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#4855TOWN OF YARMOUTH BOARD OF APPEALS APPLICATION The following Rules and Regulations are hereby adopted by the Yarmouth Board of Appeals and shall govern the submission of all Appeals, Applications for Special Permit, Applications for Comprehensive Permit, and Petitions for Variance to the board and the conduct of all hearings held thereon. These Rules and Regulations are adopted in accordance with M. G. L. Chapter 40A '9 & 12. In the event of a conflict between any of these Rules and Regulations, the provisions of any by-law or statute, as the case may be shall prevail. The invalidity of any section or provision of these Rules and Regulations shall not invalidate any other section or provision hereof. 1.All Appeals, applications for Special Permit or Comprehensive Permit, and petitions for Variance to the Board shall be submitted on the forms provided by the Board for such applications. 2.Two (2) original applications (attached) (no photocopies), type written or hand printed) and a copy of the most recent deed must be completed and signed by the Petitioner, the Property Owner and Building Commissioner prior to filing the application with the Board of Appeals. 3.If determined by the Building Commissioner, a formal Site Plan Review hearing must be completed prior to filing the application with the Board of Appeals 4.On the application, in the space provided for ³Project´: after the word ³property´, summarize what it is the applicant proposes to do, (see sample provided on application) as this is the information used for the legal advertisement in the newspaper. The hearing could be illegal if this information is incorrect or incomplete. 5.All Appeals, applications for Special Permits and Variances must be accompanied by 6 Certified Plot Plans & Elevation Plans not more then 2 years old (13 Certified Plot Plans if within the Aquifer Protection District if commercial project), (Comprehensive Permits must be accompanied by 19 sets of plans along with proof of filing a copy with the Cape Cod Commission), The petitioner shall file with the application sufficient plans and drawings so that the Board can address all of the criteria prepared by a Registered Land Surveyor or qualified Professional Engineer which shall show; the locus; the parcel or parcels of land involved; the existing or proposed building or buildings; the proposed additions or alterations of existing buildings with all dimensions set forth; the location of the septic; the existing or proposed frontage, front, side, rear line distances; all perimeter dimensions (existing and proposed); location and width of abutting, and on-site, street and drives, parking, existing topography; a grading plan, areas of proposed and retained vegetation, distinction between upland and wetland. In the case of new construction, renovations and additions, raze and replacements, accessory apartments, the Board also requires architectural renderings, sketches or elevations, scaled floor plans and certified plot plans showing existing and proposed conditions) However, the Board may in its discretion waive these requirements or request additional material considered necessary for its review of the application. Extra copies of the plans will be disposed of after the hearing unless otherwise requested. 6.For all Appeals, applications for Special Permits or Comprehensive Permits, or Variances the applicant shall provide the current Assessors Map and Lot Number for the property which is subject of the petition, and accompanied by a list, by the current Assessor’s MAP & LOT Number, of the abutters (see assessors Certification for Abutters List attached) 7.Residential applications for Special Permits, Variances or request to overturn the decision of the Building Inspector must be accompanied by a filing fee of $125.00, plus postage. Commercial applications for Special Permits, Variances, or request to overturn the decision of the Building Inspector must be accompanied by a filing fee of $200.00, plus postage. Application for a Comprehensive Permit (per M.G.L., ch. 40B), must be accompanied by a filing fee of $300.00, plus postage. Postage charges for all applications will be determined by multiplying the number of abutters (including the applicants parcel) times .56¢, which is the current cost for the two required mailings. 8.Hearings (max. 4) shall be held by the Board on the Second and Fourth Thursday of each month at 6:00 p. m. or at the call of the Chairman or Acting Chairman in the Yarmouth Town Offices 1146 Route 28 South Yarmouth, or at such other place as the Chairman or Acting Chairman may from time to time designate. 9.Hearings shall be held in accordance with M. G. L. Chapter 39, §23A-23C and shall be open to the public except at such times as the Board, by majority vote, shall vote to go into Executive Session in accordance with provisions of M. G. L. Chapter 39, §23A. 10.The Board may, in a particular case, waive strict compliance with the requirements of these Rules and Regulations when, in the judgment of the Board, such action is in the public interest and not inconsistent with the Zoning Enabling Act or the Zoning By-laws of the Town of Yarmouth. CONDITIONS At each and every hearing of the Board of Appeals, whether you are seeking a Variance, Special Permit, or Comprehensive Permit, the following conditions or criteria will apply: Conditions for a VARIANCE: The Board of Appeals may authorize, upon appeal, a Variance from the terms of the Zoning By- laws with respect to and including Variances for use, with respect to particular land or structures. Such Variances shall be granted only in cases where the Board of Appeals finds ALL of the following: 1.A literal enforcement of the provisions of the by-law would involve a substantial hardship, financial or otherwise, to the petitioner or appellant. AND 2.The hardship is owing to circumstances relating to the soil conditions, shape, or topography of such land or structure and especially affecting such land or structures, but not affecting generally the zoning district in which it is located. AND 3.Desirable relief may be granted without substantial detriment to the public good and without nullifying or substantially derogating from the intent or purpose of such ordinance or bylaw. Conditions for a SPECIAL PERMIT or a COMPREHENSIVE PERMIT: The Board of Appeals approval or special exceptions shall not be granted unless the applicant demonstrates that no undue nuisance, hazard, or congestion will be created and that there will be no substantial harm to the established or future character of the neighborhood nor of the town. TOWN OF YARMOUTH BOARD OF APPEALS APPLICATION FOR HEARING Appeal#:__________________ Hearing Date: _______________________Fee$___________ Owner-Applicant: _____________________________________________________________ (Full Names- including d/b/a) ______________________________________________________________________________ (Address) (Telephone Number)(Email Address) and is the (check one) Owner Tenant Prospective Buyer Other Interested Party Property:This application relates to the property located at:_____________________________ __________________ and shown on the Assessor's Map #:___________as Parcel#: __________ Zoning District:_________ If property is on an un-constructed (paper) street name of nearest cross street, or other identifying location:__________________________________________________ Project: The applicant seeks permission to undertake the following construction/use/activity (give a brief description of the project. i.e.: “add a 10' by 15' deck to the front of our house” or “change the use of the existing building on the property"): RELIEF REQUESTED: The applicant seeks the following relief from the Board of Appeals: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 1)_____REVERSE THE DECISION OF THE BUILDING INSPECTOR OR THE ZONING ADMINISTRATOR dated ______attach a copy of the decision appealed from). State the reason for reversal and the ruling which you request the Board to make._________________________ _____________________________________________________________________________ _____________________________________________________________________________ 2)____ SPECIAL PERMIT under §_______________of the Yarmouth Zoning By-law and/or for a use authorized upon Special Permit in the "Use Regulation Schedule" §202.5 ______.(use space below if needed) 3)____VARIANCE from the Yarmouth Zoning By-law. Specify all sections of the by-law from which relief is requested, and, as to each section, specify the relief sought: Section: __________ Relief sought: _______________________________________________ Section: __________ Relief sought: _______________________________________________ Section: __________ Relief sought: _______________________________________________ ADDITIONAL INFORMATION: Please use the space below to provide any additional information which you feel should be included in your application: ______________________________________________________________________________ ______________________________________________________________________________ FACT SHEET Current Owner of Property as listed on the deed (if other than applicant): ________________ ______________________________________________________________________________ Name & Address Title deed reference: Book & Page#___________________or Certificate #__________________ Land Court Lot #_________Plan #________ (provide copy of recent deed) Use Classification: Existing: _________________________§202.5 #________________ Proposed: _________________________§202.5 #________________ Is the property vacant: ______________ If so, how long?: ____________________ Lot Information Size/Area: ____________Plan Book and Page ________/______Lot#______ Is this property within the Aquifer Protection Overlay District? Yes ________ No ________ Have you completed a formal commercial site plan review (if needed)? Yes____ No_______ Other Department(s) Reviewing Project: Indicate the other Town Departments which are/ have/ or will review this project, and indicate the status of their review process:______________ ______________________________________________________________________________ ______________________________________________________________________________ Repetitive Petition: Is this a re-application: _______ If yes, do you have Planning Board Approval? _________ Prior Relief: If the property in question has been the subject of prior application to the Board of Appeals or Zoning Administrator, indicate the date and Appeal number(s) and other available information. Include a copy of the decision(s) with this application: ______________________________________________________________________________ ______________________________________________________________________________ Building Commissioner Comments: ________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________ Applicant’s /Attorney /Agent Signature Owner's Signature Address:_______________________________ ______________________________________ Phone_________________________________ E-Mail:________________________________ ____________________________________ Building Commissioner Signature Date TOWN OF YARMOUTH BOARD OF APPEALS APPLICATION FOR HEARING Appeal#:__________________ Hearing Date: _______________________Fee$___________ Owner-Applicant: _____________________________________________________________ (Full Names- including d/b/a) ______________________________________________________________________________ (Address) (Telephone Number)(Email Address) and is the (check one) Owner Tenant Prospective Buyer Other Interested Party Property: This application relates to the property located at:_____________________________ __________________ and shown on the Assessor's Map #:___________as Parcel#: __________ Zoning District:_________ If property is on an un-constructed (paper) street name of nearest cross street, or other identifying location:__________________________________________________ Project: The applicant seeks permission to undertake the following construction/use/activity (give a brief description of the project. i.e.: “add a 10' by 15' deck to the front of our house” or “change the use of the existing building on the property"): RELIEF REQUESTED: The applicant seeks the following relief from the Board of Appeals: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 1)_____REVERSE THE DECISION OF THE BUILDING INSPECTOR OR THE ZONING ADMINISTRATOR dated ______attach a copy of the decision appealed from). State the reason for reversal and the ruling which you request the Board to make._________________________ _____________________________________________________________________________ _____________________________________________________________________________ 2)____ SPECIAL PERMIT under §_______________of the Yarmouth Zoning By-law and/or for a use authorized upon Special Permit in the "Use Regulation Schedule" §202.5 ______.(use space below if needed) 3)____VARIANCE from the Yarmouth Zoning By-law. Specify all sections of the by-law from which relief is requested, and, as to each section, specify the relief sought: Section: __________ Relief sought: _______________________________________________ Section: __________ Relief sought: _______________________________________________ Section: __________ Relief sought: _______________________________________________ ADDITIONAL INFORMATION: Please use the space below to provide any additional information which you feel should be included in your application: ______________________________________________________________________________ ______________________________________________________________________________ FACT SHEET Current Owner of Property as listed on the deed (if other than applicant): ________________ ______________________________________________________________________________ Name & Address Title deed reference: Book & Page#___________________or Certificate #__________________ Land Court Lot #_________Plan #________ (provide copy of recent deed) Use Classification: Existing: _________________________§202.5 #________________ Proposed: _________________________§202.5 #________________ Is the property vacant: ______________ If so, how long?: ____________________ Lot Information Size/Area: ____________Plan Book and Page ________/______Lot#______ Is this property within the Aquifer Protection Overlay District? Yes ________ No ________ Have you completed a formal commercial site plan review (if needed)? Yes____ No_______ Other Department(s) Reviewing Project: Indicate the other Town Departments which are/ have/ or will review this project, and indicate the status of their review process:______________ ______________________________________________________________________________ ______________________________________________________________________________ Repetitive Petition: Is this a re-application: _______ If yes, do you have Planning Board Approval? _________ Prior Relief: If the property in question has been the subject of prior application to the Board of Appeals or Zoning Administrator, indicate the date and Appeal number(s) and other available information. Include a copy of the decision(s) with this application: ______________________________________________________________________________ ______________________________________________________________________________ Building Commissioner Comments: ________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________ Applicant’s /Attorney /Agent Signature Owner's Signature Address:_______________________________ ______________________________________ Phone_________________________________ E-Mail:________________________________ ____________________________________ Building Commissioner Signature Date YARMOUTH BOARD OF APPEALS ABUTTERS LIST Petition#_______________ Name_____________________________________ Filing Date:________________Hearing Date:___________________________ Property Location:_________________________________________________ Notices must be sent to the petitioner (applicant), abutters, and owners of land directly opposite on any public or private street or way, and abutters to the abutters (only within 300 feet of the property line) of the petitioner as they appear on the most recent applicable tax list. Provide only the abutters map and lot number . Postage charges for all applications will be determined by multiplying the number of abutters (and the parcel (s)in question) times .56¢, which is the current cost for the two required mailings. Add that to the application fee and include your check with the application. Map Number Lot Number Map Number Lot Number Applicant # Abutters #’s 2 Labels-1 Hard Copy ______________________________ Assessors Field Card with photo Andy Machado, Director of Assessing SCHEDULE OF BOARD OF APPEALS MEETINGS FOR 2020 (subject to change) The Yarmouth Board of Appeals meets at 6:00 p.m. on Thursdays, in the Hearing Room at Town Hall, located at 1146 Route 28, South Yarmouth. FILING DEADLINE* 12:00 p.m. HEARING DATE December 18, 2019 January 9 January 2 January 23 January 22 February 13 February 5 February 27 February 19 March 12 March 4 March 26 March 18 April 9 April 1 April 23 April 22 May 14 May 6 May 28 May 20 June 11 June 3 June 25 June 17 July 9 July 1 July 23 July 22 August 13 August 5 August 27 August 19 September 10 September 2 September 24 September 16 October 8 September 30 October 22 October 21 November 12 November 18 December 10 *Note: The Board of Appeals will take four (4) applications/petitions per meeting/agenda. If the agenda fills before the filing deadline you will be placed on the agenda for the next meeting. It shall be the policy of the Board to conclude all hearings by 10:00 PM. To this end, the agenda for all hearings shall be closed once it appears to the Board that additional matters will not be able to be accommodated within this time limitation. In the event that the hearings scheduled on an agenda are not concluded by 10:00 PM, the Board may announce that no new matters shall be commenced thereafter, and shall close the hearing as soon thereafter as the Board determines to be appropriate. Any matters not concluded on the scheduled date shall be continued to the next available agenda. FACTSHEET Curre11t o, ner of Propcrty as 1isted 011 the deed (if other than applicant): Ttie sa1Tre above r Title deed ,eter n : Bo0k c.� ])ag # 32702, Page 258 or Certificate # _______ _ Land Court L t # ____ Plan# ____ (provide copy of recent deed) 202.5 #A 1 la ift aii -n: E,'i ttng: Single Family Dwelling Propo d: Single Fami ly Dwelling ------- '202.5 #A 1 ------- l th pr p �, ,,a ant: _N _o _____ if so> ho ,1v long?: ________ _ / 87 Lot# 4Lot Information ize/ rea: 18 ,901 sq ft Plan Book and Page 139 -----;=-=:::::::;:---;::::::=::;- I thi prop rt y ,,rithin the Aqt1ifer Protection Overlay District? Yes --====---No -====� Ha\1 )'OU con1pleted a forma'! con1mercial site plan review (if needed)? Yes O o , v' . Othet " Department(s) Reviewing P1�oject: Indicate tt1e otl1er Town Departmer1ts whicl1 ar ha\1 , or ,vill r vie, this project, and indicate the status of thejr revie,;y process: _____ _ Healih aod Bui1dinQ Departments Repetitive Petition: Is this a re-app1ication: --==� If yes., do you have Planning Bot1rd App ro\1 al? 1 1 Prior Reiief� ff the-property -in question has ·been the subject of -p rior applica1ion 10 the .Board of Appeals or Zoning Admini strator, indicate the date and Appeal nw11ber( ) and other a aiJabl informa ti on. Tnclnde a copy of ·the dec-ision(s) with this app lication: N/A ·Building Co1rnrti ... --·ioner Co1nrr1ent : ____________________ _ -·omey /Agent Address: 3 Regia Ad. W.Yarmouth 1 MA 02673-----J)hone (508) 815-6573E-Majl: daycareswe etdrea ms@gmail.com - ignatur EXISTING BASEMENT PLANSCALE: 1/4"=1'-0"FULL BASEMENTUNFINISHEDELECTRIC PANELFURNACEWATERHEATERWATERSUPPLYELECTRIC METER(3)2x12 BEAM - DROPPEDSEPTIC PIPE(3)14" LVL BEAM - DROPPEDUPALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORSDCODOOR DIMENSION:6'-0" W x 6'-6" HWINDOW DIMENSION:3'-5 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H7'-6"TO BOTTOMOF JOISTSRETAINING WALLSLAB ON GRADEEXISTING FIRST FLOOR PLANSCALE: 1/4"=1'-0"2-CAR GARAGEBEDROOM #1DININGLIVING ROOMBATH #1KITCHENCLOSETWALK-INDNDECKRETAINING WALL3/0 x 6/8 2/8 x 6/8 2/8 x 6/83/0 x 6/8PORCHCLOSETUPWINDOW DIMENSION:2'-9 5/8" W x 4'-8 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-8 7/8" HWASHERDRYERLAUNDRY1/2 BATH/ALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HFAMILY ROOM7'-11"OPEN TO ABOVESDCOSDGAS METEREX-1 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioExisting Basement & 1st Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 EXISTING SECOND FLOOR PLANSCALE: 1/4"=1'-0"BEDROOM #2BEDROOM #3CLOSETCLOSETWINDOW DIMENSION:2'-5 5/8" W x 3'-4 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H WINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HOPEN TO BELOWBATH #2WINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H7'-6"7'-6"PLAY ROOMWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION: 2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:5'-11 7/8" W x 1'-5" HCLOSETSDSDATTIC ACCESSUNFINISHEDWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-2" W x 2'-2" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORSDCO- EXISTING WALL TO REMAIN- EXISTING WALL TO BE REMOVEDLEGENDEX-2 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioExisting 2nd Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 PROPOSED BASEMENT PLANSCALE: 1/4"=1'-0"NEW PLAYROOMELECTRIC PANELFURNACEWATERHEATERWATERSUPPLYELECTRIC METER(3)2x12ACCESS TO SEPTIC PIPE(3)14" LVL'sUPSDCOMECHANICAL ROOMNEW WET BARNEW PLAYROOMNEW BATH #336" x 72"BATHTUB7'-6"TO BOTTOMOF JOISTSSTORAGE36" HIGH24" HIGH36" VANITY36" VANITY2/62/612'-0"6'-1"7'-012"7'-814"17'-8"7'-1"7'-7"6'-334"RETAINING WALLSLAB ON GRADE1" AIR SPACE2x4 STUDS @ 16" O.C/PRESSURE TREATED PLATER-15 FORMALDEHYDE-FREE FIBERGLASS INSULATION12" BLUE BOARDSKIM COAT PLASTER, SMOOTH FINISHPROPOSED FIRST FLOOR PLANSCALE: 1/4"=1'-0"2-CAR GARAGEBEDROOM #1DININGLIVING ROOMBATH #1KITCHENCLOSETWALK-INDNDECKRETAINING WALL3/0 x 6/8 2/8 x 6/8 2/8 x 6/83/0 x 6/8PORCHCLOSETUPWASHERDRYERLAUNDRY1/2 BATH/FAMILY ROOM7'-11"OPEN TO ABOVEEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGSDCOSDGAS METERA-1 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioProposed Basement & 1st Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 PROPOSED SECOND FLOOR PLANSCALE: 1/4"=1'-0"BEDROOM #2BEDROOM #3CLOSETCLOSETOPEN TO BELOWBATH #27'-6"7'-6"PLAY ROOMCLOSETSDSDATTIC ACCESSNEW CLOSET- EXISTING WALL TO REMAINLEGEND- NEW WALLNEW OFFICENEW BEDROOM #4NEW CLOSETNEW CLOSET5'-0"EXISTINGEXISTINGEXISTINGEXISTINGSDSDCO3/0OPENING5/05/02/6DNA-2 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioProposed Second Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 EXISTING BASEMENT PLANSCALE: 1/4"=1'-0"FULL BASEMENTUNFINISHEDELECTRIC PANELFURNACEWATERHEATERWATERSUPPLYELECTRIC METER(3)2x12 BEAM - DROPPEDSEPTIC PIPE(3)14" LVL BEAM - DROPPEDUPALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORSDCODOOR DIMENSION:6'-0" W x 6'-6" HWINDOW DIMENSION:3'-5 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H7'-6"TO BOTTOMOF JOISTSRETAINING WALLSLAB ON GRADEEXISTING FIRST FLOOR PLANSCALE: 1/4"=1'-0"2-CAR GARAGEBEDROOM #1DININGLIVING ROOMBATH #1KITCHENCLOSETWALK-INDNDECKRETAINING WALL3/0 x 6/8 2/8 x 6/8 2/8 x 6/83/0 x 6/8PORCHCLOSETUPWINDOW DIMENSION:2'-9 5/8" W x 4'-8 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-8 7/8" HWASHERDRYERLAUNDRY1/2 BATH/ALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HFAMILY ROOM7'-11"OPEN TO ABOVESDCOSDGAS METEREX-1 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioExisting Basement & 1st Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 EXISTING SECOND FLOOR PLANSCALE: 1/4"=1'-0"BEDROOM #2BEDROOM #3CLOSETCLOSETWINDOW DIMENSION:2'-5 5/8" W x 3'-4 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H WINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HOPEN TO BELOWBATH #2WINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H7'-6"7'-6"PLAY ROOMWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION: 2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:5'-11 7/8" W x 1'-5" HCLOSETSDSDATTIC ACCESSUNFINISHEDWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-2" W x 2'-2" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORSDCO- EXISTING WALL TO REMAIN- EXISTING WALL TO BE REMOVEDLEGENDEX-2 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioExisting 2nd Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 PROPOSED BASEMENT PLANSCALE: 1/4"=1'-0"NEW PLAYROOMELECTRIC PANELFURNACEWATERHEATERWATERSUPPLYELECTRIC METER(3)2x12ACCESS TO SEPTIC PIPE(3)14" LVL'sUPSDCOMECHANICAL ROOMNEW WET BARNEW PLAYROOMNEW BATH #336" x 72"BATHTUB7'-6"TO BOTTOMOF JOISTSSTORAGE36" HIGH24" HIGH36" VANITY36" VANITY2/62/612'-0"6'-1"7'-012"7'-814"17'-8"7'-1"7'-7"6'-334"RETAINING WALLSLAB ON GRADE1" AIR SPACE2x4 STUDS @ 16" O.C/PRESSURE TREATED PLATER-15 FORMALDEHYDE-FREE FIBERGLASS INSULATION12" BLUE BOARDSKIM COAT PLASTER, SMOOTH FINISHPROPOSED FIRST FLOOR PLANSCALE: 1/4"=1'-0"2-CAR GARAGEBEDROOM #1DININGLIVING ROOMBATH #1KITCHENCLOSETWALK-INDNDECKRETAINING WALL3/0 x 6/8 2/8 x 6/8 2/8 x 6/83/0 x 6/8PORCHCLOSETUPWASHERDRYERLAUNDRY1/2 BATH/FAMILY ROOM7'-11"OPEN TO ABOVEEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGSDCOSDGAS METERA-1 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioProposed Basement & 1st Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 PROPOSED SECOND FLOOR PLANSCALE: 1/4"=1'-0"BEDROOM #2BEDROOM #3CLOSETCLOSETOPEN TO BELOWBATH #27'-6"7'-6"PLAY ROOMCLOSETSDSDATTIC ACCESSNEW CLOSET- EXISTING WALL TO REMAINLEGEND- NEW WALLNEW OFFICENEW BEDROOM #4NEW CLOSETNEW CLOSET5'-0"EXISTINGEXISTINGEXISTINGEXISTINGSDSDCO3/0OPENING5/05/02/6DNA-2 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioProposed Second Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 2840DH2840DH2840DH511682840DH 26682840DH 2840DH2840DH2840DH26682840DH 2840DH2840DH 2840DH26682840DH UP E1E1 Elevation 1 2'-6 7/8"2'-8"3'-1 1/4"5'-11"3'-5 3/4"2'-8"4'-2 3/8"1'-8"2'-8"1'-8" 6'-5"7'-7"1'-9"22'-3"18' 56'3'-1 1/8"2'-8"1'-1 13/16"6'-10 15/16"19'-1 1/16"2'-8"28'-8"4'-2"16'36'-6 3/16"12'-8"16'4'-2"12'-8 9/16"2'-8"2'-7 13/16" 18'-0 3/8"3'-8 3/16"6'3'-8 3/16"24'-7 1/4" 56'1'-3 1/4"2'-8"1'-3 1/4"5'-2 1/2"1'-3 1/4"2'-8"1'-3 1/4"5'-2 1/2"NEW MECHANIC ROOM NEW WET BAR NEW BATHROOM NEW GAME ROOM LIVING AREA BASEMENT 1430 SQ FT ADDRESS: 3 ROGIA RD WEST YARMOUTH ONWER: ROSANGELA TEIXEIRA 2840DH2840DH 2840DH2840DH3068 30682840DH 266850682840DH2840DH2840DH2840DH2840DH 2840DH26683068 90809080 2668 2668 2668 2168UP E1E1 Elevation 1 4'-1 1/8"2'-8"4'-3 1/4"2'-9 9/16"2'-8"3'-0 5/8"1'-8"2'-8"1'-8" 2'-9 13/16"2'-8"2'-6 7/16"2'-8"3'-3 3/4"2'-6 1/4"3'3'-9 5/8"2'-8"5'-3 3/16"2'-8"4'-0 15/16"3'-3 9/16"2'-8"4'-2 7/16"3'4'-10"1'-3 1/8"9'1'-4 7/8"9'1'-4" 14'24'18'22' 78'8'-3 3/8"2'-8"6'-0 7/8"8'-11 3/4"17'-0 1/4"2'-8"28'-8"4'-2"5'-10 5/8"22'36'-6 3/16"12'-6 5/8"16'-1 3/8"4'-2"16'-11 1/8"3'2'-0 7/8"9'-2 1/16"5'3'-10 5/16" 22'18'-0 3/8"3'-8 3/16"6'3'-8 3/16"11'-0 3/8"8'-6 3/16"5'-0 11/16" 78'1'-7 1/8"2'-8"11 3/8"5'-2 1/2"1'-3 1/4"2'-8"1'-3 1/4"5'-2 1/2"1917 SQ FT 17'-8" X 5'-8" 17'-1" X 12'-0" LIVING AREA FISRT FLOOR EXISTENT GARAGE EXISTENT DINING ROOM EXISTENT LIVE ROOM EXISTENT KITCHEN EXISTENT BATHROOMEXISTENT BATHROOM EXISTENT CLOSED EXISTENT BEDROOM ADDRESS: 3 ROGIA RD WEST YARMOUTH ONWER: ROSANGELA TEIXEIRA DECK DECK 2840DH2840DH 2840DH2840DH2840DH2840DH2840DH2840DH2840DH 406826682668 32682668556826682840DH266826682668 2668 4214TH 2668 UP E1E1 Elevation 1 11 3/8"2'-8"8'-6 5/8"2'-8"1'-7 11/16"4'-6 1/16"2'-8"2'-2 3/4"2'-5 13/16"2'-8"3'-1 5/8"2'-8"3'-2 9/16" 14'9'-6 13/16"14'-5 3/16"18'22' 78'9'-5 3/16"2'-8"4'-0 3/16"16'-1 3/8"9'-10 5/8"2'-8"28'-8"5'-10 5/8"4'-7"2'-8"7'-3"14'-6"12'-6 5/8"4'-3 1/4"2'-8"7'-0 13/16"2'-8"5'-1 15/16"9'-2 7/8"2'-8"1'-9 1/8" 21'-10"13'-8"2'-5 1/2"16'-5 11/16"9'-4 13/16"14'-2" 78' 1826 SQ FT LIVING AREA SECOND FLOOR EXISTENT BEDROOM EXISTENT CLOSED EXISTENT LIVE ROOM EXISTENT BEDROOMEXISTENI BATHROOM NEW BEDROOM NEW OFFICE NEW HALL ADDRESS: 3 ROGIA RD WEST YARMOUTH ONWER: ROSANGELA TEIXEIRA NEW CLOSED NEW CLOSED EXISTING BASEMENT PLANSCALE: 1/4"=1'-0"FULL BASEMENTUNFINISHEDELECTRIC PANELFURNACEWATERHEATERWATERSUPPLYELECTRIC METER(3)2x12 BEAM - DROPPEDSEPTIC PIPE(3)14" LVL BEAM - DROPPEDUPALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORSDCODOOR DIMENSION:6'-0" W x 6'-6" HWINDOW DIMENSION:3'-5 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H7'-6"TO BOTTOMOF JOISTSRETAINING WALLSLAB ON GRADEEXISTING FIRST FLOOR PLANSCALE: 1/4"=1'-0"2-CAR GARAGEBEDROOM #1DININGLIVING ROOMBATH #1KITCHENCLOSETWALK-INDNDECKRETAINING WALL3/0 x 6/8 2/8 x 6/8 2/8 x 6/83/0 x 6/8PORCHCLOSETUPWINDOW DIMENSION:2'-9 5/8" W x 4'-8 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-8 7/8" HWASHERDRYERLAUNDRY1/2 BATH/ALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HFAMILY ROOM7'-11"OPEN TO ABOVESDCOSDGAS METEREX-1 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioExisting Basement & 1st Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 EXISTING SECOND FLOOR PLANSCALE: 1/4"=1'-0"BEDROOM #2BEDROOM #3CLOSETCLOSETWINDOW DIMENSION:2'-5 5/8" W x 3'-4 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H WINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HOPEN TO BELOWBATH #2WINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" H7'-6"7'-6"PLAY ROOMWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION: 2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:5'-11 7/8" W x 1'-5" HCLOSETSDSDATTIC ACCESSUNFINISHEDWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HWINDOW DIMENSION:2'-2" W x 2'-2" HWINDOW DIMENSION:2'-9 5/8" W x 4'-0 7/8" HALARM LEGEND - EXISTING EXISTING SMOKE DETECTOREXISTING CARBON MONOXIDE DETECTORSDCOHDEXISTING HEAT DETECTORSDCO- EXISTING WALL TO REMAIN- EXISTING WALL TO BE REMOVEDLEGENDEX-2 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioExisting 2nd Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 PROPOSED BASEMENT PLANSCALE: 1/4"=1'-0"NEW PLAYROOMELECTRIC PANELFURNACEWATERHEATERWATERSUPPLYELECTRIC METER(3)2x12ACCESS TO SEPTIC PIPE(3)14" LVL'sUPSDCOMECHANICAL ROOMNEW WET BARNEW PLAYROOMNEW BATH #336" x 72"BATHTUB7'-6"TO BOTTOMOF JOISTSSTORAGE36" HIGH24" HIGH36" VANITY36" VANITY2/62/612'-0"6'-1"7'-012"7'-814"17'-8"7'-1"7'-7"6'-334"RETAINING WALLSLAB ON GRADE1" AIR SPACE2x4 STUDS @ 16" O.C/PRESSURE TREATED PLATER-15 FORMALDEHYDE-FREE FIBERGLASS INSULATION12" BLUE BOARDSKIM COAT PLASTER, SMOOTH FINISHPROPOSED FIRST FLOOR PLANSCALE: 1/4"=1'-0"2-CAR GARAGEBEDROOM #1DININGLIVING ROOMBATH #1KITCHENCLOSETWALK-INDNDECKRETAINING WALL3/0 x 6/8 2/8 x 6/8 2/8 x 6/83/0 x 6/8PORCHCLOSETUPWASHERDRYERLAUNDRY1/2 BATH/FAMILY ROOM7'-11"OPEN TO ABOVEEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGEXISTINGSDCOSDGAS METERA-1 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioProposed Basement & 1st Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 PROPOSED SECOND FLOOR PLANSCALE: 1/4"=1'-0"BEDROOM #2BEDROOM #3CLOSETCLOSETOPEN TO BELOWBATH #27'-6"7'-6"PLAY ROOMCLOSETSDSDATTIC ACCESSNEW CLOSET- EXISTING WALL TO REMAINLEGEND- NEW WALLNEW OFFICENEW BEDROOM #4NEW CLOSETNEW CLOSET5'-0"EXISTINGEXISTINGEXISTINGEXISTINGSDSDCO3/0OPENING5/05/02/6DNA-2 Phone: (508) 308 8614 PO Box 1106 - Harwich, MA 02645 LA CASA StudioProposed Second Floor Plan Date: 06.18.2020 Teixeira Residence3 Rogia Rd., West Yarmouth, MA 02673 t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 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. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth City/Town MA State 02536 Zip Code 1-508-495-0905 Telephone Number SI3971 License Number B. Certification I certify that:I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. Fails Inspector’s Signature 11-22-19 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of faiure. 2) System Conditionally Passes: One or more system components as described in the “ConditionalPass” section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for “yes”, “no” or “not determined” (Y, N, ND) for the following statements. If “not determined,” please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y N ND (Explain below): t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced Y N ND (Explain below): obstruction is removed Y N ND (Explain below): distribution box is leveled or replaced Y N ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced Y N ND (Explain below): obstruction is removed Y N ND (Explain below): 3) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other f ailure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate “Yes” or “No” to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6” below invert or available volume is less than ½ day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either “yes” or “no” to each of the following, in addition to the questions in Section C.4. Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a mapped Zone II of a public water supply well t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) If you have answered “yes” to any question in Section C.5 the system is considered a significant threat, or answered “yes” to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate “yes” or “no” for each of the following for all inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Wasthe facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 Description: Number of current residents: 0 Does residence have a garbage grinder? Yes No Does residence have a water treatment unit? Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Yes No Laundry system inspected? Yes No Seasonal use? Yes No Water meter readings, if available (last 2 years usage (gpd)): 53gpd/2yrs Detail: Sump pump? Yes No Last date of occupancy: 2019 Date t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Yes No Water treatment unit present? Yes No If yes, discharges to: Industrial waste holding tank present? Yes No Non-sanitary waste discharged to the Title 5 system? Yes No Water meter readings, if available: Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other (describe): Approximate age of all components, date installed (if known) and source of information: 2011 Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer (locate on site plan): Depth below grade: 30" 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.): Good condition. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24" 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: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dim ensions: Capacity: gallons Design Flow: gallons per day t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: Yes No Alarm level: Alarm in working order: Yes No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? Yes No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: Yes No* Alarms in working order: Yes No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: leaching chambers number: 3-500's leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number: innovative/alternative system Type/name of technology: t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good working order and empty at inspection with no visible stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth – top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 10' feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show groundwater at greater than 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 18 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank – Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 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. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth City/Town MA State 02536 Zip Code 1-508-495-0905 Telephone Number SI3971 License Number B. Certification I certify that:I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);I have personally inspected the sewage disposal system at theproperty address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. Fails Inspector’s Signature 11-22-19 Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of faiure. 2) System Conditionally Passes: One or more system components as described in the “ConditionalPass” section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for “yes”, “no” or “not determined” (Y, N, ND) for the following statements. If “not determined,” please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. Y N ND (Explain below): t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced Y N ND (Explain below): obstruction is removed Y N ND (Explain below): distribution box is leveled or replaced Y N ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced Y N ND (Explain below): obstruction is removed Y N ND (Explain below): 3) Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 4 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other f ailure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate “Yes” or “No” to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6” below invert or available volume is less than ½ day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either “yes” or “no” to each of the following, in addition to the questions in Section C.4. Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area – IWPA) or a mapped Zone II of a public water supply well t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection C. Inspection Summary (cont.) If you have answered “yes” to any question in Section C.5 the system is considered a significant threat, or answered “yes” to any question in Section C.4 above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate “yes” or “no” for each of the following for all inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Wasthe facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 Description: Number of current residents: 0 Does residence have a garbage grinder? Yes No Does residence have a water treatment unit? Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Yes No Laundry system inspected? Yes No Seasonal use? Yes No Water meter readings, if available (last 2 years usage (gpd)): 53gpd/2yrs Detail: Sump pump? Yes No Last date of occupancy: 2019 Date t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Yes No Water treatment unit present? Yes No If yes, discharges to: Industrial waste holding tank present? Yes No Non-sanitary waste discharged to the Title 5 system? Yes No Water meter readings, if available: Last date of occupancy/use: Date Other (describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 9 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other (describe): Approximate age of all components, date installed (if known) and source of information: 2011 Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer (locate on site plan): Depth below grade: 30" 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.): Good condition. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 24" 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: 1500 gal Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 0 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete metal fiberglass polyethylene other (explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: concrete metal fiberglass polyethylene other (explain): Dim ensions: Capacity: gallons Design Flow: gallons per day t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 12 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: Yes No Alarm level: Alarm in working order: Yes No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? Yes No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from field. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 13 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 10. Pump Chamber (locate on site plan): Pumps in working order: Yes No* Alarms in working order: Yes No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: leaching chambers number: 3-500's leaching galleries number: leaching trenches number, length: leaching fields number, dimensions: overflow cesspool number: innovative/alternative system Type/name of technology: t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach chambers in good working order and empty at inspection with no visible stain lines. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth – top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow Yes No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below drawing attached separately t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope Surface water Check cellar Shallow wells Estimated depth to high ground water: 10' feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: Original design plans show groundwater at greater than 10'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc • rev. 7/26/2018 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 18 of 18 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 Rogia Rd Property Address Steve Cotto Owner’s Name Yarmouth City/Town MA State 02664 Zip Code 11-22-19 Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank – Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included Condition: License Number: 9056556Program Number: P-186552 | 8032507 Charlie Baker, Governor THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF EARLY EDUCATION AND CARE Regular License to Provide Family Child Care Services In accordance with the provisions of Chapter 15D of the General laws, and regulations established by the Department of Early Education and Care, a license is hereby granted to: Program Name:Teixeira, Rosangela Address:3 Rogia road, West Yarmouth, MA 02673 Total Capacity:10 Floors/Rooms:1ST FLOOR: KITCHEN, LIVING ROOM, DINING ROOM License amended for change of address effective 3/16/2020. Issue date: 03/16/2020 Expiration date: 03/15/2023 License printed on: 03/17/2020 Licensor:Celina Mendes Samantha L. Aigner-Treworgy, Commissioner Please Post Conspicuously This License is Not Transferable Teixeira, Rosangela 3 Rogia road West Yarmouth, MA 02673 PI-IHDY-014 (10/14) CERTIFICATE OF INSURANCE is hereby issued to Item 1. Certificate Holder: Partner Name1: Business Name: Item 2. Mailing Address: And Item 3. Master Policy Holder: ADULTS AND CHILDRENS RISK PURCHASING GROUP and its Certified Providers Item 4. Mailing Address: Hays Companies, IDS Center, Suite 700, 80 South 81h Street, Minneapolis, MN 55402 Item 5. Certificate #: Item 6. License Classification: Item 7. Cancellation: Provisions are outlined in the Master Policy; a complete copy of which is available at your request. Item 8. Effective Date: Expiration Date: Item 9. GENERAL LIABILITY I PROFESSIONAL LIABILITY Issued by: Item 10. LIMITS OF INSURANCE General Aggregate (Other Than Products-Completed Operations) Each Occurrence (Includes Products-Completed Operations and Personal and Advertising Injury) Damage to Premises Rented to You Any One Premises $ Abuse or Molestation Aggregate Abuse or Molestation Each Occurrence Animal Injury Each Occurrence Animal Injury Aggregate Item 11. ACCIDENT INSURANCE Issued by: $ $ $ $ $ $ This policy provides accidental Medical Expense and Accidental Death and Dismemberment coverage and is subject to a $ O Deductible. Item 12. LIMITS: Accidental Death Accidental Dismemberment $ $ Accidental Medical Dental Limit $ $ Item 13. BUSINESS PERSONAL PROPERTY AND BUSINESS INTERRUPTION Issued by: This policy is subject to a $ 250 Deductible. Effective Date: Item 14. LIMITS: Business Personal Property ADMINISTERED BY: Hays Companies IDS Center, Suite 700 80 South 81h Street Minneapolis, MN 55402 $ Expiration Date: Business Interruption $ Authorized Representative THE ENCLOSED FORMS DO NOT CONSTITUTE A COMPLETE POLICY CONTRACT. FOR A COMPLETE POLICY, CONTACT ADULTS AND CHILDRENS RISK PURCHASING GROUP. 0 1,000,000 100,000 09/26/2020 3,000,000 10 CHILDREN 1,00010,000 Rosangela Teixeira Rosangela Teixeira 3 Rogia road West Yarmouth, MA 02673 100,000 0 STARNET INSURANCE COMPANY - Policy Number : PAI V00100168001 2,000 10,000 100,000 50,000 25,000 1978 20011972 PHILADELPHIA INDEMNITY INSURANCE COMPANY - Policy Number : PHPK1961681 NA 09/26/2019 NA