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HomeMy WebLinkAbout0122 WHISTLEBERRY DRIVE - Health 122 WHISTLEBERRY DRIVE, M. MILLS A= 063 084 4, p . { TOWN OF BARNSTABLE L� [ pp l LOCATION I VV S7�/t�`� ®�ss� �✓•-371" SEWAGE # VILLAGE�. ,�r S. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �/`� (size) K� NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �7I COMPLIANCE DATE: �� I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by " I ( � ' `Z�``t S Lis Y12 4K 34 6�- Commonwealth of Massachusetts 01�3" o8q Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 W_histleberry Rd Property Address r ' Owner Casey_ information is Owner's Name required for Marstons Mills Y Ma 02648 4-20-21 1 every page. City/Town State Zip Code Date of.lnspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. Inspector Information When fillirg out p ( �3 9i?- forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address r _Centerville Ma 02632 City/Town State Zip Code 508-420_4534 S14297 '&wA Telephone Number License Number " B. Cei-Iirication I certify that- I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 GMR 15.000); 1 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 system: 1. ❑ 03Sses 2. ❑ Conditionally Passes 3. ❑ Nseas Further Evaluation by the Local Approving Authority 4. ❑ Fails 4-20-21 Inspe AWs 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 rop_ditions 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 1 of 18 Commonwealth of Massachusetts r I Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 122 Whistlebe , Rd Property Address Owner Cas_EY- — ---- --- information is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code 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. Co.iirnents: At time of inspection this system met all minimum passing requirements. This report can not predict the future performance under the same or increased usage. this septic was installed in June of 1986 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. Cnc;k the box fcr"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 2 of 18 f Commonwealth of Massachusetts IP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Whistleberry Rd Property Address Owner CasE-y _ information is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection C. inspection Summary (coot.) 2) Systarn 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 tc 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): r j obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 1 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts Il Title. 5 Official Inspection Form I' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I� ^ JF// 122 Wh stleberr Rd —-- �- - - —y-------- Property Address Owner Cal—E y- -- — -- inforLtion is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection 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) uatermines that the system is functioning in a manner that protects the public health, safety and environment: 1 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. C J 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 ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 1Z 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts 14P Title 5 official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments k 1, 122 WhistlPherry Rd Property Address Owner Casey -- -- - information is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cunt.) Yes No El 0 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 'h day flow ❑ M Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: U Any portion of the SAS, cesspool or privy is below high ground water elevation. U Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. LJ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. U Any portion of a cesspool or privy is within 50 feet of a private water supply well. LJ 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.) Tine system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails. 1 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 CA. Yes No the system is within 400 feet of a surface drinking water supply E, ❑ 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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I , Commonwealth of Massachusetts I` `rifle 5 Official Inspection Form Subsurface Sewage disposal System Form - Not for Voluntary Assessments = � 122 Whist leberr Rd Property Address Owner Casey- -- — -- ------ information is Owner's Name requi-ed for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) IF ycu have answered "yes" to any question in Section C.5 the system is considered a significant threat t;r answered "yes" to any question in Section CA above the large system has failed. The owrier or operator of any large system considered a significant threat under Section C.5 or failed urd.-r Section .A 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" r'or each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health IJ Were any of the system components pumped out in the previous two weeks? CT<l ❑ 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 U this inspection? U Were as built plans of the system obtained and examined? (if they were not available note as N/A) I ❑ Was the facility or dwelling inspected for signs of sewage back up? IXI LJ Was the site inspected for signs of break out? U Were all system ccinponents, excluding the SAS, located on site? !� U 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: I� ❑ Existing information. For example, a plan at the Board of Health. Ll M 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•-ev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts is I Title 5 Official Inspection Form ° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Whistleber-v Rd Property Address Owner CasE V - — — — -- - --- - — ---- — information is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. Sys�-cm Information 1. Residential Flow Conditions: Nurnber of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Des_-!ipti:,r: According tc as-built card this system consists of a 1500 gallon septic tank, d-box,and 6x6 leach pit ,Alit' ^`t of stone. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: is !ujndy on:a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No information in..this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: currentlyoccupied t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 f - Commonwealth of Massachusetts w l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !s 122 Whistleberry Rd u Property Address -.___—_--__-_--�----- Owner Casc-y — ---- --- --- ----- -- informatics is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code 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) Lases 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(descr be below): 3. Pumping Records: Source of information: owner stated pumping in 2020 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 122 Whistleberry Rd Property Address Cas6y inform Owneraticr is Owner's Name — --_-�-- _----- ---- - required fcr Marstons_Mills Ma 02648 4-20-21 every page. City(Town State Zip Code Date of Inspection D. System. information (cont.) 4. Typ, oi System: Septic tank, distribution box, soil absorption system Single cesspool L Overflow cesspool Privy L; Shared system (yes or no) (if yes, attach previous inspection records, if any) V 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 J Tight tank. Attach a copy of the DEP approval. I Other(describe): Approx;mate age of all components, date installed (if known) and source of information: 1986 per as-built card Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 � Commonwealth of Massachusetts IP Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /r 122 Whistleber-y Rd ---- ------ ---- Property Address Owner Casey_- — — ----- ------ — information is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Gept,c Tank (locate on site plan): Det tr below grade: 6 inchesfeet 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 per as-built Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance fron- 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.): ?arik was functioning properly at time of inspection. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts i/ip TiMe 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 122 Whistleberry Rd -- Property Address Owner GaSE y - —- ---- --- — informaticn is Owner's Name required fo- Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. System. Information (cont.) ?. Gre::se 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 Co'!.,nents (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 trade: Material of construction: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 f Commonwealth of Massachusetts �;_ ` Wa. 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 122 Whistleberry. Rd _ _---- -- Propeny Address Owner C3S-E)/ - — ---- -------- ---- — informatior is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. 'System Information (coat.) 3. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (tiondition 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" C�I:,ra�.r�ts (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.): t5insp.doc-rev.7(26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts -=; l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 122 Whistlehe.n Rd Property Address Owne CaSEy Owner's Name information is required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. system Information (cont.) 10. Pump Chamber(locate on site plan): Pumos in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumas 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: 1 6x6 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: V leaching fields number, dimensions: U overflow cesspool number: u innovative/alternative system Type/name of technology: t5insp.doc rev.7,26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 122 Whistleberry Rd -- ------- Property Address Owner Ca`',Ey - — ---- --- - ---- — --- information is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): F,r vvaS opanec anc Had about 18 inches of space from pipe invert to standing liquid. 12. Cesspools (cesspoo! must be pumped as part of inspection) (locate on site plan): Number and configuration Dectni —top cf liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No C�}.--,.ncnts (note co,1,-Jvon of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.i. t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 1-�N, Commonwealth of Massachusetts �v Tift 5 Official inspection Form ,1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � - 122 Whistleberry Rd Property Address — Owner CaSEy - — — ------- -- -- — — informaticn is Owner's Name required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privr (locate on site plan): Materials of construction: Dimensions Deptn of solids Ccirments (,tote 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 Commonwealth of Massachusetts �v ,, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °1 122 Whistleberry Rd Property Address caSEy inform — Owneration s Owner's Name — -- ------_ — -- _— required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection D. System information (cont.) 14. Sketch Of Sewage Disposal System: Prov"cle.. 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 :ui{ding. Check one of the boxes below: ❑ hand-sketch in the area below F ti,iwawing attached separately t5insp.doc•rev.7426/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 (1171\ Commonwealth of Massachusetts 9 F. 1P Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments v 122 Whistleberry Rd --- ------------------ Property Address CaSEy Owne Owner's Name information is required for Marstons Mills Ma 02648 4-20-21 every page. City./Town State Zip Code Date of Inspection D. System Information (cont.) 15. side e:,xam: C Check Slope ❑ Surface water Check cellar 5 Shallow wells Estimated depth to high ground water: greater than 5 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) L 1 Checked with local Board of Health - explain: U Checked with local excavators, installers - (attach documentation) Dj Accessed USGS database -explain: You must describe how you established the high ground water elevation: property is at a high elevation with no ground water near Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7i26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts TiVe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments J 1_22 WhistlePerry/ Rd _ Property Address CAFE y Owner Owner's Name information is required for Marstons Mills Ma 02648 4-20-21 every page. City/Town State Zip Code Date of Inspection �v Repert Completeness Checklist Completa all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. S. 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 ZI D. System Information: For 8: T ight/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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Assessing As-Built Cards Page 1 of 2 TOWN�OF BARNSTABLE LocX1101V ao� �J�' St L,.i�-, Dom. SEWAGE$ VMLAGE _4S. &'r i I �. ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. y Y�L SEPTIC TANK CAPACITY V LEACHING FACfi=:(type) �t (size) NO.OF BEDROOMS _ _ BUILDER OR OWNER PERMITDATE: �I 9 COMPLIANCE DATE: �� I 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 Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by lr V (� '`t 6,1 I�iI �t 3`� S https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?map... 5/4/2021 Assessing As-Built Cards Page 2 of 2 https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?map... 5/4/2021 203.1! A/ r� nc . Q Ll3,578 S.9 f.00 Ac. C.is.fnd. SO ! wide &Xdeck vt `B s: �? � y 4-'v . or o•. N o r Sb 170• .Cot 6 1 y':ai bate 4-4-86 s<< R.U. Cape En Ceh t i :i ed Not 14 49 ka,�Got. 4Z ad !d a 6 0 ya�vua., l~i 02 f -1 �Ot/ IA 13e4nr� •lot S a4 ahown on a plan. o gh t,d, Gaitd xF 14 above the 'l hza t.CrGe t ry►► and �ecoaded .rn huczd�ced year $l o o d p l a gin. f3a�cn�s taG.l e �?eqi'� Sk 3419 Pq�. S Jhe G w u.c.Ld,�yu' mho n on .tlE4 pax iA- .Coccited on the glwwul ad, lshotun vll eteon, and.meets tie let- back 4-ecau& c rentd. oi- the gown of 6'a4n1,,:aG.te. T�i ann x-6 Ala TROY WILLIAMS RECEIV7.n. _A 16, SEPTIC INSPECTIONS to I Jaw Certified by MA Department of Environmental Protection (508) 760-1819 A c HMTH DST 40 Old Bass River Road OF BMSTASL South Dennis,MA 02660 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe Gmw wr .S�cntary O( Argeo Paul Celluccl David B.Struhs lU U.Gw.m« can M r © ey SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION / Property Address: 0,2 of Owner. ��y k SGr,✓L �o�u•�`� Date of Inapeotion oC7 G / /�/1 i S• (If different) Name �2 Nme of Inspecto Company Name,Address dnd Telephone Number. /0 1p�l /� 406�v r y G-L o i n. �pVb,6''X i 3 a k / CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes — Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Im_xctor s Signature Date: 411',23 The System Inspector 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 repert 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 At, B, C, or D. A) SYSTEM PASSES: 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criterie not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: /v// One or more system components need to be replaced or repaired. The system. upon completion of the replacement or repair, passes inspection Indicate yes, no, or not determined (Y, N, or ND i Describe basis of determination to al] instances If"not determined'. explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltratuon, or tank failure is imr*anent The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Heath (re� sec ,'C3;o57 1 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) Property Addrem IO2 a W fin',S��c �s r✓`� Owner. C 5 Date of.Inspection: . Bl SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(8) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced 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 01 Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: H14 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: 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. 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A � CERTIFICATION(oontinued) Property Address: 1, a W ;5 T/e e✓sue Owner. 5 C—s 9 Date of Inapeotion: �/2 3 D) SYSTEM FAILS: 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. — 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. — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. — Liquid depth in cesspool is leas 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 — 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. — 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 conform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: /v /1 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: — 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) 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 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address Owner. c3 G 5 Date of Inspeotlon: 3 Check if the following have been done: 1� limping information was requested of the owner, occupant, and Board of Health. V 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. Aa 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. V All system components, excluding the Soil Absorption System, have been located on the site. AZ"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. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. ZThe facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' I SYSTEM INFORMATION Property Address: 9aa W S� l c✓v/ Owner. Date o /✓f Inspection y/a 3 /Y G RESIDENTIAL FLOW CONDITIONS Design flow:_-JID gallons Number of bedrooms:, Number of current residents: O Garbage grinder(yes or no):—�g S Laundry connected to system(yes or no):—SE�E S Seasonal use(yea or no):/LO Water meter readings, if available: .S = y g ODD d �c. Last date of occupancy: 74r 5 Yh bL 44 , COMMERCIAL/INDUSTRLAL• Type of establishment: Design flow: mllons/day Grease trap present: (yea or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: /f /.J 5 Gl U� !�. 4:a, -c system pumped as part of inspection: (yes or no) /VO _ If yes, volume Pumped: eallons Reason for pumping: 'I']'PE F 9FSTEM �I septic tank/distribution box/soil absorption system Singie cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of/all components, date installed (if]mown) and source of information< /InS�A G jae✓—G s— -4 d , l Sewage odon detected when arriving at the site: (yes or no) AL 0 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addrem Owner. Date of Inspection: (7 y/a3 SEPTIC TANK:z (locate on site plan) Depth below grade: Materiel of constructton: _concrete_metal_FRP_other(explain) Dimensions: Ll ,r 7'Jl'G ' / S 6 0 � / �. S Sludge depth: "/ 07 / 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:A/a .S �"✓�^ Distance from bottom of scum to bottom of outlet tee or baffle: ,6/(j S G v Comments: (recommendation for pumping, condition inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) JG e S ✓ i c C­r cv✓4-t-,-4- 0 r O O>'- C.L. d L. J ✓Gh !n �. GREASE TRAP (locate or.:site plan Depth below grade: Material of construction: _concrete_metal_FRP _other(ezplain) 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: 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.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addreew 10202 4,L)I,,s cr�Owner. Date of Inspection: s TIGHT OR HOLDING TANK: A//9 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP--.other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level anS,4istribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER._ l (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 11;03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(oontinued) Property Addrem !0?-2 Owner. Q L Date of Inapeotion: �J V/-z3l9 6 SOIL ABSORPTION SYSTEM (SAS);, (locate on Mite Place, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: leaching pits, number: 6�G /�� ���A c �• [.v;7 /S�h . leaching chambers, number:_ leeching galleries, number- leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: J Comments: (note condition of soil, signs of hydraulic failure, level of nding, condition of vegetation,etc.) cJ v'n.-_ CESSPOOLS:f /q (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: ir-flow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: A114 (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.) (revised 11/03/95) 8 f 4 • t' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 a.Z !j Owner: G s 6 Date of-Inspection: 43 ��6 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 41 1 /Saoy�llo� 10 w a 'sjjw, DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level method of determination or approximation: L S , o� C d L- vt , u ry All o C- IAL, i 9 of ia�,�_ .�;r�. ASSESSOR'S MAP NO PARCEL" t 0'r,;A-! 'IO N S E W A G E PE R M I T NO. :, li.� '` ' a � e 6 `VILLAGE I N S T A LLER'S NAME i ADDRESS X- S.U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � � CY�� �C�'l1� � tZ� �. '\G`CJ't �1� r � � i .. �. �� � �`�� c?� 0 � i� �� _ � _ - . ...: �� ' ��� ASSESSORS MAP NO: -266 PARCEL NO.: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .v"`....................OF...... Appliratiun for Biupuuttl Workii Tunutrurtiun Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: �� ........ .1t l S ..R!(....(...---...... ..................................... - --__- Location-A ress _•._.•.--- .----. --•-------------or Lot No. �- ------------------------------------ .............................................. Owner Address W Installer PQ Address G UType of Building Size Lot......1-_ 2..--.._..Sq.—facet Dwelling +—✓No. of Bedrooms....._ ......................._.......Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of persons............................ Showers � YP g --------•------------------• P ( ) — Cafeteria ( ) dOther fixtures -----------------•------------------•--•---••--------------------------------------=-------------•----- Design Flow,......3_,.7.........................gallons per person per day. Total daily flow__ _ gal WSeptic Tank Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width_.. _. ...... Total Length__-- 4r--..._ Total leaching area....................sq. ft. Seepage Pit No.--__-___-_/._.... Diameter.__...-... ._�.. Depth below inlet................. Total leaching area..;.....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percoiation Test Resulps Performed b � �._ _ � Y---------- - - - �•�---•-•--•----------•-----------. Date......���-.�V........... J Test Pit No. l._.._... ..minutes per inch Depth of Test Pit.................... Depth to ground water..0.(.......... az, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ tx ................................•...................•••-••-------••--••- ------........ ....... •. .37 Description of oil.....0.---.3........-.._•-d71-' ....----•---•g--•----.----•-•-•---_-----•-3..........- mc."&. .�. �.,����L� w13VMV------------------------------------------------------------------------------------------------------------------------------------•-----........._............ x -------------------------------------------------------------------------------------------------------------------------------------- •- ....................................- ------------------------- U Nature of Repairs or Alterations—Answer when applicable.........................................................:..................................... •-------------------------==•----.......---•----•-•-----•-----------•---------------•-------------...........----------...----------•----------•--------------------------------...._._............-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provsions of TI'LU 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until I ca e Compliance bas be n issued by the board of health. �"— .. ..................................•..... .........................._...- te Ap ion Approved BY................ ------...... P ` Application Disapproved for the following reasons:............. ---------••.................•---------.._..-----....--� -----•--•----._..._,Date -•....................................--•---------•----...---•-------•..................------..•..............••................ Date PermitNo.......................................................-- Issued....................................................... ....... Fimz3m THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............0 e ` f I�-&. .......................................... Appliration for Disposal Works Tonstrudion Prrutit Application is hereby made for a Permit to Construct �or Repair an Individual Sewage Disposal System at: ....:-I"' T 'S.......... ............ ........)M.A.t%6................................... or Lot No. .......... Owner •Address f4 .......... .......... Installer Address pi co Type of Building Size Lot ........I&rof&t U u'Dwelling—T�o. of Bedrooms........ ................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons........_.............._._.. Showers Cafeteria Otherfixtures ........................................................................................ D;V X- -------------------- Design Flow........Y511.0.........................gallons per person per day. Total daily flow....wVA..........:......A._...:.gallons. IY4 Septic Tank—Liquid capacity............gallons Length................ Width._.._........_.. Diameter.._..._._....... Depth...._............ Disposal Trench—No Width_ �I.......... Total Length.........*.4*... Total leaching area...................sq. V&_ '" ...... Diameter.....___ Depth below inlet..... ......... Total leaching area. 319....sq. ft. Seepage Pit No---_-----/ .6. ­­VX--- Z Other Distribution box Dosi Percolation Test Resul Performedf rmed by. ................................ Date...... .......... 12/ Test Pit No. ..minutes per inch Depth of Test Pit.................... Depth to ground water..01 A.4........ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.._....._......_.__. Depth to ground water....__..._..._.......... P4 .................................................................... ;r......... Wz ........i..........._';"?A.. ----tal.................. 0 Description of Soil..... .........orn... ........................... ----------Inme. g -------------------------------------------71------*.......­-------------------*--------------------------- ---------- ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System,in accordance with the provisions of TITLE - 5 of the State Sanitary Code--,The undersigned further agrees not to place the system in operation until ca e Compliance has blen issued by the board of health. ................... i1p;�oi .....Lit�------------------------------------------ ........#10 Ap ion App B .::Mh17 • ......... .Y-----------------------------------------A------ ------------------------------------------- 6 .-,- Date ApplicationDisapproved for the following reasons:..........................................................................................................- .........................7......................................................................................................................................... Date PermitNo............... ................................. Issued-...................................I................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF` HE LTH ... .. .. .............OF..... ................................ Tafifirate of Toutpliaurr TH VIS TO CERT FY That the Individual Sewage Disposal System constructed (4110100077 Repaired by... ......................................ii........ I....................................................................... Ij%er at........................r_�... . ..... has been installed:i f h,accordance 4with the provis ns of TITLE 5 of The State Sanitary Code as d ribed in the application for'.Disposal Works Construction Permit ------- dated....... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUA ANTES THATT�E �_ SYSTEM WILL" U14CTION SATISFACTORY. DATE............ ......................... .TP" ............................................................... ........................ Inspector COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. . .....04A%� No. .................OF.....3A444APU.......................................... .......... Fn.(%�............ Disposal. iVor.%T4nstrnrffVtf*r4fit Permissionisheje granted.. +M .mac ..................................................................................---- to Const uct ( )Wr-Rep�air Individual S Dlspk��31S Aem 4k. aL Individual ewage. I � N A .... ........ M ....... at ..... A Street as shown on the application for Disposal Works Construction Perrijit fs .................. ................ ......................Board of Health DATE.__ . ......................................... I............. 20 FORM 1255 A-."M. SULKIN, INC., BOSTON i i '_----- ��� 11,2 � � I J�# \ I j /, may �4 \���-''`-� "� / / , -�'" - � �L--✓-f/� �G. �i..� ,• / If, •+ ��� •� J I I - �j i T /lid'' , .�,, �.�y//✓�`...�.. All / fix �� y3.5' SE✓>:G 1 77;A Al f I I /5�U 6,4 z.G s: - OAS/6"�/' /-'fit�_..,�1 a~/v�t�,�r-,r' / „/•�/ Z ,�i�" ��' �..�.s.S" 717 I 7.,A :- _ <' -•cJvG..� �/O T Ls'.� GJ.S�.I� Tv G�'�F,E�I�./� LG�T` .. -