONCRETE BOUND ---W ,WATER LINE SCAL E 1 .. 20 AUGUST 30 . 2012 4 HYDRANT REVISED: AUGUST / . 2013 G GAS L I NE /� HA /� SECOND FLOOR PLAN OHW- OVER HEAD WIRES S T E P H E N A . H A A S -0 LIGHT POST ---E- UNDERGROUND ELECTRIC LINE ENGINEERING , I N C 121"03' -T- UNDERGROUND TELEPHONE l NE 923 Route 6 A N 87024'40"W `} -- -� Yca rmou t h p o r t MA . 02675 CTV- UNDERGROUND CABLEV l S l ON LINE` „-`•° � r• •�T I � �-`� +40.4 SPOT ELEVATION �-�` �//� ���' ( 508 ) 362--8 1 32 ..--40------- EXISTING CONTOU . ( 5 0 8 ) 3 6 7-- 1 6 9 1 0 10 20 40 4D PROPOSED CONTOOR" t JOB NO: 12- 125 i