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0193 PALOMINO DRIVE - Health
193 Palomino Drive 297-049 Barnstable ,e i I i f ............ .... . i k } i I `II II I i _ � 1 Commonwealth of Massachusetts- . Title 5 Official Inspection Form IM Subsurface Sewage Disposal System Form :Not for Voluntary Assessments M 193 Palomino Dr. Property Address William Russell Owner Owner's Name information is + required for every Barnstable Ma 02630 3/11/201.4 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector:. key to move your cursor-do not Sean M. Jones, VVV I use the return Name of Inspector key. S.M.Jones Title V Septic Inspection, ITV Company Name 74 Beldan Ln. ` Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com SI4522 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 tq Pection,§.340 of Title 5(310 CMR 15.000).The system: : ' b ® Passes ❑ Conditionally Passes ❑ (Fails o ❑ Needs Further Evaluation by the Local Approving Authority 3/11/2014 Inspector's Signature bate' in 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` I at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. jjq,j t t5ins•3/13 7 Title 5 Officia'"o. bsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 193 Palomino Dr Property Address William Russell ' Owner Owner's Name information is Barnstable Ma' 02630 3/11/2014 required for every -. page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The dwelling located at 193 Palomino Dr. is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and 5 infiltrators. The system was found to be in proper working condition at the time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y,-N, ND)for the following statements. If"not determined, please explain. ` r 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): y t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection . Form - ' Subsurface Sewage Disposal System Form -Notfor.Voluntary Assessments 193 Palomino Dr e SV Property Address William Russell Owner Owner's Name information is Barnstable Ma 02630 3/11/2014 required for every page. Cityrrown 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(cone.): ❑ Observation`of sewage backup or breakout 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(Explainbelow): ❑ 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-3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 3 of 17 r Commonwealth of Massachusetts ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 193 Palomino Dr Property Address William Russell Owner Owner's Name " information is Barnstable Ma 02630 -3/11/2014 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any), determines that the system is functioning in a manner that protects the public health, safety and environment: , ❑ The system has a septic tank and soil absorption system (SAS) and the'SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone'1 of a public water supply. El 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 r ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface,of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded = or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments M 193 Palomino Dr Property Address .n William Russell Owner Owner's Name information is Barnstable Ma 02630 3/11/2014 required for every ' page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ' Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or, obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within,100 feet of a surface water supply or tributary to a surface water supply..' ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a.public well. , ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but.greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided.that no other failure criteria are triggered.A copy of the analysis and chain,of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 O,000gpd. 0 ® The system fails.,I have determined that one or more of the above failure criteria exist as described in 310 C_ MR 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, imaddition 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 mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 5 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 193 Palomino Dr Property Address William Russell Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2014 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or`'no"as to each of the following: Yes No ; ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the.previous two week period? M ❑ Z. 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? ti ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil'Absorption System(SAS)on the site has been determined based on: ® ❑ Existing.information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR.15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 gpd, t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 193 Palomino Dr Property Address William Russell Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2014 page. CitylTown State Zip Code Date of Inspection { D. System Information Description: Number of current residents: 4 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? El Yes ® No Water meter readings, if available(last 2 years usage (god)): Detail: 2012= 13,000 2013=97,000 Sump pump? ❑ Yes ® .No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15:203):, Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding,tank present? o ❑ 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 ; 193 Palomino Dr Property Address _ William Russell Owner Owner's Name information is Barnstable Ma 02636 3/11/2014 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the irispection? ` ❑ 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 l/A system by system operatorunder contract ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): I t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 , f X Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Palomino Dr y 4 Ar ley . Property Address William Russell Owner Owners Name information is required for every Barnstable Ma -02630 3/11/2014 page. - Citylrown State Zip Code Date of Inspection D. System Information(cost.) Approximate age of all components, date installed (if known)and source of information: t system repaired 12/29/1999 per town records, tank is original 1984` Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade. 4 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): System has a single sewer line that runs under the foundation,joints were good, system is vented through roof Septic Tank(locate on site plan): Depth below grade: 3.5 •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 gallons Sludge depth: 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 193 Palomino Dr i „M r Property Address P William Russell Owner Owner's Name , information is required for every Barnstable Ma 02630 3/11/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) ` Distance from top of sludge to bottom of outlet tee,or baffle 3 3" 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? opened covers, 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.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Inlet and outlet covers are on risers. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness , Distance from'top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. M 193 Palomino Dr Property Address William Russell Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2014 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: w 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.): d} *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 193 Palomino Dr Property Address William Russell Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2014 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence ofr solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and was found in good condition, no rot, water level was even with outlet invert. Recommend installing riser for easy access to box. f Pump Chamber(locate on site plan): Pumps in working order: ❑. Yes ❑ No* r Alarms in working order: ❑ Yes' ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): * If pumps or alarms are notin 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 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form Not for Voluntary Assessments 193 Palomino'Dr Property Address William Russell Owner Owner's Name information is Barnstable Ma 02630 3/11/2014 required for every - page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 5 Infiltrators leaching galleries number:- ❑ leaching trenches number, length: ❑ leaching fields number, dimensions. . ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,.signs of hydraulic failure;level of ponding, damp soil, condition of vegetation, etc.): No sign of saturation, vegetation was normal 5 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 i Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments �M 193 Palomino Dr Property Address William Russell Owner Owner's Name information is Barnstable Y required for every Ma 02630 3/11/2014- page. Citylrown 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.): ' r 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 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 193 Palomino Dr Property Address William Russell Owner Owner's Name information is Barnstable 02630 3/11/2014 required for every page. City/Town f State Zip Code Date of Inspection D. System Information (cont.) 4 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 © c . 0 2 A-c 32 A-2 3S f3-Z 3-7 ,. 4.3 3 I io 13-3 N 2 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 193 Palomino Dr Property Address William Russell Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2014 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells . 'y Estimated depth to high ground water: `12'+ feet' Please indicate all methods used to determine the high ground water elevation:. ❑ Obtained from system design plans on record . If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole with.in 150 feet of SAS) t , ❑ Checked with local Board of.Health-' explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain:" . You must describe how round high you established the water y g g ate elevation. Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System:Page 16 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 193 Palomino Dr Property Address William Russell Owner Owner's Name t, information is required for every Barnstable Ma 02630 '3/11/2014 page. Cityrrown 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 • 4 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 DEED RESTRICTION WHEREAS, WILLIAM D. RUSSELL and TAMMY J. RUSSELL, of 82 Stebbins Road, Monson, MA 01057 are the owners of 193 Palomino Road, Barnstable, Massachusetts 02630 (hereinafter referred to as Lot 97, #193 Palomino Road, Barnstable, Barnstable County, Massachusetts 02630 and being shown on a plan entitled`Bacon Farms Estates Section 2" by Eldredge Surveying Co., dated October 3, 1973, duly recorded with the Barnstable County Registry of Deeds in Plan Book 280, Page 55. WHEREAS, WILLIAM D. RUSSELL and TAMMY J. RUSSELL, as the owner(s) of said lot agreed with the Town of Barnstable Board of Health to a. restriction as to the number of bedrooms which can be included .in the present home built on said lot to FOUR bedrooms. HOWEVER, as a pre-condition to adding any additional bedrooms on said lot and in said home or any addition to said home that increases the number of bedrooms in said home, owner(s) have agreed with the Town of Barnstable Board of Health that they will have to obtain a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage for the total number of bedrooms to be included in said home and any additions thereto; HOWEVER, if the premises are ever connected to a town sewer system, this restriction will become null and void. NOW,THEREFORE, WILLIAM D. RUSSELL and TAMMY J. RUSSELL do hereby place the following restriction on their above-referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title. Until such time as they or a successor(s) in interest in title to the above-referenced Lot 97, #193 Palomino Road, Barnstable, Massachusetts intend to add additional bedrooms to the present home on said Lot, William D. Russell and Tammy J. Russell agree that the house as presently located upon said lot shall contain no more than FOUR bedrooms and that this shall be a permanent deed restriction affecting said Lot 97 until and unless they or their successors in interest in title desire to add additional bedrooms and comply with all conditions outlined herein. I . For title, see Deed recorded with the Barnstable County Registry of Deeds in Book 22920, Page 64. r Executed as a sealed instrument this c%, Oday of April, 2014. dl m D. Russell Tammy J.VU II COMMONWEALTH OF MASSACHUSETTS County, ss; April , 2014. Then personally appeared the above-named William D. Russell, who proved to me through satisfactory evidence of identification, which was a . le, , /t��Ss to be the person whose name is signed on the preceding or attached document, and swore or affirmed to me that the contents of the document are truthful and accurate to the best of his/her knowledge and belief and acknowledged to me that he/she signed it voluntarily for its stated purpose. Notary Public: My commission ex COLLEEN C.KELLEY Le Notuy Public Commission Exp1m;Oct 2.2020 COMMONWEALTH OF MASSACHUSETTS County, ss; April o , 2014 Then personally appeared the above-named Tammy J. Russell, who proved to me through satisfactory evidence of identification, which was a U_&" MS to be the person whose name is signed on the preceding or attached document, and swore or affirmed to me that the contents of the document are truthful and accurate to the best of his/her knowledge and belief and acknowledged to me that he/she signed it voluntarily for its stated purpose. Notary Public: My commission expires: ' COLLEEN C.KELLEY Nolay Palk S�� Missal Commission EWAM Oat 2.2020 BARNSTABLE REGISTRY OF DEEDS document are truthful and accurate to the best of his/her knowledge and belief and acknowledged to me that he/she signed it voluntarily for its stated purpose. Notary Public: My commission expires: ' COLLEEN C.KELLEY Notary Pik Massadmetts •r, Commission E10M Oct 2,2020 BARNSTABLE REGISTRY OF DEEDS te TROY WILLIAMS /0-.Y 5 SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 COMMONWEALTH OF MASSACI-iUSET1'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT' OF ENVIRONMENTAL PROTECTION TITLE S OFFICIAL INSPEC CON FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A s2 ,+Q -( J Ph1_QM),A D-r� CERTIFICATION �`f T oZ.. 1 o 193 Palimino Drive r perlN Add ress: Barnstable,MA i ry Owner's Name: Estate of Karen Dent c; Owner's Address: c/o Ellen Dent �P (' 193 Palimino Drive, Barnstable,MA 02632 ti I Date of Inspection: June 6,2007 C2 / t '�S'5 Name of Inspector: Troy M. Williams 1C� Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive South Dennis,MA 02660 cn r- � Telephone Number: (508)385-1300 'M CERTIFICATION S'FATENVIEN"T I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP appro%ed system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The sdsieni Passes Conditionall.v Passes Needs f urther ["valuation b).the Local Approving Authority Fails Inspector's Signature: .................. Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,060 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 Although system meets the rninimurn requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This Inspection represents the conditions of the systern on the Date of Inspection noted above. ""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: Title 5 Inspection Form 6/15/2000 paee 1 of II Page 2 of 01TICIAL INSPECTION PORN) - NO 'J'.0 Oft VOLUN rOv AssEsSmrNTs SUBSURFACE SCWAGII, IHSIJ'O�A)!.. SAS"1'Ii�lY1 I1VS1<'ll?C'1'ION Y OY21V1 !'AIZI A 193 Palimino Drive R`I')JJh)I�'A'I yON (continued) Barnstable MA l'ropc1-ly Address: Estate of Karen Dent June 6,2007 Owner: Dale ol.Inspectiou: e . luspecliou Stuluuary: Cl►eck AjI ,C,I) or f / AMAYS eull►plele all of Seclion I) A. Systcn► Passes: ✓ t have not luund any in(illnlakoll wllicl►iullicaies that �ii)y of Ibc lailure criteria described in 310 CMIt 15.303 or in 310 CM2 15.30,1 exist. Any failure utlelia nut evalualed ale indicaled below. Conuuents: ' !)- Systcl►l Cqulliliuually Passes; One or mole syslen►colnponeltls as cleserihed ill the"Conditional Pass"section need tab , eplaced or repaired.The system, upon completion of lbe leplacenlenl of lepail, as appruvad by the bbard Ile hh, will pass. Answer yes, uo of,Ilot delL'I'llllllell(Y,N,ND) in the ti)l the following statements. . "not delerinioed"please explain. The septic lank is metal imil over 20 years old* llr lice sepllc tack (Wll ter Illelal of.tlol) is strticturally unsound, exhibits substantial iufiltratjon or exlillration of lank fitllllre Is II I niocill. System will pass inspection 1(.tbt; existing tank is replaced with a complying septic lank as approved by t Noard of I)tall)). *A nlelal septic lank will pass itlspccljon ((it is sUlicturally snliml, t leaking and if a C'ellilicate of Cnmpli�ince jndicaling thal the tank is less lhan 20 years old is 4vailahle. N[)explain: Observalion of sewage backup of bleat'- out high static wales level in the dishi.bulion box clue to broken or ollstnlcled pipe(s)or flue to a broken,seltlecl or► evell tlisll Ihliliorl box. Syslen) will glass it)specljor) jf(wilt) approval of Board ofIjeallh): -_—. broke .�ipe(s).aie chlacell ob' ruction is rerr)ny6tj . tstribuliorl box is leyeleel or replaced ND explain: hlie system rcr red pt►llyling more than 4 tunes a ycal'due to broken or obstntcled pipe(s).'rbe system will Pass inspeclion if Ih approval ul.Ihe floard ol'Ilealth): . --h-okell pipe(s) air lCplacttl c)bslntction is l'emcived ' NI)ex llaln: - ,1,: page 3 of I 1 011TICIAL INSPECTION VORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SCI WAGJ DISPOSA1l, SYS'[CM MNSPECTION'li'OltlYl ! A1l 'l' A CCIZ11 VICAT>ION (continued). 1'roperty Address: 193 Palimino Drive Barnstable,MA Owucr: Estate of Karen Dent Dale of Inspectiau: June 6,2007 C. Further Evaluation is Iteyuircd Ily tllc 13i1ard olAle►lilt; Conditions exist whicli rerluife further evalualioi►by Ow Board of Ileal,lh in order 16 delenyline if the syslefil is lulling to protect public health,safely or the erivironntenl. 1. System will pass unless llomu-d of IMeallil rfefcrinitics in accordance wills 310 CIYIIl 15.30300) ll!al fhe systelll is lltlt tllllctltlllllig ill a Ill.lfilter wllich will Ill Out public llcilllh,safely and ll►c cu ' anmenl: Cesspool or privy is within 50 Jett of it surface water _ Cesspool or privy is within 50 Itel of a bordering vegetated wcdand or•a sail mi 1 2. System will tail unless the hoard fit Ilcallil (allif l'llblic Walcr 1pjllicr, if any) deleri►liues Ihal the syslenl is functitiuing In it ruanner Illal protects the puldic Ilealt ,safely and euvil-ollnlefil. 'I•llc systciu has if septic oink and soil ahsorpiion sy nl(SAS)and the SAS is within 100 feel of a surface water supply or tributary to a surface water st ply. — The syslem has if septic lank and SAS ail( it SAS is within it Lone 1 of a public wales supply.. _ The systeni has it sel)tic tank aml S and the SAS is within 50 feel of it private water suplily well. _ The sysieln has a septic lank lit SAS and [lie SAS is less Ihan 100 feet bill 50 feel or mole fiom a privale water supply well". Ihod used I6 dclermine dislance **fills system passes if e well water analysis,heitilrined at a DEP cerlified lattoralo►-y, fof coliforrn hacleda and volatile rganic compounds inrlicales lh?l Ilse well.is flee fioln pollution from that facility and the presence of it L]lonla pilrogell and rltlrille rltll(1¢en is equal tU nr less Ilion 5 pplll, pl'OVIdCd that 11Q older failltre c0le!i, . re trigge►ed. A copy of the analysis must Ue atlached to this form. 3. Olhcl: Page I of 1 1 O1"FICIAI. INSPECTION FORM - NO'li' FOR 'VOI WFARYASSIESSkIIENTS SU4SUR11M I? Sl!;'4'VAGA" DJSI'USAI� SVS'leIA/l INSP ECI'ION'I-Oum I'ART A � CIE ll'I'll'U'A`j'ION (continued) 193 Palimino Drive 1'roperty Address: Barnstable, MA Estate of Karen Dent Owner; June 6,2007 [);lie of luspcclion: 1). syslcot failure Criteria applicable In all Systems; You most indicaic "yes"of"mo" to cacll of 1110 li,llowirig lur ull inspections: Yes No Back op of sewage into lacilily i,r syslct7l Colt"ponenl iluc u)overloaded of clogged.SAS ui cesspool Discharge of ponding of el'llueut to Ilse surface of the ground or surface waters slut:to an overloaded or clogged SAS o, cesspool Static liquid level ill (lit distributiOn. box above Millet invert title to lilt overloaded or clogged SAS or ✓ Cesspool Liquid depth ill Cesspool is less Il,ali 6" beli,w invert or available voiunie is less titan %ilay flow Required piuoping more than'I lines in the last yt:;lr NOT title to clogged or obslri,cicd pipe(s). Nunlhci of limes pumped - __ _✓ Any poitiou of the SAS, cesspool or(n ivy is below liigii ground water elevation. ✓ Any portion of cesspool of privy is within 100 Iecl mf a surface water supply or It ibtllary it) a sui face water supply. ___ ✓ Any portion ul'a cesspool of privy is within it Lmt,t l of'it public well. _ ✓ Any poitiom of a cesspool mr piivy is will,iu 50 feel ()I'll private water supply well. ✓ Any poiliom of a cesspool of 1),ivy is less than 100 feet but greater Ihar1 50 leel from a private water Supply well Willi no acccpial,lc water quality analysis. IThis sysle,n passes if like well wilier analysis, pe1101-med al a IWI' cerlified laboralpry, lily colifor,u backlit► and volatile organic eomy)otlnds indicates That the well is Irec (roll,pulluliol► Iro11k That fat ilfly .u1d II)i prescuce o!anlntouia nitrogen and nilrale nitrogen is cilual 10 or less 111art 5 ppn►, provided Ilia! no oll►el- failw-c criteria ;u-e Iribbt:red. A copy o(tbc ;u►alysis rood lie allachcd 10 Ihis form►.) . _ALa_(Yes/No)'I'he systen► tails. I have dctenmineti ilial title qr u)oic of the above li-lih,re criteria exist as ticscribed in 310 CNIR 15.103, Ihcrefoie the sysicni fails. 'file system owner should contact the Board of' Ilcalih to delern,ine what will be necessary to coiiecl.lhc faihire. 1;_ Lai'ge Systelus: I'o he consillel-cil a (argc syslciu 111P syslclil lulls! serve.1 i';lcilily will► it esigir 1161ky of 10,000 bpil it) 15,600 gpd. t, You must indicate either"yes"or"110" to each of the liillilwing: (The fallowing criteria apply to large systems in atliilii)n to the crib is above) yes no the systeol is within 1100 feel ()[it stlilace tit inicit water supply the syslei,) is within 200 feel Oki 11 ibulitry a Sill I"iCe drinking water supply _ tilt syslerll is located in a nilrogell St ►llve arc:, (lnlerim Wellhead 1'rolecliou Aica— MIA)or it mapped `Lone 11 of it public water Supply l If you!lave a,lsweietl"yes" to any title• ton in Seelion 1 the system is considered it significant threat, of answered "yes" ill Sectiot►l) above the laigt • Stahl Itas failed. `I'be owner of opelalor of at►y large syslell►considered a significant 111r0ilt u►►tier Scctit)r► r . i failed Iltltler Seclit111 t)si)illi 11pyilde (Ile systelp ill accordillice wi11131Q CIvi12 1 S.311g.`like systenI owner slit d coi►lact the al�hiul)t rate fegidikai of lice of tilt Dep Irinlet 1. Page 5 of 11 0141ICIAL INSITC 1,JON li`flljiM - Nf)f FOR VO1AJN`I'AI2V ASSESSIVIL+ N,I S SUBSUR ACE SEWAOC PISI'OW SYS'l CM IN PECTION 'Follm Cl�lrerr��s�� I'rop►ct ty Address: 193 Palimino Drive Barnstable,MA Ow►lcr: Estate of Karen Dent Dale of Inspection; June 6,2007 Check if the lidlowing have been clone. You mist indicate"yes"or"tlo" as to each of the following: Yes No _-- futuping ioforn lilt.i(III was providul by tilt owner, occupanl,or Board nflleabh Were ally of,tile system eonlponetlls pumped out lit tilt previous two weeks '? I/ _ lias the systel l received norirlal flows in the previoys two week peruxl'? flaw large volumes of walcr been inlrpdtIced Io lht systelu recently or its part of this inspection'? _✓ _ Were as built plans ilf lllc system obtained ant)exa,lpioed'?(II Ihcy were not available note as N/A) Was the facility or dwelling inspecled fir signs of sewage back tip'? _ Was the site il)spcctcil fur signs of break nut`? Were all system c011iponcnls, excluding lie SAS, located on silo '? Were the septic tank manholes ul)covercil,operictl, anti the interior of ilic tank'inspected for the condition of the baffles or tees, malciial ofconstruction, dinlcllsiuns, dcplh of litluid, ticpllt of sludge anal depth of scum? _ Was the lacil.ity owner(alul occupants if different f ionI owner)provided with inf ormaliou on file proper tnaiuleoancc of subsurlace sewage disposal syslenis '? The size and localfon til Iltc Soil Absorplion Syslent(SAS) oil tilt site has been detelmined'based on: YC5 no l:xisting inlorinalion. I m example, if plan Ill the (ipartl of I leallh. I)Bferlllined ill file fleld(If ally of(lie fallltre Criteria 1-41alctj to Part Cis at issue approxi4palintl of distance is unacceptable)[310 CM It 15.302(3)(b)) f _ Page 6 ill plyli'ICIAL INSPECTION DORM - NOT 1'012 'V()I.UN`I'Al2Y ASSESSI., 1'S SNJIISuIZI�ACI� SN��wAG��� r�Is��c�sA1.. sYs�r�I��vr INsl�re`I'1�?N �vIZN1 $YS'ITM INVOjZMA'N'ION I'foperty Address: 193 Palimino Drive Barnstable,MA Owner: Estate of Karen Dent Date of Inspection: June 6,2007 lel,OVY CONhl'r'IONS 12L SIt)IWI'lAl. Number of bedrooms(design): Nuplber of beclrooll (actual): L/ D SIGN flow basal on 316 CIVIR 15.203 (fai example; 110 gpd x I/of bell ioilms): `/Ky_— Number o f current residents: _ Does Iesideuce have a garbage;biiodei(yes or Ila): `i(-S Is laundry all a separate sewage system(yes or Ila): AlO if yes separate inspection required Laundi y syslcm inspected(yes or no): Seasonal use: (yes of Ina): Water Rueter readings, if available(last 2 years usage(6pd)): 06_0)_ o271uo� ���/,� aS- 0 6 = C/oOu Sump pump(yes or no): _/l/j Last date ill occopallcy: _O LL✓!Q� yJ COMMIS ItCIA1,/1NI)US'1'12IA1.: Type of eslablishmcnl: _— -- Design flow(based on 310 CMIt. 15.203): Basis of Resign flow(sea ts/persons/sglt,elc.): -- - ------_ -- Grease (rap present(yes of Ila): - --- - Industrial waste bolding tank present(yes of.Ila): _ Non-sanilat y waste discharged to the Title 5 system es or no): Water meter mailings, if available: List date of oceupancy/use: --------- - --- -- O'htllat(describe): -- --- ---- — (:tNIItA1_ IN1�O►i1v1:1'1'1ON l'uunping Itccorlls - Soulce of infbrulalioo: Was systelu 1)u111pell as part of Ile inspection(yes or nu): NO it yes, Volonle P11111pul: gallons -- llow was tfuanlily pulpped delefnlined'1 Iteasiln for pllnlpUlg: - -- -- ----------- — Tyl'I;0r Sysliftyl Septic tank, 1listribmion box,sail absorption syslcnl Single cesspool —-Overflow cesspool Pi ivy _Shared system(yes or no)(jf yes, allach previous inspection records, if any) Innovative/Alternative leclnolo6Y. Allacb a copy of lbe current operation and ruainlenallce contract(to be obtainetl frolp system owner) _"fight tank Allacb a copy of Illc Dff' approval _Otbei(describe):--- --- --- ------ - Approximate age of gill compouenls, (late insiallett(if known)anti source of infol-11 lion: f Z/ �l 9� /0�,,. c,o�•,�l frk,,�.� . Wei e sewage atlofs t(elccletl when alliving at file site(yes of r►q): .vo t . Page 7 of l 1 OFFICIAL INS1TC'li'I()N r+ORM - NUT FOR VOr,UN`I'E*,RY ASSESSMENTS SUASURFACE SCI WAGI? J SPOSAII, SYS'1'I?M INSPECTI ONTORM PA10t (= S'YS'I'>tl ►vI IN1+01. INIA`r'ION (cuntiniled) I'ruptrly Address: 193 Palimino Drive Barnstable,MA. Estate of Karen Dent Dale of luspeclio": June 6,.2007 BUILDING Sly Wj,At(locate un site plan) t)eplh below grade: f Malcrials of construction:_cast 11611 _60 1'vc__._other(explain): _ Distance lium privale water supply well of suction lice: A C'unuurnts(on con(litioll of joints, venting, evidence of leakage,i;lc.): —1 Sle-l''I'IC'1'ANIC: /(locate un site plan) J)Cplll below giade: Maleiial of Cal slnlclion: _Metal f bciglass _polyelhyleile _ olhei(explaill)--- _ If tank is metal list age: _ Is age confilrilrd by a Celtific,lle of Compliance(yes Of lib):_(attach a copy of certificate) Dimensions: Sludge deplll: Distance fiool top ofsludgt to holloni ol'oullel lee pr ballle: Scuul thickness: ra '' - -- — Distance from lop ofscuirl to lop of outlel lee or ba111e: -- 6 Distance front bottom of scum to bolWm of outlet lee of baftl(.:--g '' ; Ilow were(lirutnsions detelmilled:—T,., --- --- -- - - Columcnls(oil polnpiug ieculniucu(lalious, inlel anal nutlet We oI baflle'condilion, structural iolegiily, liquid levels as ielaled ill mullet invert, evidence of leakage; elc.): �.t,.t.,S_ w,t.v_w• p�=���r-Y1!���la-��-t--��f Q= Ww�-L:�.7J�_.E-�-��S�C_�"a��-_/�n����` � A a �ti(�-. ( S ✓tt��s 5 K S`�-✓'7 �: ' h S U✓t ��p`" WO✓k..nl c.>r..t.s�rs - _(Iocale oit slit plan) - Depth below grade:— Mal.eiial of CQIIShilcllmll: --_concrete_ IYICIal=_llherglass—_pulyetlryl e other (txplaifl):_ Dil-flensiolls: .— ---- -_-- Scup►Thickness: — Distance from lop of scllnl to lop of outlel lee ill-baffle: — — — Dislanez ti'oln boltulil ol'scuul to boltom of pullet lee of l' .flc: Daft ol'last lluiigling: . comments(Oil puiupiug►ecom,uendo(ions,inlet it , outlel lee or ba(11e Condition, slntctural integrity, ligtlicl levels as Itlated to outlet invert, evidriice,o(leakage c.): Page 8 of I l . OFFICIAL INS1'VC'110N yiORM — No T le011 y01_.UN•!!'AR Y ASSESSMENTS SrJ�tSrJIII�AcN? S y��t<i; 018110W_, $YS ` IV! MNsrrccrION J�ogm J'A SYS"I'' M INFORMATION (conliuued) Properly Address; 193 Palimino Drive Barnstable,MA Owner: Estate of Karen Dent 1)ate of Inspection. June 6,2007 1'CGII P or ItOI.I).(NG"PANIC; (tank must he punipccl at jirne of inspecti (locate oil site plan) Depth hdow grade:--- Material of construction: co,icrete nlelall__fihel.glalss_ lolyethyiene oil er(explain): Dimensions.----- — --- ------ Capacity;_ -- —gallons Design blow: Alarm present(yes m nCi): _ Alarm Level: Alarm in working order es of no): — Date of last pumping: -- Coolrne„ts(Condition Of alarm a'd Iloa witches,et(;.): I)ISTIZII UTION ROX: (ifprese't Illust be opelled)(iOC81C Oil site plan) Depth of liquid level 'above outlet invert: Coaulients('Cite if box is level and distribution to outlets equal; any evidence of solids carryover, any evidence of leakage into or out of hox,ctc.): I iA Sal: s aLjcAe_ 01en �e�e.�.� &J"- oln '�'Sw�tjon . I'LJIVl1'C'IIAIVIIIL R:_ (locale till site plain) ro I'tlulps jn wo kil►g order(yes or tau): Alarms jn woi*iq cutler(yes or oo): Cornnlents(hole condition of pump chamber, conditio (pumps and appurtenances; etc.): Page 9 of 01, ICIAI INSI'Ii(- 'JON jeORNI Nt?'!' >tiY))f2 'Y(pl..rKl ARY ASASSM 1 NTS C'1ION FORM SYST1l-M INF()12►y>rA'!'ION (continue(l) PI-oper(y Address: 193 Palimino Drive , Barnstable,MA Q+vner: Estate of Karen Dent late of lospecOon: June 6,2007 SOIL ABSORP'l'lON SYS'J'LNJ (SAS): ✓ (loci►(e 611 site Ill-III,exgay:►tinll not I-etluired) if SAS not located explain wl►y: , T Type leaching pits, number._ leaching chambers, iiuniber: _�_— i.A (�vv �,. S w S r►� - leaching gallclies, iitimber: —_ leaching belittles, ntillibcr, lcnglll: leaching fields, number, dimensions: -- — ovcrlluw cesspool, uuniber: _ — -- --..— — _-- innoviilive/ullernative system `type/nai�ie of tecblloloby; _____________—_-- _ Conuuenls(nolc condition of soil, signs of Hydraulic (iiihirc, level of pootliug, damp soil, condition of vegetation, etc.): ii �-•---�Yl.�--`i c�---.s-l�h��sn.�—� ..� lv�ry 4t-�.. � G�.�a l,�l C'Ii SSj'OOI.S: (cesspool nulsz1" f ins4iceliom oci le on site plan) Number and cuntigunlliuu: Depth— lop of hyoid to ildel invert: Depth o f solids layer: — - Depth oi'scum layer:Dimensions of cesspool:Maleiialsofconslnlctioll:Indication ofgioundwalelinflow(y -- -- conln+ents(hand cotltlitiun.ofsoil sll0, level of ponding,condition of vegetation'.Cie.): l'IiIVY; (locale till site lilac) Materials of construclioi►'— --- — - _ Uimcusions: -- -- -- - Depth of solids: --- coionients(dote con(lilioi►of soil,,ssigns ol,hydnit ;c failure, level ofpoliding, coudilion of vegetation,etc.): MIT INSITC ION FORM - NOT FOR VOVIjN'1'ARY ASSESSMENTS SVPS1JR AC1!: Sj�� yAGE 01$1'(- SAI, SYS'1'1!M 1NSPCIC iON VORM J'A RT C SYS'1I-W INj?014fATj0N (cooti►iuecl) 193 Palimino Drive Properly Address: Barnstable,MA Estate of Karen Dent Qwuer: June 6,2007 Date of Inspection: Sltl.'I'Cll OF SI WA(..E OISl'()SAL SYSff' IVI Provide a sketch of the sewage disposal syste►»including ties to at least two pe}manenl relcrence landmarks or benehmai ks. locale all wells within 100 feet. I..ocate where public wilful-supply enleis the building. 0 3 ► Lj .lU . Page I l of OP ICIA1, INSPECTION IeORM — NO'j' M�:OR VOLUNTARY ASSESSMENTS NTS SUBSURFACE SEWAGE I)�SI'OS�Ca SYS I'I�IVI INSPECTION FORM 1'A 10'. SVS EM INCet:)R NJ A'li'ION (conlinue(j) Properly Address: 193 Palimino Drive Barnstable,MA O1Y1er. Estate of Karen Dent 11111e of Inspection; June 6,2007 SITE EXAM Slope Sul face walci Check cellar Shallow wells P still,aled depth lu ground water gllccl Adjusled high ground water cicva(iAn — feel Pleikse indicale(cheek) all u,clhods used to dclernuoc the high 61oi.111d Willer elevation: Obtained Iioo1 systcw design plans oil record - II'chrc:kcd, dale of design plan reviewed: Observed site(abulti,ig properly/ohscrvalioo hole wilhip 1 S0 feet of SAS) ---� -�- Checked Willi local lloald of Ileallh-explain; - Checked with local excavalors, insl;illcrs-(allach documu:nla(iou) -.--- -- -� Accessed IJSOS You ,uusl(C describe how you cslablished AUie high gruuuil w;ilcr clevali,iu: (I� ._.-._'__�J..�_7-_._�+_.:�✓L=�.!✓,r-�_+-.G-L1�`o-�'� -.t�4'!%�F..�',�.�_---- -�-♦�--=3.d�.�--�5��.-:t'��GJ4.�Oa_1--- cam -.- 60. 1 ' Y` 6T Y 71, This report has been prepared and the systern Inspecled as of the date of inspection. This reporl is not a warranty or guarantee that the system will function properly In the future. There have been no warranties or guarantees, either expressed,writtet?or implled, relating to tale syslern, tt►e Inspection and/or this report. I1 . . McKean, Thomas From: McKean, Thomas Sent: Monday, February 02, 2004 10:11 AM To: Mcauliffe, Paulette Cc: Health Office Subject: 193 Palomino Drive/ Karen Dent The septic questionnaire application regarding the above-referenced address received on 1/28/04 is disapproved due to the following reasons: - The septic system capacity is limited to only four bedrooms according to the permit issued; however five bedrooms were counted on the submitted floor plans. The following suggestions are provided: a) Upgrade the septic system to a five bedroom capacity system, or, b) Have an engineer inspect the existing system to determine whether the leaching capacity could handle five bedrooms and to determine the condition and functionality of the existing system, or, c) Convert the existing "den" room into an open (non-private) room by removing the door and providing a minimum five feet opening at the doorway there. .1 a 1 Town of Barnstable fi Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX:. 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. Ms. Karen Dent February 26, 2004 193 Palomino Drive Barnstable, MA Dear Ms. Dent: On Tuesday February 17, 2004, the Board of Health held a public meeting to discuss your request not to consider the "d6n" in your home as a bedroom. Your request regarding the above referenced matter was scheduled on that agenda; however you were not present. Therefore, your request was postponed to the next Board of Health meeting which is scheduled to be held on Tuesday March 30, 2004 at 7:00 p.m. at the Town Hall second floor Hearing.Room. We hope that you will be available to attend the next meeting. If not, please communicate to us in writing (via mail or facsimile #508 790-6304) to request a continuance. Sinc reAyoayne Chairman Board of Health Town of Barnstable sewerVarianceBomstein2 Town of Barnstable uAaa , Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-8624644 Susan G.Rask,R.S. FAX. 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. February 26, 2004 Ms. Karen Dent 193 Palomino Drive Barnstable, MA RE�,Septi#cam��a,acii����rs�s��� r�c�r��Ca ant tr9�3�I'alc���� oDri�ve�Bar�sta>71e '��,,,,na:�, „f .�»+�Fk:�H' .•»sue .,.�::, ,3,�;��.�. ..8. rz.,_ s..a.-�.,..+a.�x •'r�h.,a. «�<,mar :5�.„.:t"n...�..,,.. ..�;.„a�wa__. �`'"�.. Dear Ms. Dent: On Tuesday February 17, 2004, the Board of Health held a public meeting to discuss your request not to consider the "d6n" in your home as a bedroom. Your request regarding the above referenced matter was scheduled on that agenda;however you were not present. Therefore, your request was postponed to the next Board of Health meeting which is scheduled to be held on Tuesday March 30, 2004 at 7:00 p.m. at the Town Hall second floor Hearing.Room. We hope that you will be available to attend the next meeting. If not, please .communicate to us in writing (via mail or facsimile #508 790-6304) to request a continuance. Sinc re y yo Wayne iller, M.D. Chairman Board of Health Town of Barnstable f I sewerVarianceBornstein2 Town of Barnstable Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,RS. FAX:. 508-790 6304 Sumner Kaufman,MSPH Wayne Miller,M.D. Ms. Karen Dent February 26, 2004 193 Palomino Drive Barnstable, MA Dear Ms. Dent: On Tuesday February 17, 2004, the Board of Health held a public meeting to discuss your request not to consider the "den in your home as a bedroom. Your request regarding the above referenced matter was scheduled on that agenda; however you were not present. Therefore, your request was postponed to the next Board of Health meeting which is scheduled to be held on Tuesday March 30, 2004 at 7:00 p.m. at the Town Hall second floor Hearing Room. We hope that you will be available to attend the next meeting. If not, please. communicate to us in writing (via mail or facsimile #508 790-6304) to-request a continuance. Sinc re y you Wayne/Miller, M.D. Chairman Board of Health Town of Barnstable sewerV arianceB omstein2 • i' Y vat 3 �ta► f k _R lo, TOWN OF BARNSTABLE BUILDING PERMIT A,'="PLICATION s _ Map. '2 9 7 Parcel-.�7 Permit# _ H L5ealth Division date Issued -- Conservation Division I I ,�, :ee„ Tax Collectors 3 SYSTEM tiT'iJ:"'T g Treasurer !NS :'.t.E.D IN GOftqF�L!„�'%, �l Planning Dept._. _ 1111TH TITLE 5 ENV1RONf41ENTAL COD- �„ f Date Definitive P n pr ved by Planning Board TOW?N', REGUj.!`Tt0,. j Historic-OKH Preservation/Hyannis r`f Project Street Address l93 '91.0NJ/,-✓0 �RIV6 Village ��9RNST/?BLE Owner KAREN Address /93 .z1COM/^/O �,eiYE Telephone 508 - .36 2 —7 71-51/ Permit Request (f01/116-R 7- r`X/`�T//y'G /CA)R GA�PAG�" TO -7 /`i°M// Y ROOM. ADO .S x/O ' DE1/K ANO STrI /R.5 TO <�RI449E /9i Square feet: 1st floor: existing 9// proposed y Za Z 2nd floor; existing 8y0 pi,olmsed Nc Total new 20112 Valuation 1413, 500 Zoni;1g District R!r / _Flood Plain C Groundwater Overlay Construction Type FRAme- Lot Size_ / 03 AoRE _Grandfathered: O Yes O No .If yes,attach supporting documentation. Dwelling Type: Single Family 0 Two Family 0 Multi-Family(#units) Age of Existing Structure l6 Yk-s Historic House: C]Yes 0 No Or,,'-)Id King's Highway: ®Yes O No Basement Type: ❑Full ❑Crawl 0 Walkout. ❑Other Basement Finished Area(sq.ft.) Basement Unfinished X-a q jt) �40�,.umberN of Baths; Full: existing new Half ex,;ainr; new umber of Bedrooms: existing �� new __ Total Room Count(not including baths):existing 8 new Fi;S' f{)o Room Count s Heat Type and Fuel: ❑Gas 0 Oil ❑Electric ❑Other _ Central Air: 0 Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No "4AV6d L Detached garage:O existing 0 new size _ Pool:0 existing 0 new size Barn;0 existing ❑new size Attached garage:®existing 0 new size He Shed:0 existing ❑new size -Other: Zoning Boara of Appeals Authorization 0 Appeal# Recorded. Commercial ❑Yes 0 No If yes,site plan review# Current Use 14aME- Proposed Use SA Mc_ _ BUILDER INFORMATION Name _Telephone Number Address License# _ _•_Horm� Improvement Contractor Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L',t a.ysTA45 e SIGNATURE h I� , -- DATE /Vo✓ 21 Zooa THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) mA , I / L DATA ` /SSJE i 9•ZI.OU j L 11-Z2-0J KEY lrEh1 Nc :�` ` DESCRIPTION BA,,, WINAND. °S AlbvE8AY' 30-3442-18W i D WIN. ANa A'LuyE DH 2O92 K/ S_ 000A AND- 47i2ENCHW00D G<-/0l"C, FWG 60. L W B(- Doo — tSr Fozo DooR ' CF — Fbwrc CEILING FAN SB SMOKE ObTECTOI? !su uTJ/06 WA16.5 R-fl ClIuacEFroae aI9 i o O --------'— r T r.-� T-r-r I I i j I ��l ® l ( \ DRYEK VEIV A: TC' G t: ll. ./.,.NYrlENr i i SB Mo)•E IS) KG � I �I J1�✓ �1Ffi7 �'aE 'y � � ! ---- - - —_ -_---- ENTRY � I l 5 IMP'� I c/,,JE �- -- i l H. 8A5E6CARt� I HLAT 'OKC f� •�. �tAY.: I _ �l -- --- - 3 ---- - - .....- --- -- -- 'Ll -CK, --....._ -- ---- - - vAi,.lc;-wa --tn'11LY i 00,11 CONI_`'..i'$l0/i � � ,-f/ 1.• l l 1 . J�...- ' r. a r TOWN OF -BAANSTABL . BUILDING PE:f,,"-1-IT i L ID 297— 040 •:EOBASE, ID 20932, 32 103 PALOMINO—DRIVE W , BARNSTABIT a T 511E., _ p t DEVEDEVELOPMENTD STRICT BA sat' DE�:`kIl `I'IflN C:01ri CxAR�� ;E 'I'C) i�'(zY`1 ' RM/ ADD 5"'"X 10'DEOIt REA PERMIT TYPE BR,EMOD TITLE . 9i"DENT-IAWkl:,'T'Mt`V C jN`J RACTOR&AROPERTY OW',' D partment of Health, Safety . and Environmental Services WTAL, TEES ' $. 0 U _ .4,34 RESID A:DD/AL`/C;ON"V Fnl x r; �3 �'E . VGA - * BARN3TABLE.16 !� ' F s BUII.�'�fFW ION \ BY DATE QUED 11/20/2000 EXPIRATION I:?A`1E FIT jq .. .. TOWN OF BARNSTABLE BUILDING'PERMIT APPLICATION a Map 2 9 7 Parcel 0 419 Permit# + Health Division , � 1� _ Date Issued Conservation-Division S/ Fee �,5 D Tax Collector SEPTIC SYSTEM MUST r �` Treasurer 1` a :' 3 INSTALLED IN COMPLIANC Planning Dept. WITH TITLE 5 ENVIR®NIVIENTi4L CODS A. tf o Date DefinitiveJPjnpved by Planning Board TOWN REGULF�TIaMI`.- Historic-OKHPreservation/Hyannis Project Street Address l 93 10,44 4NJIn/O R/yE Village 74 BI-E' Owner KAREAl D61vT Address /9.3 P41_0NI1^/0 Z7,elw Telephone .SOB - 36 2 -973/ Permit Request Con/✓[=RT E-XIS7IA16 /CAR To q 64M11-Y ROOM. ADD X/O DECK i9N0 Z741,ol S TO Square feet: 1st floor:existing 91/ proposed /2a 2 2nd floor existing 8No proposed : Nc Total new 20,'12 Valuation Zoning Zoningf District R F I Flood Plain C Groundwater Overlay a Construction Type Lot Size /. 0.3 ACRE Grandfatfiered: Ell Yes , � ❑No•: If yes, attach supporting documentation. Dwelling Type: Single Family W Two Family 0 Multi-Family(#urnts) ' Age of Existing Structure /6 YRS Historic House: ❑Yes : ®No On Old King's Highway: ®Yes ❑No Basement Type: ❑Full ❑Crawl 0 Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) /o Number of Baths: Full: existing new Half;existing new N,uvG� Number of Bedrooms: existing new Total Room Count(not including baths):existing 8 new=9 First'Floor Room Count S Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes 0 No Fireplaces: Existing New Existing wood/coal stove: 0 Yes 0 No L Detached garage:0 existing 0 new size Pool:O existing Q new size Barn:O existing ❑new size Attached garage:N existing ❑new size KC Shed:0 existing ❑new size' ' Other: Zoning Board of Appeals Authorization Cl: Appeal# Recorded,0 Commercial ❑Yes ® No If yes,site pla6review# �` I Current Use I-IoME ` Proposed Use sAME ,4 BUILDER INFORMATION Name ® W /U .ram. Telephone Number 1: Address ! i License"'# ' Home Improvement Contractor# E Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 0AR1V37A51-E' ham. SIGNATURE DATE: '' Nay 2Z� Z0oa r ; B,k 19221 P's 173 �86876 11-08-2004 s'li 12 16P REGULATORY AGREEMENT AND DECLARATION OF RESTRICTIVE COVENANTS THIS REGULATO Y AGREEMENT and DECLARATION OF RESTRICTIVE CbVENANTS,is made this��day of_�� __,2004,by and between Karen K.Dent of 193 Palomino Drive, Barnstable,MA 02630,and its successors and assigns (hereinafter the "Owner"),and the TOWN OF BARNSTABLE (the"Municipality'),a political subdivision of the Commonwealth; WHEREAS the Owner has been granted a Comprehensive Permit under Massachusetts General Law Chapter 40B and local regulations by the Zoning Board of Appeals to permit the creation of an accessory apartment in an owner occupied dwelling which will be rented to a Low or Moderate Income Person/Family(hereinafter "Designated Affordable Unit";and WHEREAS,the owner of said lot has agreed to a restriction requested by the Board of Health to limit the maximum number of total bedrooms on the subject locus,including both the owner-occupied dwelling and the accessory apartment,to no more than four bedrooms as a precondition for allowing the owner to utilize the existing septic system for the proposed Designated Affordable Unit; NOW THEREFORE,in mutual consideration of the agreements and covenants contained herein,and other good and valuable consideration,the receipt and sufficiency of which is hereby acknowledged,the parties agree as follows: I PROTECT SOOPE AND DESIGN: A The terms of this Agreement and Covenant regulate the property located at 193 Palomino Drive, Barnstable,MA,as further described in Exhibit"A"hereto annexed. B. The Project located at 193 Palomino Drive,Barnstable,MA will consist of one accessory apartment unit which will be rented to an eligible low or moderate income individual or family(the"Designated Affordable Unit" or the"Unit"). G The Owner agrees to construct the Project in accordance with the terms of the comprehensive permit, Appeal No.2004- 57 and any plans submitted therewith and all applicable state,federal and municipal laws and regulations (A copy of the comprehensive permit is annexed hereto as Exhibit"B"). D. The Owner agrees to occupy the principal dwelling unit located on the property as their year round residence in accordance with the terms of the comprehensive permit. E. The Owner agrees that the subject locus,including the owner-occupied single-family home and the accessory Designated Affordable Unit,shall contain a maximum of four(4) bedrooms. The Owner further agrees that the existing"den" or"family room"shall not be used for sleeping purposes 11 THE OWNER'S COVENANTS AND RESPONSIBILITIES: A. THE OWNER HEREBY REPRESENTS,COVENANTS AND WARRANTS AS FOLLOWS: 1 In receiving the comprehensive permit to create the Designated Affordable unit,the Owner agreed that the Designated Affordable Unit shall be set aside in perpetuity for the public purpose of providing safe and decent housing to persons of low income(herein defined as 80% or less of the median income of Barnstable- Yarmouth Metropolitan Statistical Area MSA)and that the Designated Affordable Unit shall be deemed to be impressed with a public trust. 2, The Designated Affordable Unit shall be rented in perpetuity to a household with a maYim„m income of 80%of Area Median Income or less of the Area Median Income(A14 of Barnstable-Yarmouth Metropolitan Statistical Area(MSA) and that rent(including utilities)shall not exceed the rents established bythe Department of Housing and Urban Development(HUD)for a household whose income is 80%of the median income of ` o►G� 01 l oe Bk 19221 Pg 174 #86876 Metropolitan Statistical Area. In the event that utilities are separately metered the utility Barnstable-YarmouthMetrop p y y allowance established by the Barnstable Housing Authority shall be deducted from HUD's rent level. 3. The Designated Affordable Unit will be retained as permanent,year round rental dwelling units with at least one-year leases. 4. The Owner has the full legal right,power and authorityto execute and deliver this Agreement. 5. The execution and performance of this Agreement by the Owner will not violate or,as applicable,has not violated any provision of law,rule or regulation,or any order of any court or other agency or governmental body,and will not violate or,as applicable,has not violated any provision of any indenture,agreement,mortgage, mortgage note,or other instrument to which the Owner is a party or by which it or the Owner is bound,will not result in the creation or imposition of any prohibited encumbrance of any nature. 6. The Owner,at the time of execution and delivery of this Agreement,has good,clear marketable title to the premises. 7. There is no action,suit or proceeding at law or in equity or by or before any governmental instrumentality or other agency now pending,or,to the knowledge of the Owner,threatened against or affecting it,or any of its properties or rights,which,if adversely determined,would materially impair its right to carry on business substantially as now conducted(and as now contemplated by this Agreement) or would materially adversely affect its financial condition. B. GOMPLIANC E The Owner hereby agrees that any and all requirements of the laws of the Commonwealth of Massachusetts to be satisfied in order for the provisions of this Agreement to constitute restrictions and . covenants ruining with the land shall be deemed to be satisfied in full and that any requirements of privileges of estate are also deemed to be satisfied in full. C. LIMITATION ON PROFITS 1. The Owner agrees to limit his/her profit by renting the Designated Affordable Unit in perpetuityto a household with a maximum income of 80% or less of the Area Median Income (A14 of Barnstable-Yarmouth Metropolitan Statistical Area(MBA) and that rent(including utilities) shall not exceed the rents established by the Department of Housing and Urban Development(HUD)for a household whose income is 80% of the median income of Barnstable-Yarmouth Metropolitan Statistical Area. In the event that utilities are separately metered, the utility allowance established by the Barnstable Housing Authority shall be deducted from HUD's rent level. 2. The Owner shall annually deliver to the Municipality and to the Monitoring Agent,as designated by the Town Manager,proof that the Designated Affordable Unit is rented,the tenant's income verification,a copy of the lease agreement and the rent charged for the unit or units. Such information shall also be forwarded to the Monitoring Agent within 30 days of the occupation of the dwelling unit or units by a new tenant. The Owner shall notify the Monitoring Agent,as designated by the Town Manager,within thirty(30)days of the date that a tenant has vacated the Designated Affordable Unit. IV MUNICIPALITY COVENANTS AND RESPONSIBILITIES 1. The MUNICIPALITY,through the monitoring agent designated by the Town Manager agrees to perform the duties of verifying that the Designated Affordable Unit is being rented in perpetuity to a household with a maximum income of 80% or less of the Area Median Income(AMI) of Barnstable-Yarmouth Metropolitan Statistical Area(MSA)and that rent(including utilities) shall not exceed the rents established by the Department of Housing and Urban Development(1-M)for a household whose income is 80%of the median 2 Bk 19221 Pg 175 #86876 i income of Barnstable-Yarmouth Metropolitan Statistical Area.In the event that utilities are separately metered, the utility allowance established by the Barnstable Housing Authority shall be deducted fromHUD's rent level. G OFAGREEMENT: Upon execution,the OWNER shall immediately cause this Agreement and any amendments hereto to be recorded with the Registry of Deeds for Barnstable County or,if the Project consists in whole or in part of registered land,file this Agreement and any amendments hereto with the RegistryDistrict of the Barnstable Land Court(collectively hereinafter the"Registryof Deeds"),and the Owner shall pay all fees and charges incurred in connection therewith. Upon recording or filling,as applicable,the Owner shall immediately transmit to the Municipality evidence of such recording or filing including the date and instiument,book and page or registration number of the Agreement. VI GOVERNING OF AGREEMENT: This Agreement shall be governed by the laws of the Commonwealth of Massachusetts. Any amendments to this Agreement must be in writing and executed by all of the parties hereto. The invalidity of any clause,part or provision of this Agreement shall not affect the validity of the remaining portions hereof. VIII. NOTICE: All notices to be given pursuant to this Agreement shall be in writing and shall be deemed given when delivered by hand or when mailed by certified or registered mail,postage prepaid,return receipt requested,to the parties hereto at the addresses set forth below,or to such other place as a parry may from time to time designate by written notice. IX. HOLD HARMLESS: The Owner hereby agrees to indemnify and hold harmless Municipality and/or its delegate from any and all actions or inactions by the Owner,its agents,servants or employees which result in claims made against Municipality and/or its delegate,including but not limited to awards,judgments,out-of-pocket expenses and attorneys fees necessitated by such actions. X ENTIRE UNDERSTANDING: A This Agreement shall constitute the entire understanding between the parties and any amendments or changes hereto must be in writing,executed by the parties,and appended to this document: B. This Agreement and all of the covenants,agreements and restrictions contained herein shall be deemed to be for the public purpose of providing safe affordable housing and shall be deemed to be,and by these presents are,granted by the Owner to run in perpetuity in favor of and be held by the Municipality as any other permanent restriction held by a governmental body as that term is used in MGL Ch. 184,Section 26 which shall run with the land described in Exhibit"A"hereto annexed and shall be binding upon the Owner and all successors in title. This Agreement is made for the benefit of the Municipality and the Municipality shall be deemed to.be the holder of the restriction created by this Agreement. The Municipality has determined that the acquiring of such a restriction is in the public interest. The Municipalityshall not be subject to the defense of lack of privity of estate. The covenants and restrictions contained in this Agreement shall be deemed to affect the title to the property described in Exhibit"A". 3 Bk 19221 Pg 176 #86876 i XI. TERM OF AGREEMENT: The term of this Agreement shall be perpetual,provided,however,that the Owner of a Designated Affordable Unit or Units may voluntarily cancel the granted Comprehensive Permit and the terms and restrictions imposed herein. Such cancellation shall onlytake effect after. 1) expiration of the lease terms entered into between the Owner and Tenant occupying said unit and 2)notification by the Owner of said dwelling to the Zoning Board of Appeals of his/her desire to cancel the Comprehensive permit upon a date certain and the recording of said notice at the Barnstable County Registry of Deeds or Barnstable County Registry of the Land Court as the case may be,thus rendering said Comprehensive Permit void. Upon the cancellation of the comprehensive pen nit,the property which is the subject matter of this restrictive covenant shall revert to the use permitted under zoning and the restrictive covenant shall be rendered void. )M. SUOC E5SORS AND ASSIGNS: A. The Parties to this Agreement intend,declare,and covenant on behalf of themselves and any successors and assigns their rights and duties as defined in this Regulatory Agreement and the attached comprehensive permit. B. The Owner intends,declares,and covenants on behalf of itself and its successors and assigns (i)that this Agreement and the covenants,agreements and restrictions contained herein shall be and are covenants running with the land,encumbering the Project for the term of this Agreement,and are binding upon the Owner's successors in title,(iri) are not merely personal covenants'of the Owner,and(1)shall bind the Owner,its successors and assigns and inure to the benefit of the Municipality and its successors and assigns for the term of the Agreement. )(III. DEFAULT: If any default,violation or breach by the Owner of this Agreement is not cured to the satisfaction of the Monitoring Agent within thirty(30) days after notice to the Owner thereof,then the Monitoring Agent may send notification to the Municipality that the Owner is in violation of the terms and conditions hereof. The Municipality may exercise any remedy available to it...The Owner will pay all costs and expenses,including legal fees,incurred by the Monitoring Agent in enforcing this Agreement and the Owner hereby agrees that the Municipality and the Monitoring Agent will have a lien on the Project to secure payment of such costs and expenses. The Monitoring Agent may perfect such alien on the Project by recording a certificate setting forth the amount of the costs and expense due and owing in the Registry of Deeds or the Registry of the District Land Court for Barnstable County. A purchaser of the Projector any portion thereof will be liable for the payment of any unpaid costs and expenses,that were the subject of a perfected lien prior to the purchaser's acquisition of the Project or portion thereof. XIV. MORTGAGEE CONSENT: The Owner represents and warrants that it has obtained the consent of all existing mortgagees of the Project to the execution and recording of this Agreement and to the terms and conditions hereof and that all such mortgagees have executed consent to this Agreement. 4 Bk 19221 Pg 177 #86876 IN WITNESS WHEREOF,we hereunto set our hands and seals tl-sW ay of ,200Y OWNER BY. Signarure - ' Printed: Karen K.Dent COMMONWEALTH OF MMSAC HUSETTS County of Barnstable,ss: 8 C't- ), 9 ,2004 On this I day of 2003before me,the undersigned notary public,personally appeared the Owner(s) ,proved to me through satisfact ryevi_ of identification,which were (�A,-Y� —,to be the pe (v names is signed on the precedingor attached document and acknowled ed to be that he/she on i voluntarily for the stated purposes. 't o; r••>F: .'4�•J � m 4 Notary Public Printed: MA A e, t, t tj C P. Il H (,o P— �,� !, ��'•.t• _ My Commission Expires: J Z TOWN OF STABLE BY: Signature Printed:John C;.Klimm,Town Manager COMMONWEALTH OF MMSAC H JSETTS Countyof Barnstable ss: t1, l5t ,2004. On this /S�day of 20t&6efore me,the undersigned notary public,personally appeared T h n, '► {,.i rn r, ,the Town Manager for the Town of Barnstable,proved tome through satisfactory evidence of identification,which were ro ,to be the person whose name is signed on the preceding or attached document and ackn6wlecYged to be that he/she signed it voluntarily for the stated purposes. Notary Pu 'e Printed My Commission Expires. v I Bk 19221 Pg 178 #86876 QUITCLAIM DEED We, JOHN E. GIBSON and HOLLY T. GIBSON, of 193 Palomino Drive, Barnstable, Barnstable County, Massachusetts, for consideration of$249,000.00, grant to: KAREN K. DENT, individually, of P.O. Box 205 Cummaquid, Massachusetts 02637, with quitclaim covenants . . . the land, together with the buildings thereon, situated in BARNSTABLE, Barnstable County, Massachusetts, with a mailing address of 193 Palomino Drive, Barnstable, Massachusetts 02630, more particularly described as follows: E- . m_ LOT 97 as shown on a plan entitled Bacon Farms Estate, Section 2, by Eldredge Surveying Co., dated October 3, 1973 and duly recorded in Barnstable Registry of Deeds, Plan Book 280, Page 55. Street address 193 Palomino Drive, Barnstable, Massachusetts. The above described premises are conveyed together with a right of way for all purposes for which streets are commonly used in the Town of Barnstable or may hereafter be used which way and streets are shown on a plan entitled 'Bacon Farms Estates: dated June 17, 1972, by Charles N. Savery, Inc.", recorded with said Deeds in Plan Book 260, Page 42. Excepting from the above described premises a certain partial release of easement and right of way to New England Telephone and Telegraph Co. and New Bedford Gas & Edison Light Co. given by Wakefield Savings Bank dated May 9, 1975 recorded in Barnstable County Registry of Deeds on May 16, 1975, as Instrument No. 09247 in Book 2103, Page 330. See also release recorded with Barnstable Deeds in Book 2183, Page 147. Also excepting from the above described premises a certain easement to the Inhabitants of the Barnstable Fire District give by Pearl Freeman, Trustee dated September 29, 1973 in order to lay, maintain, operate and repair and remove water mains, pipes, .shutoffs, service boxes and other equipment and connections. J'F Bk 19221 Pg 179 #86876 e �'r For our title, see deed from Cheryl Gibson Noonan et n ax to Book us, dated 18, Page 1219b, and recorded with the Barnstable County Registry of Deeds 315. c - , WITNESS our hands and seals this 2�day of t-F- 2000._` '�'�- John E. Gibson Holly T. Gibson COMMONWEALTH OF MASSACHUSETTS , 2000 Barnstable, ss. 3 3 C .. - _. Then personally appeared the above named John E. Gibson and Holly T. Gibson, and acknowledged the foregoing instrument to be their free act and deed, before me, Notary P lic- SE ] my commission expires: 2 I Bk 19221 Pg 180 #86876 101'4 112: 22 e t- r( Vv•r1 l- .. Zrw,� Town of Barnstable Zoning Board of Appeals Comprehensive Permit Decision and Notice Appeal 2004-57-Dent Applicant Karen K.Dent Property Address: 193 Palomino Drive,Barnstable,MA Assessor's Map/Parcel• Map 297 Parcel 049 Zoning: Residential F-1 Groundwater Overlay: AP Aquifer Protection Overlay District Applicant: The applicant is Karen K.Dent,who resides at 193 Palomino Drive,Barnstable,MA. Relief Requested: The applicant has applied for a Comprehensive Permit under the General Law of the Commonwealth of Massachusetts,Chapter 40B-§20-23 and in accordance with the General Ordinance of the Town of Barnstable Chapter III,Article LXV,"Pre-existing and Unpermitted Dwelling Units and for New Dwelling Units in Existing Structures," more commonly termed the"Accessory Affordable Housing Program." She wants to create an accessory affordable unit at a single-fan- ly owner-occupied residential dwelling in accordance with all the conditions of this permit. The issuance of this Comprehensive Permit would allow for an owner-occupied single-family residence with an accessory affordable apartment within the single-family dwelling. Locus and Background: The property is a 1.02-acre lot that is developed with a 4-bedroom,3 t/z -bathroom,2,027 square feet single-family,Cape Cod style home. The applicant has owned the property since 2000. A partial unit already existed when the applicant bought the property. They applicant has used the area as a family room. She heard about the program through the media and has stepped forward to create an affordable unit. The proposed accessory unit will be built in the basement of the main house. It will be a one- bedroom at approximately 450 square feet. The locus is in a Residential F-1,in the AP-Aquifer Protection Overlay District. Procedural Summary: This application for a Comprehensive Permit was filed at the Town Clerk's Office and the Office of the Zoning Board of Appeals. A public hearing before the Zoning Board of Appeals Hearing Officer was duly advertised and notice was sent to all abutters in accordance with MGL Chapter 40A. The hearing was opened on July 21,2004,at which time the Hearing Officer,Gail Nightingale,granted the Comprehensive Permit. Also present was Paulette Theresa-McAuliffe,Accessory Affordable Housing Program Coordinator. f Bk 19221 Pg 181 #86876 Findings as to Standing and The Comprehensive Permit: At the July21,2004 hearing,the Hearing Officer made the following findings of fact: 1. The applicant is Karen K.Dent with an address of 193 Palomino Drive,Barnstable,MA. Ms.Dent has owned the property since March 31,2000 as documented and recorded at the Registry of Deeds in Book 12917 page 217. She is requesting a Comprehensive Permit to create an affordable rental apartment to be accessoryto the single-family owner-occupied residential dwelling. The applicant has submitted a copy of a certified deed recorded at the Barnstable Registry of Deeds documenting her ownership of the property. In addition,she has submitted a certified plot plan dated March 13,2000. 2. The applicant was issued a Project Eligibility(site approval) letter dated May 24,2004 from Kevin Shea,Director,Office of Community&Economic Development,qualifying the application for the Accessory Affordable Housing Program. The source of the subsidyis the federal Community Development Block Grant(CDBG)program 3. The proposed rental unit will be approximately450 square feet and will have one bedroom It will be located in the basement of the main house. 4. The property is in the AP-Aquifer Protection Overlay District.The Public Health Division has: verified that the proposed property meets both the conditions of the State's Title V Environmental Code and local Board of Health requirements,plus,approved the septic system at the site for a total of four bedrooms as per a letter from Dr.Wayne Miller,Chairman of the Board of Health,dated April 1,2004. . 4a. The Board of Health gave the.applicant a special Wiling during it's public hearing on March 30, 2004. It was determined that the applicant's current septic is equipped to handle a total of four(4) bedrooms. After investigation and deliberation on the matter,the Board approved Ms.Dent's request for program participation through Dr.Miller's letter for the following reasons: "... thefarraly MOM[or dent is dearly not beiT used for sloping purposes, based upon•as [subrrnttadl;b)ta pmadej.. testirr vm gizm diet it would not be feasible to widen flee dwvay to fzze fed as 7vgt cl in other cases cline to plumbing pipes and&t zed wiring present within the=11 invrrrliatay adjacent to the domurA and d_the propene is not lo=W within a desumtal�sensitize area as deft W with the State E nnimnmerrtal Caele, Tide V. 7be►�fom there is not any restnaicns in negani to the maci"=num7er•of babuom allot at this site in the ezar dw the septic system is desigred and cmn&W&w&sq[iaerrt c Vwty for the mni-er of bdroonx prnpased" 4b. The applicant has agreed to sign a written clause that will be placed in the Accessory Affordable Housing Program's standard Deed Restriction limiting the total number of bedrooms to four. The signed Regulatory Agreement will be recorded with the Barnstable County Registry of Deeds upon receiving ZBA approval,plus,completing the 20-day appeal period on the Comprehensive Permit. 5. The town of Barnstable completed an inspection of the property on January 16,2004. It was noted that while structurally feasible to create a full unit in the basement,the following is needed: A stove and oven;and a kitchen sink It was also noted that the main room in the unit needed a smoke detector. The apartment will be built according to the plans submitted by the property owner and initialed bythe ZBA Hearing Officer. The applicant is aware that a final inspection by the Building Division will be required and that the Building Division also has to perform all necessary inspections to assure that the unit meets applicable minimum state and local code requirements before she is issued an Amnesty Certificate of Compliance. 2 ` Bk 19221 Pg 182 #86876 6. On April 16,2004,the applicant signed an Accessory Affordable Housing(Amnesty) Program Affidavit agreeing to complywith the program's requirements,including owner occupancy of the principal dwelling unit and further agreeing to comply with the provisions set forth in Article LXV(65) of the Town Ordinances that include their signing and recording of the Regulatory Agreement&Declaration of Restrictive Covenants. The subsidizing agency has deterrruned that the signing and recording of the regulatory agreement qualifies the applicant as a"limited dividend organization" as that term is used under M.G.L.c.40B %20-23. 7. Under Chapter 3,Article LXV(65) of the Town Ordinances,the affordable unit must be rented at an affordable rent to a person or family whose income is 80% or less of the Area Median Income (AMI) of Bamstable-Yarmouth Metropolitan Statistical Area(MSA). 8. According to the Massachusetts Department of Housing and CommunityDevelopment,as of September 4,2003,5.11% of the town's year-round housing stock qualified as affordable housing units. The town has not reached the statutory minimum under M.G.L.c.40B §§20-23 or its implementing regulations. Under the Town of Barnstable's Local Comprehensive Plan,the use of existing housing to create affordable units and the dispersal of these units throughout the town is encouraged. 9. Based upon the findings,the project is deemed consistent with local needs because it adequately promotes the objective of providing affordable housing for the Town of Barnstable without jeopardizing the health and safety of the occupants provided all conditions of the Comprehensive Permit are strictly followed. Ruling and Conditions: Based upon the findings,the applicant,Karen K.Dent,is grunted a Comprehensive Permit to permit the creation of an accessory apartment of 450 square feet within a single-family owner-occupied residential dwelling,subject to the following conditions: 1. The property owner shall occupy the principal dwelling as her year-round residence. 2. Occupancy of the affordable unit shall not exceed two people. 3. This unit shall not be occupied by a family member of the owner. 4. To meet the requirements of affordability,the applicant must rent the unit to a person or family whose income is 80%or less of the Area Median Income (AMI) of Barnstable-Yarmouth Metropolitan Statistical Area(MSA),adjusted by household size. The monthly rent payable by a household inclusive of utilities shall not exceed 30%of the monthly household income of a household earning 80% of the median income,adjusted by household size. In the event that utilities are separately metered,the utility allowance established by the town of Barnstable shall be deducted from rent level so calculated. 5. All leases shall have a minimum term of one year. 6. The property owner must obtain a building permit for the accessory affordable unit whether the unit is new or pre-existing. Before the issuance of an occupancy permit and Certificate of Compliance for the unit,the Building Commissioner must determine that the unit conforms with the approved plans as submitted to the file (as initialed by the ZBA Hearing Officer and submitted with the building permit application)and meets state building,fire,and sanitary codes. The unit must also comply with applicable state on-site wastewater discharge requirements. 3 — Bk 19221 Pg 183 #86876 7. The applicant may select their own tenant(s)provided the tenant(s) meet all requirements of the program and provided that person(s) income is reviewed and approved bythe Office of Community&Economic Development of the town of Barnstable as a qualified individual. The applicant will be required to work with the town to provide information necessary to document that the tenant(s) qualify. To insure that the unit is rented in an open and fair basis to an income eligible individual or family,the unit must be listed with the town whenever a vacancy occurs. Also,the applicant must notify the Office of Community&Economic Development of a � vacancy whenever it occurs. 8. Every twelve months the applicant shall review the income eligibility of those individuals occupying the unit. No later than a year from the date of issuance of this Comprehensive Permit the applicant shall file with the Office of Community&Economic Development of the town of Barnstable an annual affidavit listing the rent charged and income level of the occupant(s) of the unit. The applicant shall provide the town any additional information it deems necessary to verify the information provided in the affidavit. Upon any report from the town that the terms and conditions of this permit are not being upheld,the Zoning Board of Appeals or it's Hearing Officer shall have the ability to hold a hearing to show cause as to why this permit should not be revoked. 9. The Accessory Affordable Unit shall be affordable in perpetuity(as affordable is defined herein) unless this Comprehensive Permit is rendered void. 10. This Comprehensive Permit shall not be transferable to any other person or entity without the prior approval of the Hearing Officer or Zoning Board of Appeals. This decision,the Regulatory Agreement and Declaration of Restrictive Covenants and all other necessary documents shall be filed at the Barnstable County Registry of Deeds. If.the ownership of the property is transferred,the town of Barnstable shall be notified within 60 days the name and address of the new owner. 11. All parking for the dwelling and accessory unit shall be accommodated on site,and no lodging shall be permitted on site for the duration of this Comprehensive Pernik. I 12. This Comprehensive Permit must be exercised and the unit occupied within 12 months of its issuance or it shall expire. Transmission of the Decision of the Hearing Officer to the Barnstable Zoning Board of Appeals i In accordance with Part II,Section 4.02 and Pan III,Section 3.72 of the Town of Barnstable Administrative Code,the hearing officer transmitted her written decision to the Zoning Board of Appeals on July 21,2004 and fourteen days having elapsed since said transmittal with the Zoning Board of Appeals taking.no action to reverse the decision,this decision becomes the decision for this Comprehensive Permit application. Ordered: Comprehensive Permit 2004-57 has been granted with conditions. Appeals of this decision,if any,shall be made to the Barnstable Superior Court pursuant to MGL Chapter 40A,Section 17,within twenty(20) days after the date of the filing of this decision in the office of the Town Clerk. The applicant has the right to appAal this decision as outlined in MGL Chapter 40B,Section 22. G tda ightingal , aring ficer Date I, Hutchen 'der,Clerk of the Town of Barnstable,Bamstab chus*�ty, ereby certify that twenty(20) days have elapsed since the Zoning Board a[Appg.. this l$cis n and that no appeal of the decision has been filed in a office of the To Na nRR ST A8L 'f�! x S9 Signed and sealed this day of o aria e* s per)ury. da Hutchenrider,Town Clerk 4 BARNSTABLE REGISTRY OF DEEDS S FtHE THY Town of Barnstable iARNSTMLE. MASS. 1639. Board of Health �0 ArEp�tA . . P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,MS Wayne Miller,M.D. April 1, 2004 Ms. Karen Dent 193 Palomino Drive Barnstable, MA 02630 Dear Ms. Dent, During the public Board of Health meeting held on March 30, 2004, the Board voted unanimously in favor of approving your request to utilize the existing septic system for the proposed amnesty program affordable unit within your home. The Board has no objection to your proposal to utilize a maximum of four bedrooms at your property and to maintain the structural design and use of your existing "den" or "family room." This permission is granted with the following conditions: (1) No more than four bedrooms total are authorized at this property at this time. The existing "den" or"family room" shall not be utilized for sleeping purposes. (2) The Board of Health specifically conditions its approval of the applicant's "amnesty program septic questionnaire form" for the existing septic system, upon the recording by the applicant of a deed restriction limiting the total number of bedrooms to four. With regard to the form that said restriction takes, the applicant may elect one of two options, either a) Prior to filing for a comprehensive permit under the town's accessory affordable apartment (amnesty) ordinance, recording at the Registry of Deeds a separate properly worded deed restriction, signed by the property owner, restricting the number of bedrooms at this property to the four bedroom maximum allowed; or b) requesting the inclusion of the "four bedroom maximum" language as part of the restrictive covenants required by the Zoning Board of Appeals as a condition of the issuance of the comprehensive permit. The applicant shall provide the Board of Health proof of compliance with this condition no latter than sixty (60) days after the issuance of any comprehensive permit for the subject property. The existing septic system was designed to handle a maximum of four bedrooms. After reviewing the proposed floor plans of the accessory affordable housing unit and existing home, Public Health Division staff became concerned that the total number of rooms which are normally defined or considered as "bedrooms" would over-tax the existing septic system and would cause hydraulic failure, ultimately and potentially resulting in a source of pollution and threat to public health. This permission is granted because it is the opinion of the Board that the "family room" is clearly not being used for sleeping purposes, based upon the photographs and DentKaren 1 testimony provided. Also, the applicant's representative provided testimony that it would not be feasible to widen the doorway to five feet as required in other cases due to plumbing pipes and electrical wiring present within the wall immediately adjacent to the existing doorway. In addition, this property is not located within a designated nitrogen sensitive area as defined within the State Environmental Code, Title 5. Therefore there is not any restrictions in regards to the maximum number of bedrooms allowed at this site in the event that the septic system is designed and constructed with sufficient capacit for the number of bedrooms proposed. Sinc e y yours, W yne Iler, D. Chairm DentKaren 1 SMOKE DETECTORS REVIEWED IMPORTANT - UPGRADE REQUIRED STATE BUILDING CODE REQUIRES THE UPGRADING OF BARNSTABLE BUILDING DEPT. SMOKE DETECTORS FOR THE ENTIRE DWELLING WHEN ONE OR MORE SLEEPING AREAS ARE ADDED OR CREATED. NOTE: A SEPARATE. PERMIT IS REQUIRED FOR THE FIRE DEPARTMENT. DATE INSTALLATION OF SMOKE DETECTORS-THE ELECTRICAL BOTH SIGNATURES ARE REQUIRED FOR PERMITTING D F'E/M PORCH PERMIT DOES NOT SATISFY.THIS REQUIREMENT, Q ❑ o m \ [�ATI-I c L OS 22-=1 I T / 22 DEN - 2F3'�1 L/v RM; . 6"6 s I S7- Fl-0OM PLAN 193 PAt_0A4iAl �� owNe�t K,�GNT` l3�+T14 ^� STOI'AGE s 2 Np J LOOR 113 P4L OkIiNO PA' ID 8 Rna G; STO� 46E G�?Ir UT1 Ll " Y ROOM SCALE /g" O 03 F,�40411YO DR__ -2Z-041 S S LAY , 13 /2ivi L l V Rm' o _ 5TORA�F BAR AG� ❑ 0 u Tl L 17-Y GOON( s i Lf SEAL E�g=�t PeR LEyEL AP 7- t R E'A = q,5 0 F PA1-oM1/VO DR NSTi k;DENT 1 I McKean, Thomas From: McKean, Thomas Sent: Monday, February 02, 2004 10:11 AM To: Mcauliffe, Paulette Cc: Health Office Subject: 193 Palomino Drive/ Karen Dent The septic questionnaire application regarding the above-referenced address received on 1/28/04 is disapproved due to the following reasons: The septic system capacity is limited to only four bedrooms according to the permit issued; however five bedrooms were counted on the submitted floor plans. The following suggestions are provided: a) Upgrade the septic system to a five bedroom capacity system, or, b) Have an engineer inspect the existing system to determine whether the leaching capacity could handle five bedrooms and to determine the condition and functionality of the existing system, or, c) Convert the existing "den" room into an open (non-private) room by removing the door and providing a minimum five feet opening at the doorway there. e , - w 1 I Town of Barnstable o A Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,RS. FAX:. 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. i Ms. Karen Dent February 26, 2004 193 Palomino Drive Barnstable, MA lyt x ��&. K S�etcapat�resusedra £uuntat193P�koroD�] aastale a,...,..�Y rs.."r Dear Ms. Dent: On Tuesday February 17, 2004, the Board of Health held a public meeting to discuss your request not to consider the "den" in your home as a bedroom. Your request regarding the above referenced matter was scheduled on that agenda; however you were not present. Therefore, your request was postponed to the next Board of Health meeting which is scheduled to be held on Tuesday March 30, 2004 at 7:00 p.m. at the Town Hall second floor Hearing Room. We hope that you will be available to attend the next meeting. If not, please communicate to us in writing (via mail or facsimile #508 790-6304) to request a continuance. SiWyo Chairman Board of Health Town of Barnstable sewerV arianceB ornstein2 ' MAR. 02 ' 04 (WED) 11 :47 I6 DEPT (DP) 1 508 394 4051 PAGE. 1/1 Wayne Miller, M.D. March 3,2004 Chairman Board of Health Town of Barnstable 200 Main Street Hyannis, MA 02601 RE: Septic Capacity Versus Bedroom Count at 193 Palomino Drive, Barnstable Dear Dr. Miller, I have received your letter dated February 26, 2004 regarding the above matter. I was not present at the public meeting on February 17, 2004 because I had no knowledge that my request was scheduled on the agenda. Had I known this, I surely would have attended. Thank you for postponing my request until March 30,2004, I appreciate the ample notice. If there are any forms to complete or information that I should have with me,please advise. My fax number is(508)394-4051. I can also be reached during the day at(508) 760-7210. Sincerely, Karen Dent 193 Palomino Drive Barnstable, MA 03630 I -A To: Thomas McKean From: Karen Dent Date: February 3, 2004 Subject: 193 Palomino Drive - Dear Mr. McKean, I was disappointed to hear that you did not approve the septic questionnaire application on my home. I believe the existing septic system to be adequate for the four bedrooms in the home, and that the room labeled"Den"on the submitted plans should not be considered a bedroom. Half of this room is used as a TV area and the other half is a sewing studio with closeted shelving to hold my extensive fabric collection— see photos. Since I live alone, I have no need for additional bedrooms. Enclosed is a copy of the Building Permit application submitted to the town on Nov. 22, 2000. The permit request was to convert an existing one-car garage to a family room. It was approved by the Health Division. Please note in the area of number of bedrooms the notation of"No Change". Someone added the"4"to existing and"0"to new. Since this information was not provided by me, I can only assume that someone else obtained this information and filled it in. At no time was the subject of too many bedrooms raised. Permit#50223 was issued without question. Please accept this new information and reconsider my application for the Amnesty Program. Thank you for your consideration. Karen Dent 508 362-9731 h 508 760-7210 w TOWN OF BAMSTABLE LOCATION / n�/L lirr,1�/�.�^! ���t�9,+ SEWAGE # c� VILLAGE54LSSESSOR'S MAP & LOT ~ ' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /a d J ' LEACHING FACILr Y: (type) i.y fog ) (size.) •21 NO.OF BEDROOMS WWW IW OR OWNER 1,Vsx 6� PERMITDATE: f COMPLIANCE DATE: �r Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility — Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by� 1 �►� y�� TB � r 7�5"z.Ll 7r- t I TOWN OF BARNSTABLE t� COCAnON /9-3 P41-1f,,Y,,y lr'� 10 l SEWAGE # n a VJLLAGE e ms: Mod O .'V�nLL�SESSOR'S MAP& LOTk 59 INSTALLER'S NAME&PHONE NO. 17116Ci40 y ce-y i/-C SEPTIC TANK CAPACITY .10 d :J LEACHING FACILITY: (type) r (size) J� NO.OF BEDROOMS _ OR OWNER PERMITDATE: 9',_19 :COMPLIANCE DATE: ® Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility..(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin faci 'ty) Feet ` l Furnished by ,. �. �� ,� i - t �_ .. � .� 1 ,� 1.3.E j�f�..s �_ �03 � ��- �� - 1 No. Fe _ THE COMMONWEALTH OF MASSACHUSETTS Entered in corn steer. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS v 01pprication for &.5poal *pgtem Construction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System XIndividual Components Location Address or Lot No. L(3 Pl4 a AVY,,o Owner's Name,Address and Tel.No. W2w,g�ri�i P Assessor's Map/Parcel 0 qcl r�Sb ro Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (�Lt()—GA S _5, is k 0, S 5 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow"' , gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �-ece SOH ,r kC-)Oo !r �CL( Type of S.A.S. iA C C, Description of Soil IdVLc� 1CO A if L-£ LOU,) Nature of Repairs or Alterations(Answer when applicable) 4 4S d�. i Li Vt� C Lit yl. l� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has Signed Date C Application Approved by Date 1 1-2a yf Application Disapproved for the following reasons Permit No. — Date Issued a 4, N. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: —A/- 1 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Y Tipplication for Migogal *pgtem Congtruction-PerMit f Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System XIndividual Components f ":: , - ; i I / Location Address or Lot . `-Cn, P4--<-/1� Q✓ �� Owner's Name,Address and Tel.No. Assessor's Map/Parcel �jb ro 6 � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow�� gallons. Plan Date ? Number of sheets Revision Date Title Size of Septic Tank 1&c. s'z ��n� �, 4 Type of S.A.S. r � C r�c e Description of Son. 14 A WC-C� Slav;f1 v Nature of Repairs or Alterations(Answer when applicable) t Gf L-, — c C t _SXr, eri ll ti 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 Certifi- cate of Compliance h.! enm4saned-by- - 1. €n Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No._ - 3 . Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ,x. Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( Vj' Abandoned( )by— &l D-e- lA L E S E aA--,C at Z has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. l�rf- �7�dated/7 2 Installer Designer The issuance of this permit shall not be construed as a guarantee that the Sys will function as designed. Date � "2 �} Inspecto��'�_ 44 No. !7 ' 0 ---------------Fee _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migpogai 6pgtem Con!6truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 1 �� _� evI.w a i®t t_0 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: ! Z -99 Approved by NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH RIND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLAYS) 1L , hereby certiriyy that the application for disposal works construction permit signed by me dated concerning the property located at �� ��\ Vh 'a C' meets all of the following criteria: `% The failed system is connected to a residential dwelling only. There are no commercial or business tenses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. (�There are no wetlands within 100 feet of the proposed septic system here are no private wets within 150 fert of the proposed septic systern • /There is no incense in flow and/or change in use proposed • There are no variances requested or needed-The bottom of the proposed leaching faclity will not be located less than five feet above the ma.-durum adjusted groundwater table elevation. (Adjust the g undwater table using the Frimptor method when applicable] If the S.A,S. will be located with 2J0 fert of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table e!e•/ation, Pleze complete the following: �) Tap of Ground Surface Elevation(using GIS inf6rmation) 3, 1 B) G.W. Elevation -�St O _the Ma-'C. 'Ugh G.W. Adjustment --7A`v = C) D 1F cREv CE BETWEEN a,and B b© t SIGNED : DATE. (Sketch proposed plan of system on backs. q:4eaith folder.c-t .,: 0 �.,.�--- i TOWN OF BARNSTABLE LOCATION /9-2 rl Wl e //'; SEWAGE # v � j VILLAGE_ =/�',t-9i•r/, ASSESSOR'S MAP & LOT�V''5�7 INSTALLER'S NAME&PHONE NO. 47/t1CiSI©c SEPTIC TANK CAPACITY %O d J LEACHING FACILITY: (type) (size) NO.OF BEDROOMS l WW%.QF,R OR OWNER 4,f. PERMTTDATE: / ;9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leiching Facility Feet r 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 leachin facility) Feet Furnished by v� r� -•� j{ ,� 1 rr 77 TIT I i T i a C i f IT ' i Town of Barnstable Health Inspector o f tW r Office Hours Regulatory Services .. 8:00-9:30 Thomas F.Geiler,Director 1:00-2:00 aAMSTABLE, i Only 9�AMAM v� Public Health Division rECMp�a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT- SEPTIC QUESTIONNA1 1. General Information: --- Address: / 93 / 4 eLO M/A)C) Map ,29 7 Parcel (3 �q Name: _IC 4 e F_/J -bF t -j— Phone#: S0% 36a - 973 / 2a. How many bedrooms exist at your property now? `1 2b. Are you planning to add any bedrooms?. A.)0 If yes, how many?. 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? Z 2d. Please include a copy of the floor plans for the entire property showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling.is;connected to Fpulilic sewer;skip questions 4'4jbelow 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a .If yes,how many bedrooms were approved_according to this permit? _Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 8. Is there an engineered septic system plan on file at the Health Division? YES or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO FOR OFFICE USE ONLY TO BE SIGNED BY A.HEALTH INSPECTOR/AGENT ONLY The Public Health Division has no objection to bedrooms at this property. Signed: Date: Inspector(Print): Q;/health/wpfiles/amnestyapp LOC�?ATION y 94 SEWAG+E PERMIT No. 44 VILLAGE INSTALLER'S NAME i ADDRESS---------------- OR OWNER cl i DATE PERMIT ISSYED DATE COMPLIANCE ISSUED Me- CUSKE+e Zo GG-"GOING C/,2C�� 2 97 - 051 Y/O l7s PIZOM/No D,e . Z97 - 050 - .� f CpROLE A RlCCARPI LOT 99 LOT 98 ?�3 �ARlP/�9GE CANE `� 297 -631 _ — — — — —% NB3'4725E 359.78" 10-- --AS—El EP�—T S H—OW,n —O: Ac7E-5S-O-/C— AP_ KAp_,sAl ��-=�--S-.__,�;� __ �— �o�; f�a JAL 11 �i.t �/ •I NDA IQ�.b GN DENT FAYE,Qo �i� a:: 0� ,� 186 pR fo,�i vo OQ G��-I�/�O V//99-__ y L R 31.3 �A�2.QlAG�" L•9�� o LOT 97 ti }r 4 L o z 9 / 229' 2 97• APPIr'o'y o o�yA, 2 97 -430 9 S80'10"30""iV - �'y,eEZq,v-r v �' L�SA �ETORa JEANN� M nl Zoo Vj4oA41A;o D� Z o 5 pAGLOTI 90 O� Zq� -oye LoT A, IsOCATION SEWAGE PERMIT NO. VILLAGE I INSTA LLER'S NAME ADDRESS i d UILDE R OR OWNER DATE PERMIT ISSUED L 1- 3a- DATE COMPLIANCE 1SSUED � � . ,�� �� �� �� � /�,, i / .� � � r �� � • i No..oaf-3 FEs. .. 6 THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH ` ...............OF..... . ... Appliratiou for Disposal Workii Tonstrurtinn Permit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal S�> tn at: 1 Q. .. .... -- .......... ........ ^--._..... .................................................1.-------t................ S Location-Address or Lot No. .............. -----.......---................---•--..............._................ .._........................................._............................................._...... Owner Address ------------------- - -----------•---------- Installet Address }— Type of Building 3 Size Lot.. ..... ` .�q, feet U Dwelling No. of Bedrooms.............................. .....Ex Expansion Attic►-� g— --------- p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( ) Q Other fixtures ............................................. ...... -----•------- Design :... :............. W Flow....... e�............................ 000 gallons per person peIZ�Y. Total dailyZow..: 30. ..... ..._.._..... lons. WSeptic Tank—Liquid capacityl--.._.---.gallons Length.._-.....:_..... Width_.......t_.--. Diameter:............... Depth...Or........ x Disposal Trench—No..................... Width .. ._____.. Total Length.....�re:._ Total leaching area.._.......:.........sq. ft. 3 Seepage Pit NO........A........... Diameter....1....... Depth below inlet..............F.+: Total leaching area`%`J....st.-4, GI Z Other Distribution box ) Dosin to ( ) Percolation Test Results Performed by.. l.5 °.r'a........ � . e . Date... .19.bg.i.......... Test Pit No. I.....2-......minutes per inch Depth of Test Pit._..�_ _. .-. Depth to ground water...r:lon e...... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.... _.. Depth to ground water.....�CCU vi�ere� YY� ...... ....... ...................................•----•--......................................................... O Description of Soil....._Se:....a........`'t'P-� �"��...... ........ V ..............••..••---- ----.....---•------------•-••-•-•..........-•-----•-••-•--•-•--•---...........----------•••••-••......_ . ..........._......----............. ........................... .....................-............. .------------------------------------------------- •----------------- -•........ •------- --•----------- •............. -......... -........ .--------- •••-••------- •....... - U Nature 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 MITI.:; 5 of the State SanitaryEissp-5d The undersigned further agrees not to place the system in op r ion until a rtif a of Compliance has ee by t boar of lleX Signed.._.. .... ...............................................5......... .........................._.... Date r Application Approved BY ........•-•--.........•••....._ `��.�o.::'fI .... r•- ...........Date Application Disapproved for the following reasons:---------------•--..._........__...------.--............----.---•--------........ ......------.- ---••-•-•-......----••....-•-•-•••-•...................•----•-•--..:...........-•--•••--.....-••----••-••..----•--••-................----......_...•---••=---•••--•------...----......----•.......... . Date PermitNo......................................................... Issued.....................................................- Date No.. y,3 8 ,- FFz • � � THE COMMONWEALTH OF MASSACHUSETTS r �} BOARD OF HEALTH 1P OV�Jn1 OF..... \�0.("11Sa �R' ..........................................•----.------................................................ Applirttliol4 or Dioposal Works C onstrurtiun Permit }a Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: --.........- - ...........::....n =..... � --•-• -�-•••--•�--•..�`........ = ...... -'- a L t Location Address a: or Lot No. ........-• .... •--•-•----•---•--•--•-•................................ ---•_... ._.......................... -- W Owner r—t r Y` f`- -- ep 1,1 t , >k t It,ljo Address f ,.� .............................................._..... ....... ----•-...•---•-•---••---•---•---:..--_..... .. ........... Installer Address -�- Type of Building Size Lot..'` `...:4 1.`Sq. feet Dwelling—No. of Bedrooms.•.._................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Buildin a Other—Type g ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ................................ W Design Flow_____. `?.......-�� -�..,•A...__:..�gallons-per person per,day. Total daily flow................... .....................gallons. WSeptic(Tank—Li`quid capacity�n!.d.gallons Length.. ?=___ Width:... Diameter................ Depth-_ _.___... x Disposal Trench,)No... . .........t..,Width__._.._. Total Length..........;.-_..... Total leaching area_..._....._..._...sq. ft. 3 Seepage Pit No--------- Diameter..._`�.�< Depth below inlet_._ . :: Total leaching area eJ` ` �1..:sq�ft. G J p Z Other Distribution box X) Dosing�tank ( ) Percolation Test Results Performed by---E.1c�,`t-A Falr�naw"� (J.e.: Date...2� 4� 84 ,a Test Pit/No.. 1..._2�....._m�nutes'per'inch Depth of Test Prt A' .. Depth to ground,water fs. k Test Pit NoY 2...............minutes per inch Depth of Test Pit....�� __. Depth to ground water.. COu�'?r e• .........................-•••--••--•--•= ..................... _ f O Description of Soil...... p.� o,~{ c e-c (Jl a�n -------------•-•--------••....... .._.......---.........._...-•-••-•-•••......•--••-.....-- ,," V ................................ ...... --•.....--•-•-•••-••-•••...........--••-•......----•............-•--- W : VNature of Repairs or Alterations Answer when applicable.......................... ��.___..::._..:...._:........................................ ........:...................•••-•......#----�-------••--------........... Agreement:1 <fr jf > ? The.,undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisibu`s.,of P'ITL,! 5%f}tfie'State Sanitary°Code The undersigned further,agrees not to placeshersystem in op io until a rtl a of Compliance hasrbeen issued by the boardaof h8althl �' 'f } to r �. X Sign ' ``'.�5 f 7 ✓ --....... ••...................• ... . .......... .. - j., ate S/ D Application Approved By-•--•------•-•--• '� s..A--•---•.... Date Application Disapproved for the following reasons:................................................................................................................ ----.......-•--•----:••--•-••-------•----•..................:........•-----••----------...-•--•------..........••••••--•----•-----••---•......._...•--•---•••••-•---•-•...............•---...........- Date Permit No............................. Issued.---••-............-----•••- -••............. Date --•--•••-----..._..._....» _ .�_ _ �..T.. �..uA�!-.ice•.►.ra..��-i..w..+e...r'vn..R, wF ps-r2+ .-3 nP .... .+...e..®. -.. '?^!R^.•Tn�.;-•.ant+•M .-.. •-. .l.!1-s. _..�{.e.. !3 n!.e ap +..r ., ro^ .�- ss, w .e..e .Ky.....,++�. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r- Tatif uttte of Tomplianrr THIS IS TO C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................ ...--•-•-••-••--••-•............ ..........•• ---•••••-•-....----••••-•--.........._.......--••-•----••.... ...............•--•-----•• v staller at................ ...�_ ._..._. `b` ............... .. ---•- has been installed in accordance with the provisions of TITLw 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__,1�y-'_. L ............. dated................................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT?N SATISFACTORY. ; r 1.. �1-( .._. Inspector DATE :....:............:. .._.... ....--- .... -••-........--•-•-•----•-•-•--•--........•--••.........--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH P ......................OF..................................................................................... NO... ......._ FEE.. .............. Dispnsttl: ur ,� Tunstrurtian Permit Permission is hereby granted --•------•-----•-•-----------------------•-----..._.....-•-•-•-•-.....-•-••----........................- to Construct Rep F.�_.air ( ) a dividual Sy-arage Dispo System atNo............_.I ......7. ............. .................... *........----•-----..... --••---•----•............:......... ......... Street, as shown on the application for Disposal Works Construction Permit No........ .......... Dated.... __.................................. ... ... ................ ... ,...._ - Board-of Health FI DATE.._.... ,- ------ ...... 7 - SECTION - SEWAGE + 1 - SEPTIC TANK - _"D"BOX - - LEACH— TOP / \ 1- OF FDN 11Z. a IMSLI� ..2..of„ITO 42" WASHED STONE p� / IN• L OUT INOUT- IN .04,�o Iat1TIC oNK ELEV. ELEV. ELEV. _ ELEV. 1 o'3.q a 103.'1'� I 1 ELEV. ELEV. �-�- x IT a o WASHED STONE l TEST HOLE LOG t �. TEST BY TEST DATE _ /'`j 4- WITNESS DESIGN �3 BEDROOM HOUSE T.N. 1 lob o T.H. GG" _ ELEV. cScJ � [ ELEV. At . NO •� `• � '� /,�\ ` \ L�4H soI` Igo, Ivy 4 PERG.RATE -?' MIN/IN. j_ DISPOSERI DISPOSER � G. '� �\• gyp• \� \ - 30" FLOW RATE 32io (GAL./DAY ) 330 -- -- • � ' ` \, FIKvL- 5,6tio �s �. 3ou�oczs 3�" Io�l .�( SEPTIC TANK 33o L 4RS_. \ oy�. 4-% T-- I05.0 REO'D SEPTIC TANK SIZE IQQ� ILEACH FACILITY SIDE WALLS 4'O�"J�,� = 16�.=; (2.S -411.Z_ G/D. SAND eb. °5- D BOTTOM _4�?L�4_��1����( t.o } s 21' _ G/D. TOTAL Ze.1 I-14.' USE: ot.IG _ LEACHING WATER ENCOUNTERED —'- Cl't_�_..P�--•--�, e +w. -- � � �,,,` � � 1 1 DOTES: (UNLESS OtHERWISE NOTED) Ny I. DATUM(MSL TAKEN FROM._.___�YAaiLI I.J ' .....__QUADRANGLE MAP � pp tioP c� 2.MUNICIPAL WATER__-• \`�_ - -.- AVL�ILABL'fa IO ie M�sq '`��H { �1=1` G� 3. PIPE PITCH: Y+"PER FOOT V_ OF s V_ OF \; ` 4. OESfGN LOADING FOR ALI,,PRE CAST UNITS: AASHO •_ 44i S. MIN.GROUND COVER OVER ALL.SEWAGE FACILITIES: (1) FT. ��, �y �},.� '�,y !, ------0----•--DISTANCE AS CERTIFIED 6.PIPE.JOINTS SMAI L BE LS TgWATER TIGHT ARNE ARNE H. ,:�' 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.O'F MASS. H. OJALA STATE ENVIRONMENTAL CODE TITLE 5 0OJALA { 26348 `n CIVIL r:' _ SITE l�T BAN Npo LOCUS: "fSTER�yoQ N� SU REG. J. INEI R FIEF: P"PAaED FOR: COVIL ENGINIEERS LAND SURVEYORS -- ---1------ CONTOURS (EXISTING)-.. --. ....... BOARD OF HEALTH , REG.LAND SURVEYOR(PROPOSED)-O--O-0-0 AAPROVED _ - DATE MA 8�1=.PJSTF�Fi1.� MA I Y*rmoath C- :==MA SGAL I DATE r, A • ( • < 3 G7