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HomeMy WebLinkAbout0098 WHISTLEBERRY DRIVE - Health 98 WHISTLEBERRY.D&�.Z A= 063 083 i i Commonwealth of Massachusetts ;P Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 ` 99 . Property Address —r_a 141 Owner Owner's Name information is a� N f. �' fJa �jr /0 . �Q required for every _ y (/ (J page. City/Town State Zip Code Date of Insp ction 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. Q 134pl Important:When filling out forms A. Inspector IfTec. ation on the computer, use only the tab r key to move your Name of Inspector� Y `� 0 cursor-do not use the return Company Name key. Po do Company Address J L p y �cqs7 4a(�''1 City/To SD� �V State Zip Code fi9C+ / T Telephon tuber 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 the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that;the s 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ;5insp.doc•rev.712612018 Title 5 of,:da.;nspeadon=or..:Subsurface Sewage o:soosai System•Page t of 18 V� Commonwealth of Massachusetts P Title 5 Official Inspection Form lSubsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address I'sI Gbef.- RJ Floc.4---e_ ve- Owner Owners Name information is 1 required for every �Q �OZ / page. City/Town State Zip Code Date of Inspe 'on C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System ses: 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass'section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes'. "no°or"not determined' (Y, N, ND)for the following statements. If"not determined,' please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound., exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.00c•rev.7/26/2018 ':'Ie 5(TSaai;,specaon=om:suosurace sewage Jisposai System-?aye 2 of 18 a Commonwealth of Massachusetts -- ii� Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G✓4,s4le 6e.611 Ad Property Address / F1 L�� Owner Owner's Name information is Q K T OMS `/ A required for every ]' I page. City/Town State Zip Code Date of In pection 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 aue 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.7/26t2018 'iye 5 official:nsoecson Foam:suosutace sewage oisposal System•Page 3 of 18 r i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Il 1W rr t, R Property Address /OC �G - V4.1 Owner Owner's Name I/ information is _ ��s.�o„s Xlls , ,q oa�Y$ ,o required for every page. City/Town State Zip Code Date of InApectiont C. Inspection Summary (cons.) ❑ 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 failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ackup 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 Title 5 pPSdai Ins?ecaor.=OT:Subsurface sewage oispcsal System•Page 4 of 18 Sinsp.tloc-rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form/-Not for Voluntary Assessments Property Address OG / G Owne- Owner's Nam information is required for every e 0j 6 4$ /0 40' page. City/Town State Zip Code Date of Ir pectin 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/z than ' day flow El � 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.] ❑ he system is a cesspool serving a facility with a design flow of 2000 gpd- uuu 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 ❑ El Area system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a public water supply well Sitie 5 offldai Inspeczon= rm:Subsurface Sewage cisoosal system•Page 5 of 18 t5inap.doc•rev.7262018 (5','\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address F5, 0 Owner Owner's Name /� 10,4 ��information is G f ` '/ Q �e "ecton required for every page. City/Town State Zip Code Date o C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Ye s mping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ilQ 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)] Tine 5 ot,,dai inspe::ion-on:Sutsurface Sewage Disposal System•Page a of+.a t5insp.doc•rev.7t282018 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . . (2d Property Address 'OG Owner Owner's�Name 'information is ors [ !/sA4 Qp�b rip �� h-i�OZ required for every page. City[Town State Zip Code Date of In ec6on D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / / 64%/`d H A?4,c ca N 4Y (.sf��6N�40h 4001- O Number of current residents.- Does residence have a garbage grinder? ❑ Yes No ❑ Does residence have a water treatment unit.? Yes No If yes, discharges to: / Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes (—� No information in this report.) Laundry system inspected? Yes No Seasonaluse? es ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: ❑ Ye No Sump pump? Last date of occupancy: D = Sucsu'ace Sewage Disposal System•Page 7 of 18 "ite c o`dal i�s;,e-or.crr t5insp.doc•rev.726/2018 i Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every arS page. CitylTown State Zip Code Date of specti n D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gailons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gaiions How was quantity pumped determined? Reason for pumping: t5insp.dcc-rev.726/2018 -iue 5 offiaai insoecuon Form:suosurface Sewage Disposal system•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9F Vhqlk Property Address 41� Flo(" Owner Owners Name Q information is 0.) �� (J required for every �_ '_" f page. City/Town State Zip Code Date of I pectin D. System Information (cunt.) 4. Type of Sy Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, I any) Innovative/Altemative 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): Approxi at age of all co nYX y, date installed (if kn wn)and sou of information: Were sewage odors detected when arriving at the site? ❑ Yes No 6 •� 5. Building Sewer(locate on site plan): Depth below grade: feet Material of constructio/40 ❑ cast iron VC ❑ other(explain): / I 0 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Title 5 Otto inspection ro,'^�.suesur;ace sewage oisposai system•Page 9 of 18 t5insp.doc•rev.7/25/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form �= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments CY Property Address Owner Owner's Name information is ljylars4y4tAt �/ I D�6�� �� X) of required for every A4 page. City/Town State Zip Code Date inspect on D. System Information (cons.) 6. Septic Tank(locate on site plan): Depth below grade: feet efconstruction: ete ❑ 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 � X �n Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Vt1M ✓1 O� ��GG-Pi'C�• Cot— 7—aN 400 Q a* 71�3 �✓� OG COH d/7TON. -rtle 5 oai Inspecoon=o-n.suosurace Sewage,Disposal System-?age 70 0`is t5insp.doc-rev.W26/2018 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address OL Owner Owners Name ,' �l��yJ /O information is r3•.4 required for every page. City/Town State Zip Code Date of nspecti D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day we 5 oi`aa'inspecuon Fom:suosurfaoe Sewage Disposal system•?age t t of 18 t5insp.doc•rev.7/26/2018 r Y Commonwealth of Massachusetts .' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name a/J /�'/s At, � '0) c �/ t'X informajon is13required for every page. City/Town State Zip Code n 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 •G,L_' 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.): /VV ,1s ?dJe 5 0'�IGei Inspection For,Suosu'ace Sewage Disposal System•?age 12 of 18 t5irsep.doc•rev.7252018 Commonwealth of Massachusetts Ia Title 5 Official Inspection Form rw Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9? &AU Ap Property Address �OG�G Owner Owner's Name information is n Vpi b�f' required for every page City/Town State Zip Code Date of I pection D. System Information (coot.) 10. Pump Chamber(locate on site plan): Pumps it working order: ❑ Yes ❑ No* Alarms it 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: 6 S4'"� leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number; length.- leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelaltemative system Type/name of technology: ---- Tine 5 75aai inspe.'non=cm::SUDSLTdCe Sewage Disposai System•?age'3 of 18 5insp.doc-rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G,/�►�,sf�c 6er� Aj Property Address 1G owner owner's Name information islivae-f4s.s S /0Au required for everypage. City/Torm State Zip Code Date of Ins 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.): 12. Cesspoc-Is (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.): 7rc;e 5 Or'cai msperuen Form:SuCswiaace Sewage Disposaj System.Page to of 18 t5insp.doc-rev.726/2018 r Commonwealth of Massachusetts s. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 / w (i✓�1SWC t?oir Property Address to G!rG Cwner Owners Name • / /' reformation is Cj/f ✓1 s S OQ� /0 / 1 required for every _ d'' page. City/Town State Zip Code Date of Ins Action D. System Information (cons.) 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.): Tme 5 oifiael inspection Form.suosurtace Sewage Disposal System-?age is of 18 tsinsp.doc-rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form k�ww Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9F t �e Property Address ot 4 Flo C14-c- Owner Owner's Name information is 111149rsL ��"<� !9 /� �,Q required for every �`a ' a page. City/Town State Zip Code Date of in pectin 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 buildi . eck one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I I I F: T- i i I i of C'.1C I f v, roxb O . I 3 37 I� I -itle 5 0"clai irspamon Fo:m:Suosu.face Sewage Disposal system Page i6 of 18 t6insp.doc.rev.7/26/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 9f Ae i evrr'!7 - A_ Owner Owner's Nam/�Cal information is �1__f , /f /O arequired for every7�4 1� a ` � page. City/Town State Zip Code Date of I speoti n D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked; date of design plan reviewed: Date /Observed site (abutting property/observation hole within 150 feet of SAS) Checked wi cat Board of He�,th - explain: las 14 j — / L,-S+ R a/tvj ❑ Checked with local excavators; installers- (attach documentation) Ell, Accessed USGS database-explain.- You must des cr e h you established the high ground water elevationXe vti o Pi �_ P. - �0�✓ /..o% . Yo 5; &4, 1.5 t vi o44 14 c/ S, A S ML vim= 43 r'p u w Before fil>ng this Inspection Report, please see Report Completeness Checklist on next page. 5insp.dcc-rev.72Eu2058 Niue 5 cal.nspecaon=er-:&,os�rtace sewage Disposal systen-Page 17 of t8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 022 / 0 Is f/e Property Address fie' Owner's Name 4., information is �j �arequired for every ca, //.s �V� 9 page. City/Town State Zip Code Date of Irlspection E. Report Completeness Checklist Complete ail applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. certification: Signed & Dated and 1, 2; 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 F iIure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For �:4: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5inep.doc•rev.712612018 Title 5 Qttiaai fnspemon Fo,-n:suosu`ace sewage o,sposai sysrem•?age is of i8 DATE: _7/3.1 PROPERTY ADDRESS:_98 Wlrkstleberry food Marstons Mills,Mass. 02648 ' e On the above date, 1 inspected the septic system at the above ad' r :� Th'ls system consists of the following: 1 . 1 =1500- gallon septic tank. 2 . 1 -D.istribtti8n box. 3 . 2-1'000' gallon precast leaching pits. eased bn my Insc-action, 1 certify the following conditions: 4 . This is a title.. Five Septic System. ( 78 -Code ) 5 . The' septic system is 'in proper working order at. the present time. 6.. -Pumped septic tank as part of the inspection. 81GNATURr,: Name J P Macomber Jr_ Company:_J. P_ - Macoruber & Son- 'Inc . __Cente_rville Mass ' 02.632 Phone:---5Q8�7-5-.3338------- I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON,. INC. Tanks-Cesspools-Leachf laid: Pump+d & Instilled .Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 77.5-3338 775-6412 I • e V COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292.5500 WILLIAM F.WELD Govcmor TRUDY COXI Sccrctan ARGEO PAUL CELLUCCI Lt.Govcmor DAVID B.STRUFL SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission. PART A CERTIFICATION Property Address: 98 Whistleberry Rod.: M&M Address of Owner: Date of Inspection:7/31 /9 8 (If different) Name of Inspector- aeemer I am a DE a pro a system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J• •Macomber & Son Inc. Mailing Address: BOX 66 Centerviiie,Mass 02632 Telephone Number: 508-779-3338 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the.time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site se ge disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspect r shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AJ L;y PASSES: ave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. failure criteria not evaluated are indicated below. COMMENTS: BJ 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. Indicate ye , o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined% explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of t Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;.a the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Pape 1 o1 10 DEP on the Worid Wide Web: http:1Avww.mapnel.state.ma.usrdep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 98 Whistleberry &4 marstons mills,Mass. Owner: Anthony A. Lenci Date of Inspection: 7/31 /9 8 B) SYSTEM CONDITIONALLY PASSES (continued) ,4:4 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced ot) The system required pumping more than four 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 obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _Vb Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 4 Q Cesspool or privy is within 50 feet of a surface water 426 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ,gip The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. 4,0 The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of,a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/35/)7) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: gg Whistleberry Road: Marstons Mills,Mass. Owner: Anthony A. Lenci Date of Inspection:7/3 1 /9 8 D) SYSTEM FAILS: You must indicate ei;i.er "Yes" or "No" as to each of the following: 1/0 I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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. x Static liquid level in the di ribution box above outlet invert due to an overloaded or clogged SAS or cesspool. JC+�;A'f AiT-t Liquid depth in-e�is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q,. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 4-1 Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: You must indicate either 'Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to :public health and safety and the environment because one or more of the following conditions exist: r Yes No JiA the system is within 400 feet of a surface drinking water supply 6Cy the system is within 200 feet of a tributary to a surface drinking water supply 61F 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please.consult the local regional office of the Department for further information. (revised 04/1S/37) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 98 Whistleberry . AaP4. Marstons Mills,Mass. Owner: Anthony A. Lenci Date of Inspection:7/3.1 /9 8 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No . Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, luding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened;and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. J/ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J (rwlsod 04/25/37) ?&go 4 of 10 I f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properly address: 98 Whistleberry AaAd Marstons Mills,Mass . 0.;net: Anthony A. Lenc i Date of Inspection:7/31 /98 FLOW CONDITIONS RESIDENTIAL• Design f►� .p. kedroom for S.A.S. Number of bedrooms: Number of Current residents- Laundry connetaed to system (yes or no).A6 Seasonal use (yes or no).� Water meter readings, if av lable (last two (2) year usage ($pr,J: !sVMp Pump (yes or no)_ , J Q%L� C�I� ry$=J�Q• �/!//J :ast pate of occupancy-7— COMMERCIAVINOVSTRIAI: Type of establfshm nt:_ • AR Design flow: ,�8allonVday Crease trap prevent: (yes or noW44 industrial Waste Molding Tank present: (yes or no)&• Non•sanftat)• waste discharged to the Title 5 system: (yes or no)—,41# Wale' meter readings, if avail ble._ 'VA Last dale of occupancy. OTHER: :Oescribef d2A Last Cale of OCCvpancy GENERAL INFORMATION PUMPINC RECORDS and so ice f nformalfon. System pumped as pan of ins aeon: (yes or no) If yes, volume pumped- /f d(o allOns Reason for pumping _ JITir. TYPE OF STEM 5cptic tanVdistributton box/soil absorption system Single Cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) VA Technology etc. Copy of up to date contraal Ol he r APPROXIMATE AGE of all components, date installed lit known) and source of information: Se..agc odors detected when arriving at the site: (yes or no)/e tr.vs..a Os/)s/a71 Y.y. s of 10 r r - SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 98 Whistleberry t , Marstons .Mills,Mass . Owner: Anthony A. Lenci Date of Inspection:7/31 /9 8 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: _cast iron 11/40 PVC_other (explain) Distance fro private water supply well or suction line !Gr r Diameter `1 Comments: (condition of joints, venting, evidence of leakage, etc.) Join , SEPTIC TANK:1R0 9AA01D'V" (locate on site plan) /r Depth below grade:w� Material of construction: _concrete _metal _,Fiberglass _Polyethylene _other(explain) If tank is metal, list agQ Is age confirmed by Certificate of Compliance,444—(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: d Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bono of outlet t or baffle:_ Flow dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump tank every - Th r ieaKage. GREASE TRAP:) 0 (locate-on site plan) Depth below grade:y/9 Material of constructionG�/:concreteVAmetaI4)AFibergl ass/1�4PolyethyleneN�other(explain) Dimensions: Scum thickness: AIR Distance from top of scum to top of outlet tee or baffle:_, Distance from bottom of scum to bonom of outlet tee or baffle:_ Date of last pumping: Comments: forpumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural (recommendation integrity, evidence of leakage,-etc.) Grease trap is not prespnt - (revised O4/25/91) Page 4 of 10 Ub SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 98 Whistleberry Ratod Marstons Mi11s,Mass . Owner: Anthony A. Lenci Date cf Inspection:7/31 /9 8 TIGHT OR HOLDING TANK;ad6j&,Rank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade:JV Material of construction-�Uconcretelametal vAFiberglass,AA Polyethylene /Aother(explain) A ' Dimensions: AJA Capacity: 64 gallons Design flow: gallons/day Alarm level: AJ14 Alarm in working order, Yes; No Date of previous pumping: A15: — Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tiqht or holding tanks are not present- DISTRIBUTION BOX:' (locate on site plan) Depth of liquid level above outlet inven: VA Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or\out of box, etc.) Distribution box has two laterals The flow is not equal . A speed leveler shou1 d hP i nSta 1 1 Pd i n 1-hp hr)w Th i c uai 1 1g i vo O ual flow t-a the leaching pits No avi onno Q--f 891-d6 eaErry ever=Pie eyidefte of leakage into or out of the box. PUMP CHAMBERAZ /6 (locate on site plan) Pumps in working order: (Yes or No)- Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) -Pump chamber is not present trovf..d 04/IS/97) ?.g. 7 of 10 I r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 98 Whistleberry AaAj Marstons Mills,Mass. Owner: Anthony A. Lenci Date of Inspection: /31 /98 ' 9 SOIL ABSORPTION SYSTEM (SAS):A/W0Q/9k'�1 J19&-)tj4 (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number:_ leaching chambers, number: D leaching galleries, number.= leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: .0 Name of Technology: ,w Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand tO medium coarsr= sand;Nn gi qnq of by rcayliC failurA or nnr3i nqy Al 1 yegPtatinn is narmQl . CESSPOOLS: AI) Nt- (locate on site plan) Number and configuration: n Depth-top of liquid to inlet invert: C- Depth of solids layer: /t/i Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Cesspools are not present , Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present. PRIVY: loocate on site plan) Materials of construction: Dimensions: yi9 Depth of solids: . /U4 Comments: note condition ofsoil, signs of hydraulic failure level of Pon ing condition of vegetation, etc .) Privy' is not present (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propeny Add(ess: 98 Whistleberry Mol) Marstons Mills,Mass. Owner: Anthony A. Lenci Dale of Inspecti0n:7/31 /98 SKEZCH OF SEWAGE DISPOSAL SYSTEM: landmarks or benchmarks include ties to at least two permanent references locale all wells within 100' (Locate where public water supply comes into house) All _ a = C may�a�ons 1�'1 l,llg (tevit.b 0�/JS/17) Page .i of 10 SUBSURFACE SEWAGE DISK;: 4 SYSTEM INSPECTION FORM C SYSTEM INFOR%,, .'riON (continued) Property Address: 98 Whistleberry �Di �yjyt Owner: AntHONY A. Lenci Date of Inspection: 7/31 /9 8 r . Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater E1GHation: Obtained from Design Plans on record Observation of Site (Abutting property, bservation hole, basemtrth sump etc.) ,[, Determine it from local conditions Check with local Board of health Check FEMA Maps heck pumping records l—Check local excavators, installers ` Use USGS Data Describe in your own words how you established the High Groun4,/,rer•Elevation. Must be completed) Used Water Contours Map Gahrety & Miller MOdel 12/16/94 (revised 0{/25/$7) P49. ''Dof 10 r a•In+na•+rnirr�T—♦rnrmr•ntr.rises.nai.nmarr.�.•'wanr�..++.r.n.asrwv*+'a-�rrsnlr'+ .�Y TOWN OF Barnstable BOARD OF HEALTH SUI1SUItFACR SFK�CF QI I'U,S1L SYSTEM INS SI,FCTION FORM •- PART D •- CERTIFICATION ' Tn n�a17TTSTl.TRaI.1P5•.TrT•aT1 -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 98 Whistleberry Marstons Mills,Mass ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME Anthony A. •Lenci PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son InL; ' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or city State LIE COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 .. CERTIFICATION STATEMENT I certifythat I have personally inspected the sewage diaposa7 system r ' this address and that the information reported is true , accurate , and complete as of the time of* inspection , The inspection was performed and:,any fE.commendatlolls regarding upgrade , maintenance , and repair are consistent - with my training and experience in the proper function and maintenance of on site sewage disposal systems , Check one: Sys tevi PASSED The inspection which I have conducted has not found any information which indicates that the system fails to ade quately protect Public _health or the e envirotYmcrit as defined in 310 CMR 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this for►n. System FAILED* The inspection uhic), I have con Lcted has found that the system fails to protect the j-)ublic health and the environment in accordance with Title 6 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector tignature Date or One copy of this certification must be provided to the OWNER, ( where applicable ) and th.e BOARD 08' lIZAL7'II. the BUYER If the inspection FAILED, thb owner or""oparator shall u within o•ne year of the date of the inspection, unless alloweddortrequiredm otherwise as provided in 3.10 CHR 16 . 306 . partd .doc fib U) ZJ 7 � z S bkv THE COMMONWEALTH OF M.A.SSA.CtfUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. Issued by The Department of Environmental Protection. Junr x. tr5 Actmy, Dirccior of the L) ion ul Water Pollution Control TOWN OF BARNSTABLE LUC-AnT ON 9g WA(s-ilebenj tJ 1piwe SEWAGE # 93--`/30 VILLAGEI t �� ASSESSOR'S MAP & LOTS INSTALLER'S NAME PHONE NO. oeZIr) a - 0 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) Joao .� ENO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER -�l DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,� b TOWN OF BARNSTABLE y��� _ ��AiITON Gam` � �' SEWAGE # /�J //Z- ASSESSOR'S MAP &LOT ! INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY F LEACHING FACILITY: (type) -�� p' d (size) NO.OF BEDROOMS `V BUILDER OR OWNER ���� � e� PERMITDATE: 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 Leac 'ng Facility(If any wetlands exist within 300 feet le Feet Furnished by c ✓ r A � 0� 3,o93 No.....J.._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Diri.pnia1 Wildw Tomitrurtiun Prrutit Application is hereby made for a Permit to Construct (® ) or Repair ( ) an Individual Sewage Disposal System � Fµytjon r•ss or Lot No. �0I.. . . Address Installer Address UType of Building Size Lot...........................Sq. feet .., Dwelling—No. of Bedrooms---------- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixt re ---- - ------------------•------•-------------------------------- W Design Flow---_------------- gallons per person per day. Total daily flow......................... .._.. ... gallons. WSeptic Tank—Liquid capacity ��gallons Length-............... Width................ Diameter---------------- Depth................ x Disposal Trench-- N . .................... Wid _. .. . ._. ....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.-----© ✓__. Diameter-- . Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ ............ ------------------------------------ ------------------------- --.......... --------- -..... ....... ----------------------- •-•--------------- ---•••••. 0 Description of Soil........................................................................................................................................................................ V ............-••-•---•---•--•---------------•---•---•••--•-•----•-•-•-•--•---•••••--•-----......----•-•-••-•----•--•----•-••-•--•••------•-•-•-•--•---------•-••••----•----•............ ..........•-•--- UW ----•............ . .......... --- ----- --.-------------------------------------- -------------- --- --• ------------ -•----- ----------.... Nature o Repal s Alt- ¢SissweclI applicable.____..._.. ... ... ......... .. .... . .... ..... ................. ............................ •• ----------- ................ ................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environment ode—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as b iWeed y-the b of health. 14 Signed .......... ��r ........... d..... Application Approved By .... . .... ...... ................ . � . ... //. ......... Application Disapproved for the following rear n . ................. ................ <..................-.................. ......... ................................................ ............... . . -- ..............------ . ... ............ .. .. Permit No. ...... ..... ..... Issued ................ e...... --� 1 - u(�e r��✓"`:-"r,�,L„�y�t...�h-7v-r..-r't,..�,/•,,,t-••�,�•�Vw.+sir•.-:r--^�.v,^'t'""."'ti.y'�y,�"^^r.'xw'V _ •C" .:,Y ��,,. y,.;..0 r,��°'.,v lJ✓'. •r,�,; -L-'ti.Y1"v,-.�r.v .�...-.. �- r .r _ 1 0 63 i No....:-�.._ •- d F s s................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphration for Diriiaotial �'ii or1w Tomitrurtiort Vrrutit Application is hereby made for a Permit to Construct (® ) or Repair ( ) an Individual Sewage Disposal System at: 0 .... � , rs IfV ` _--- ---....----•-•...•.. 1ft„ or Lot No. �� 4j -•------- ----- •-•-------•...............••-......._............------ _ Or 1 r Address V ess Type of Building Installer Si ze rLot. Sq. feet r m -- ., Dwelling No. of Bed oo s .... _.-.._._Lapanslon Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------•___--.-.---- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------•-------------------------- ------------••-•--------•. Z ,.. W Design Flow.................._....___.._ gallons per person per day. Total daily flow.___........____..... .gallons. r WSeptic Tank—Liquid capacity..5�gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench--N . .................... Wid h_._._ . .._._-___-_ Total Length.................... Total leaching area..__•--.-___.__-----sq. ft. 3 Seepage Pit 1�'0...._. ... Diameter____ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date........................................ a Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....................................................... ..................................................................................................... 0 Description of Soil-...................................................................................-----------------------•------•------------------...._...................---_.-•--- U Nature o Repairs or Alteratio s—Answ r en applicable__.-_.. _...�../1_......✓7�.f� Vt�...�............... Agreement:�/ U The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmenta•1-Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliancy has beef i%ed by-theof health. Signed .........*47.............. .......................p..................................................... ..:. 1 Application Approved B PP PP y .......----.-.._ .............U<t 'C�................. Due, r Application Disapproved for the following rear,n i rl........ .............. ....---I. . ................................. .......-........................................................ ... y, �. .. ... I Tf3................. fe..-'----......... Permit No. ...... ........... ----------�-./.-----.--- Issued ................. . ..D�re ....�..�_ ........ 1 THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE (fertifiratr of Compliance THIS71 CERTIFY, That the Indivi u,l Sewage Disposal System constructed ( ) or Repaired ( ) at ...........1 .[ .......... ----- T?_�. . .®. !;I.1C�CsS / ......................... has been installed in accordance wiih the provisions of TITLE 5 of Tjhe. Sta e'Environm mental Code as described in the ap plication for Disposal Works Construction Permit No. ------��..�... .......� dated .................._..._................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C ONSTRUE AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION O SATISFACTORY. DATE...................f l>.................... ..._...... .. .....--- -------- - Inspector ............ .. - .... - ........ ......... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'��1 TOWN OF BARNSTABLE ��� f No....................•••; _—V FEE.I........,_........... Hier aott/l� /orkii To�t trtutw "Vermit Permission is hereby granted........lvl..l�.��.�1... _...._ ._ _vl_ to Constr ct r e air an Individual S wa e Di �osal S. s em atNo... r• - ,..-. . � ,... A...p ------------ Street --••-- f ! �. 9 �'.. as shown on the application for Disposal Works Construction P� -It o/__�.---_�-_C�__ D�ate�d �. G ...... 7............. Board of Health DATE.. .............' .�_...--� --•••---•••-•---••---- FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS n i I J pol PEse�zv� 6v pir- 1 ) LE�GN �o �,,A° 7.� Q FT, P,r ,. � 9 S Box 27' 0 sevnc I � � Ti}✓K y y M id 0 E'z6r�, raP o` 70' m-Z44 Pie�fos� p 4 0 ,1 kb i 7o' Al. wNiS TLE,B �� v v NOTE- �ZeYi977oNS Bi�Se'�b ON ASsvtie� A9�r��1. -S/ LOCATION SCALE . ��'?� DATE PLAN REFERENCE fj ?^�G' LoT ibd¢ w.v o A/ P2.Ae CERTIFY THAT THE SHOWN ON THIS PLAN IS LOCATED ON THE_GROUND AS SHOWN HEREON AND THAT IT.CONFORMS.TD_THE . SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. yz0•-3230 DATE . . . . . ... . . . . . .: . . . . .T��7C'3 f-fc/✓A[Ly/ - ��?i77y�/ REGISTERED LAND SURVEYOR / 0 zl,-A4 r 7,. of Z —5M6 -7 f =eL. . 9Z.00. .OP OF FOUNDATION CONCRETE COVER CONCRETE COVERS 305' ,'': 4' CAST IRON 2°MAX. 12"MAX. OR SCHEDULE 41 4"SCHEDULE 40 PV.C.(ONLY) I P.V.-3. PIPE PIPE- MIN. LEACH PITCH 1/4"PER.FT. PITCH 1/4"PER.FT. PIT PRECAST J LEACHING o' �INVER PIT OR JJ INVERT � • EL.. a•9.-!. SEPTIC TANK _INVBE�T.4 DIST. fig,/¢ >_ !;; EQUIV. �,a INVERT tL.....•.. .�. BOX EL.... . . 0. !' /boo. ,•., GAL. INVERT ` n- 0. :: 3/4"TO I V2' EL.88:7¢. B8.3/ INVERT , ww . EL... ELB7.7o �o �: WASHED ► '" w .r'• STONE JI ' • /o' DIA--� Errrco�arTG�ED PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE P- 408 3 SOIL LOG WITNESSED BY : DATE 1 .!� /9BS TIME./ "0 14!N .T8 • ��NGo BOARD OF HEALTH TEST HOLE I TEST HOLE 2 „ !MJA/4 ZD 'r- NGINEER ELEV. . ELEV. . . . . . . . . . . . . . . . . . . . . . . INooDLop-rf WaoD�orgr1 t DESIGN DATA : s0B-Sal• 3�" Sao- Z. a7.70 -077c NUMBER OF BEDROOMS SAND & �¢qy�• p TOTAL ESTIMATED FLOW GALLONS/DAY az.0S,70 BOTTOM LEACHING AREA 78 S. . S0.FT. /PIT/C,F,D. SAID SIDE LEACHING AREA 8 . . . SQ.FT./ PITV¢7/, C,RD, s � GARBAGE DISPOSAL AREA INCREASE) TOTAL LEACHING AREA . . .`�` 4 SQ.FT ` Sec.j PERCOLATION RATE 4r55 /,A'� 7tivc • MIN/INCH v. _ — LEACHING AREA PER PERCOLATION RATE /OO.. SO.FT/C•,PD .... . .WATER ENCOUNTERED TlNo /�iTS WiT.�/ NUMBER OF LEACHING PITS . . . . . . . TWO `E�T vim SY�N o.V ALC S/DES APPROVED . .. . . . . . . . . . . BOARD OF HEALTH ' DATE . . . . . . . . . . AGENT OR INSPECTOR a4ly f PETITIONER �FLOCKIE - IESIDIENCE MARSTON'S MILLS, MASS. DATE: 9-22-05 PROJECT TEAM: ANDREW T. ZALFWSKt M ANNE ROGERS THE MZO GROUP STONEHAM, MA LIST OF DRAWINGS I BASEMENT PLAN 2 FIRST FLOOR PLAN 3 Roof PLAN 4 ELEVATIONS 1. 5 ELEVATIONS II F-1 FRAMING G-1 GENERAL NOTES ❑ FDas S The MZO Group � D /l/o, KAFIICke%5211_pAq FH Sep 27 I311d7 2005 :Ic G z to 3 Z 0 r m,l r�N r z z 4 0 P y O C 0. 1. An yy ioS m Ol Z I I I I I 1$ I I I I I m I D I I I I I I m i I I I 3 I I m I I I I Z I I II9 10'i I iea' u I o 4 I oo (D I I I I I I I I I i I gg 1-CD I I I I CD .• �y- I I I I L-----------------J--------------------- UI� b O C 6.O' v 16'-CY o�c m Basement Plan The MZO GROUP F"G Flocke Residence e DLS1GNk:RS• I-IITCCIS•I'I_4NNFRS _ 1\T-M/Q@yj Tlllnff— �' Marston's Mills Mass. H/l£Cf (� t NIn—&A,.cmm.S.,-2llq. SmncLan,.,Bsadnnrn.p,�F14MIX [,C A �� 'h"ay'.xl-rq.J!!(.Faa'Flmq.JJlF•�AIaJ:mvQmz�gmn�p.a,m•xum.mmgrmq.cnm "YWEA0 E 2d-0 LOB J y E 4 O5-9 1 ---- N ------------------y __ - l�\EMOVE EXISTING =.v-u.�.wo.wNoow uNlr. YJ� I a roDock Fj ----------- ------------ ------- U � 0 � a 0 0 ji w n 9 z? - D—/Rnmi dby First Floor Plan Soda:1/4 1°B 57,77 2 The MZO GROUP