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0239 WHISTLEBERRY DRIVE - Health
'� ' WHISTLEBERk DRIVE! Marstons Mills -i ,. A = 062 - 012 . (. i , �µ Sri, .�.• � ' ova-0/,;21 ; v_J§ 2015 22:48 Jim The Inspector Man 5085349919 page 1 Gofnmonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Ass essmenks 239 Whistleberry Drive { `_J .... .,.._._.........,_..,,.,,........._...., �..�.W.,,,...._._.......... .. Property Address _ . Janice Hank Owner — _ Owner's Name — information is ' required(or every _Marstons Mllis ....:......�._ _ - MA f 264$: i 1 19 15 page. cityrrown State Zip Coder' Date oi'Inapection Inspection results must be submitted on this form. Inspection forms rttay nct be-altered in'any.. way, please see completeness checklist at the and of'the form: Important:When filling out forms A. General Infor, anon. Sly 1/30 on the computer, 5 "AOFf, use only the tab 1. Inspector! key to move your p i yG cursor-do not James D.Sears ? JAMES n,T Use the return __.__. . _ Name of inspector key. . 1 c>• I✓AR Ca ewide Ent rses LLC _— _ �_. Company Name 3 Commercial Street '',,, sljrasp� ` .. _ _ _ Company Address <. t+mmrtt. Mashpee MA ,, 02.... CityfTowrt _. __ State Zlp Code 508-477 8877 t _ w —... S1623 Telephone Number _ Lieense.Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported tseiow is true, accurate and complete as of the time of the inspection.The inspection.: was performed based on my training and experience in the proper.function and.maintenance of o. sett: sewage disposal systems. I am a DEP approved system inspector pursuetnt to Sectioni15.340 of Title 5(310,CMR 15.000). The system: i Wasses D Conditionally Passes ' Falls [;► Needs Fur?he:r Evaluation by the Local Approving Authority peotor's Signature. C7ate s The system inspector shall;submit a copy of this inspection report to the Approving Authority{Board Of Health or DEP) within 30 days of completing this inspection. if the system is a shared system or has a design%flow of 10,6010 gpd or greater,the inspectbrand tFte system avi+ne`c shall submit`the report to the appropriate regional office of the DER The original should be sent'to the system owner and copies sent to the buyer, if applicable, and the'approving authorty; ""This report only describes conditions ai the time of inspection and under'he candltions;af use at that time.This inspection does not address how the system will.perfonn fn the future under { the same or different conditions of use. tsins•3113 TiiIS.6�aai InsnecSor,�crm Sutisti°raar Sewag"D'ca�sa!SYstam•Faga t ci't7 Nov 19 2015 22:48 JIM The Inspector Man 5085349919 page 2 Commonwealth of Massachusetts Title 5 Official Inspection Font Subsurface Sewage Disposal System Form Not for Voluntary Assessments 239 Whistleberry Drive ... Propeny Address Janice Hank _ Owner O wr:.er's Name _ information is MaCStOnS MIIIS requued for every ....- MA 02648 11-19=.7 5 page. Cityfrowrt State Zip Code Date oflrisperxitln B. Certification {coat.} Inspection Summary, Check A,B,C,D or 1 afways complete all of Section b A) System Passes; _ _ l 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, An failure.cri teria teria not evaf indicated below. y uatetlare Comments: Thesystem is a 1500 Gal. Tank D Box and pit v ._, ... . _. B) System Conditionally Pas ses: __. ❑ One or more system componentsas 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 stcucturai�y unsound, exhibits substantial infiltration or exfiltration or tank failure is imrrlineit. System will.pass inspection ifthe 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 ink is less than 20 years old is available. Compliance indicating that the t 11 Y O N F1 ND(Explain below); .......................... _�-_.__ .............�,.:....:.._:__ _._..... �m..... . t5iiu+3t43 Titaa 9 Craa cia t c3 cai--ow subssie"Sew O�' aaosui Syutem•Page 2 or:ti , Nov 19 2015 2248 Jim The Inspector Ilan 5085349919 page 3 Commonwealth of Massachusetts f Title 5 Official Inspection Four Subsurface Sawa a stem Disposal System y Form Not for Voluntary Assessments V` 239 Whistleberry Dave _ ...._ ..__ Property Address. Janice Hank Griner _.:..._... ....._ . Owner's Name infdrmation is required for every Marstons Mills..............._._.__. __. MA 2648 page. City/Town State Zip,Code Date of inspection B. Certification (cant.) Pump Chamber pumps/alarrns not operational. System will pass with Board of Health approval rf purnpstalarms`are repaired; B): System Con'ditioaat y'Passes(cunt:): ❑ Observation of sewage backup or break out or high static water level in the.distributton 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): . Ell i brokcen laced pipe(s)are re P ❑ Y ❑ N 0 ND (Explain below).' obstruction is removed ❑ Y ❑ N ❑' ND{Explain below}:.' . ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below}: ... .. _. a ❑ The system required.pumping more,than 4 times a year due to broken or o'bstruck-d pip e{s} The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below.): i obstruction is removed iJ Y o N ❑ ND(Explairti W_.�. . I ......_._.. ................_ Cj Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluatian by the Board of Health in order to:deterrnirte it the system is failing to protect public health,safety or..,the environment. 1. System will pass unless Board of Health determines:I accordance with 310 CMRi 15.303{1}(b)that the system Is not functioning in a'manner which-will protect:public hs3alt.tr, safety anti the environment: i Cesspool or privy is within 50 feel of'a sur#ace water ❑ Cesspool or privy is within 5D feet of a bordering vegetated wetland or a sai,t marsh t5in6.3113 _ Ttrla 5 Oflte.at tnapQCAbn Farm-.Sub�iAave Savage Dso13Y&tsrf•Peti�1&t t7 . Nov 19 2015 22,48 Jim The Inspector Man 5085349919 page 4 Commonwealth of.Massachusetts Title 5' oT ciat inspection �o►rm i Subsurface Sewage Disposal Systern Form-Not for Volur is y Assessiments r 239 Whistleberry Dave .. Properly Andress ...�..._...._. : ; Janice Hank Owner --._.....-..._ .. _.....,_._ -,..... Owner's Name Information is rsquired for every Marstons Mills MA- . 02648 11-19-15 page, CityfTown ___....__ W _ Staff® Zip Code Date of Inspection B. Certification (coat.) 2. System will fail unless the Board of Wealth (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: Q The system has a septic tank and soil absorption system (SAS.)and the SAS is with€n 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 witltima.ZOMe1 of a public water supply. Q The system has a septic tank and SAS and the.SAS is,within 5Q feet.af a private water. supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 5t)'feet or more from a:private water supply well". Method used to:determne distance: '•This system passes if the well water analysis, performed at a t3EP certified laboratory, for fecal coliform bacteria indicates absent and the presence of:ammonia nitrogen acid nitrate nitrogr?r►;is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy cif the analysis must be attached to this form. 3. Other ... D) System Failure Criteria Applicable to All Systems: You must Indicate"Yes'' or"No"to each of the following for all inspectlonS Yes No : Q Backup of sewage into facility or system component due'to overloadedor. clogged SAS or cesspool Discharge or ponding of effluent to the surface o-f the ground or surface waters due to an overloaded or clogged SAS or cesspool Q ® Static liquid level in the distribution box above outlet invert clue tgan overloadedi or clogged SAS or cesspool Q Liquid depth in is less than 6"below invert.or available vo#ume its€ess, than%da flow i°TT,~7 T'N45.offlaaa1 H-Pevt(on F*rm'SU.as�04(vj SerregR GhSpo.sd 3ya..m•r'ago ed ti:: Nov 19 2015 22:48 Jim The inspector Man 5085349919 page 5 Commonwealth of Massachusetts E; Title 5 Official Inspection ForM . f191 Subsurface Sewage Disposal System Form -Not for Voluntary Assess men#s. t 239 Whistleberry Drive .__ . Property Addrass Janice Hank Owner _-_-_..I_-._ T_ Owner's Name information is required for every .Marston&Mills MAC 0264$ 11 19 15 page. CdyfTown: -- Ztp Corse be State te of:lnspectron B. Certification (cone) Yes No - ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped; ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation: ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply of tributary to a surface water supply; Any portion of.a cesspool or privy is within a Zone 1 of a public!,wef{ ❑ ( Any portion of a cesspool or privy is ter thin 5O feet of a private water supply Well.. _ ❑ Any porlion.of a.cesspoof or,privy is less than 100 feet,but greater than:50 feet,: from a privatewater supply:wefl with no acceptable water quality analysis: [This system passes if:the well water analysis, y , perfic►rmed at a DEF cectlfied` laboratory;.for fecal coliform bacteria indicaties absent and;the,.presence t of ammonia nitrogen and.natrate nitrogen is equal t*or is than 5 ppm provided that no other failure criteria>are triggered.A copy;al the.analysis and chain of custody must be attached to.thls form.1 ❑ The system is a cesspool serving a facility with a design flow of2000gpd 10,OOOgpd. ❑ The system falls. I have determined thatone 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:Whatw ill be:: necessary to correct the failure. E) Large Systems; To be considered a large system the system must serve a facility with"a design flow of 10,000 gpd to 16,000 gpd. For large systems; you must indicate either."yes."or`no"to each of the foll.dwir g, In addition to the questions in Section D. Yes No ❑ the system is wlthln 400 feet of a surface drinking water supply El ❑ the system is within 200 feet ofa 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 ll of a public water supply well If you have answered" es"to any Y question in Section E the system is considered.a`significantthreat, or answered"yes" in Section D above the large system has.failed.The.owner or operatorof any large system considered a significant threat under Section.E or failed under Section C7 shall upgrade the system in accordance with 310 C M R 15,304. The system owner should contact the apptdpriate regional office of the Department. tuna `ar» 9 . - Tics 5 Atrlcial 6ispeciion Fcxrn:SudsuWaon.Sa»zign Dispose!Sy¢,em Psiga"a u(11� Nov 19 2015 22:48 Jim The Inspector Man 5085349919 page 6 commonwealth of Massachuseft Tine 5 Official Inspection Form Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 239 Whlstleberrw Drive ._..�..__.__ __. _......., . _..... Property Andress Janice Hank Owner ner's Name_ ............. ........_ .._.. .. �.. .._ ....... information is Rw I required for every Marstons Mills MA 02648 _ 11-1g-15 I page. Cityfr n State Z,P Gode Sate of-lnspecx e__ -- C. Checklist _ Check if the following.have.been done.You must indicate"yes':or"rtca" as.to,each of ire following: Yes No r i Pumping information was provided by the fawner, occupant,or;Board of=Flealtti 0 Were any of the system components pumped out in the previous:two weeks') 19 Q Has the system received normal flows in the previous two week:period? ® Have large volumes of water been introduced to the system receritty or as part of this Inspection? Were as built plans of the system obtained and examined?(If they were riot available note as NIA) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up?: i 0 _ Was the site inspected for signs of break out? i f Cl. Were all system components,excluding the SAS; located,on site.? M Were the septic tank manholes uncovered, opened; and the interlor of the tank inspected for the condition of the baffles or tees,,,material of construction, dimensions, depth of liquid,.depth of sludge an depth of>scum? � Was the facility owner(and occupants if different from owner)provided .i#n l information on the proper maintenance of subsurface seitiage disposal sgs#erns? The size and location of the Soil Absorption System(SASj.on the site has: I been determined based on: Existing information. For example, a plan at the.Board of Health. ® Determined in the field (if any of the failure criteria related to Part Cis at'issue approximation of distance is unacceptable) [310 CMR 15:302(5)1 Q. System Information Residential Flow Conditions: i Number of bedrooms(design): - -- — Number of bedrooms(actual): ` DESIGN flow based on 310+ MR 15.203(for example; 110 cgpd x*of,bedrooms): 330 i, F5drs 9f13 .Tft 5 Ofrcw 1rspo3on Farm;subsLrrscaswm1 setxt0059. y •:Page89f-.,t 7. Nov 19 2015 2Z49 Jinn The Inspector Man 5085349919 page 7 Commonwealth of Massachusetts _ = Title 5 CTC Ir pe crForm..TI Subsurface Sewage Disposal.;System Form • Not for Voluntary Assessments _ 239 Whisk Drive Janice Hank Owner ..._.._ .,..._.. .... Owner's Name - _ Information is required for every Marstons Mills MA 02fi48 ---- 11 19;15 page. Citytrown _ ...._._: _.. stale Zip Code Date of Inspection D. System Information Description, The s &tem is a 1500 Gal. Tank D Box and pit. Number of.current residents: 2 .Does residence have a garbage grinder? El Yes:: No It laundry on a separate sewage system? {Include laundry system inspection information in this report_} __.. C1 Yes .No. . Laundry system inspected? 0 Yes No Seasonal use ... . Yes:: . No Water teeter readings, if available last 2 ears usage 2013-30OOOGa(s g � Y 9 (gPd?)� 2014429 OOOGafs Detail: .. ......_.................... SUMP pump? Last date of occupancy; Present? Date Comrnercialltndustrial Flow Conditions: l Type of Establishment: .......... Design flow(based on 310 CM 15.203): Gallons per daY(9pd) Basis of design flow(seats/persons/sq,ft:, etc.}: _ Grease trap present? [] Yes [❑ No: Industrial waste holding tank present? [], Yes.r-1 No. i Nan-sanitary waste discharged to the Title 5:system? _ 0 Yes. [] No Water meter readings, if available: Title 5 cf ww 4 hrspecion form:subsuo"Sirlli 3 DW04ei System rage 7 of'3£ t f .Nov 19 2015 22:49 JIM The Inspector Man 5085349919 page 8 Commonwealth of Massachusetts V Title 5 .0ifficial Inspection Forte Subsurface Sewage Disposal S stem Form - 9Not for V y a Voluntary Assessments rY _. . 239 Whis#ieberry Chive .._ __ __._.__..,._...._.._._._...._ ...._ Property Address Janice Hank Owner Owner's Name _- _.. .. information is required for every Marstons millsa7264:8 _ ..__. MA page, City/Town, _._ _... - . State Zip'Code [late nflnsptadion D. System information (cont.) Last date of occupancy/use: Date _.. _.::;._ _ £ Other(describe below): General information I Pumping Records: Source of infartnation: . 6/1611 Q-10/28/14 Was:system pumped as part of.the inspection?. : Q Yes No If yes, volume pumped: .:...: gallons How was quantity.pumped'.determined? Reason for pumping; Type of System: ® Septic tank, distribution box, soil absorption system { Q'. Singie cesspodi - { Overflow'cesspool - l i ❑ Privy g " Q Snared system(yes or no (if yes,anach previous inspection records,; f any).. ❑ -: IniiovativelAlternative technology. Attach:a copy of the current aperatibn 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. l Other(describe): _.._......... "Title 5 ONSriai;n4 ecfon Form,SubzutIace$vow oispoee!,Systsm•Page 8017 _ r Dec 08 2015, 00:29 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is Marstons Mills MA 02648 11-19,15 required for every page. City/Town Stale Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known)and source of information: 1984 Permit # 84- 160 / 11-2015 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 46" 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.): Pipeing is 4" PVC SCH 40. Septic Tank (locate on site plan): Depth below grade: 3 - feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 1 Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 o117 Dec 08 2015 00:29 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 239 Whistleberry Drive Property Address Janice Hank Owner owner's Name information is required for every Marstons Mills MA 02648 11-19-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and out let cover at 3' below grade w/inlet cover at 15". Two inlet tee's w/outlet baffle. No sign of leakage or over loading. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 6 ORldal Inspection Forth:Subsurfaca.Sewage Disposal System-Page 10 at 17 Nov '19 2015 22:50 Jim The Inspector Man 5085349919 page 11 Commonwealth of Massachusetts Title 5 official Inspection Form i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name informrequired is Merstons Mills _ MA 02648 11-19-15 ratluirod for every _ page. citylrown Slate Zp Code Date of inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related to outlet Invert,evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): i Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: i Capacity: gallons l i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i Ibins-all a Title 6 Of%d Inspamon Form:Subsurface 8wmF 0*asW 8ystan-Pow 11 of 17 f Nov '19 2015 22:51 Jim The Inspector Man 5085349919 page 12 Commonwealth of Massachusetts kqjTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Whistleberry Drive Property Address - Janice Hank Owner owners Name Information Is Marstons Mills required For every MA 02648 11-19-15 page. Cityrrown state Zip Code Date of Inspection D. System Information (oont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.): D Box is 16'x 16%34" below grade w/one line out. Box is new 11-2015 w/cover at 4"below grade. I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No- Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Mims-W13 Tips S Ofridal Inspedon Form:Subsurrace Sewage ohposa Sy6j$1•Pape 12 d I? Nov'19 2015 22:51 Jim The Inspector Man 5085349919 page 13 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Whistlebe Drive Property Address Janice Hank Owner owner's Name Informetion is Marstons Mills required for every MA 02648 11-19-15 page, Cityrrown Slate Zip Code Date of Inspection D. System Information (cons.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: Cl innovabve/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Leaching Is a 1000 precast pit w/1'stone. Pit and cover at N below grade, 1'water In pit. No sign of over loading or solid carry over. No high stain line Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No WOO.3M3 TIUe 5 Olrioid Inepacdon Form:Subeurfam Sonpe Disposal System-page 13 or 17 Nov' 19 2015 22:51 Jlm The Inspector Man 5085349919 page 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owners Name information Is required for every Marstons Mills MA 02648 11-19-15 page, cityrrown State Zip Code Dale of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.); Privy(locate on site plan): Materials of construction: Dimensions ........ - Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, ! etc.): Zips-V 1 TMe 5 Offidd kmpedion Form:Subsurface Swepe Dkpaaaf Sydem-Pape 14 of 17 i Nov' 19 2015 22:51 Jtrn The Inspector Man 5085349919 page 15 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Whistleberry Drive Property Address _ --- Janice Hank Owner Owner's Name _ infor ation required forav eryMarstons Mills MA 02648 11-19.15 Page. CkyRown State Ztp Code Dab of Inspadion D. System Information (Cont.) Sketch Of Sewage Disposal System: provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below j ❑ drawing attached separately I i 14"1 ` 33 GO?At A AVOW � 04 )�5-jf° J 4 .3 - 491-0 f., o R-3 : 3g"q lff� h A-c/= �a a i tSins•3113 Ve S Moat to act an Form:Subsurface Stom p Disposal System•Page/S or 17 f Nov' 19 2015 22:52 Jim The Inspector Man 5085349919 page 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface SewageDI 9posaa1 System Form Not for Voluntary Assessments 239 Whistlebery Drive _ Property Address Janice Hank Owner Owners Name information is requiresquired forr every Marstons Mills MA 02648 11-19-15 page. Cltyrrown state Zip Code Date of Inspection D. System Information (cont.) Site(Exam: ❑ Check Slope ❑ Surface.water ❑ Check cellar ❑ Shallow wells Nd Estimated depth t igh ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1-13-84 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) . ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 1-13-84 no G.W.•st 12'+. Bottom of pit at 9'below grade. Bottom of pit at 3'+ above T.H. Depth. i i Before filing this Inspection Report,please see Report Completeness Checklist on next e• Pa8 i tsin s-srls I Thb 5 011idd Inspection Form:Supwiliti Sewage Dlaposd byscmi•Pape 16 d 17 i ' IV& 19 2015 22:52 Jim The Inspector Man 5085349919 page 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 239 Whistleberry Drive Property Address - Janice Hank Owner Owner's Name - Informationis taect Marstons Mills MA 02648 11-19-15 required for every page. Chyrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B. C. D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file MAs-3113 Title 6 Offwht Inspection Fam:su "Mca Swap*Dispowl system•Pape 17 of IT 3 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01p riration for Disposal *pstem Construrtion Permit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No.235 W!1(.5rC,4c'gC" pp, Owner's Name,Address,and Tel.No. �Ati.P1CC Assessor'sMap/Parcel © t4K k+4ifK Installer's Name,Address,and Tel.1140. !!"08_q 1'1 $-1,7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 1" Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site"sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Sign A Date I l '4 ®I j Application Approved by Date Application Disapproved by Date for the following reasons ?ermit No. k t'!( — _ Date Issued _� I_ A� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for 33isposar �WpstPm Construction Permit APPlication for a Permit to Construct Repair Upgrade Abandon Complete System Individual Components , Location Address or Lot No.A" WiPSTr&8C" pR Owner's Name,Address,and Tel.No. MM :TANlcc HA4vk Assessor's Map/Parcel Ob;Z/e:>o, i` 9,4 (JLW 2nL "DR. Installer's Name,Address,and Tel. o. S'OB_41 1-i 2'7? Designer's Name,Address,and Tel.No. 15 3 Sa' M Type of Building: 1 Dwelling No.of Bedrooms ►" f� Lot Size sq.ft. Garbage'Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: `` Agreement: { The undersigned agrees to ensure the construction and maintenance of the afore described n-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in Aeration until a Certificate of t Fompliance has been issued by this Board of Healt . Signed Date ( " -101 Application Approved by I Y Date 0 y 2 d /J Application Disapproved by V Date for the following reasons Permit No. U I 3 Date Issued THE COMMONWEALTH OF MASSACHUSETTS „d BARNSTABLE,MASSACHUSETTS v/ Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( xl Upgraded( ) Abandoned( )by C*LWt DE 6PMW SF (, LC_ at A3 9 W ti s s rA jSg"" b Q- M M has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated I i _ `Installer C.ApIC—.t.e1lDC CV Q;«� LLC Designer N Q f 'If #bedrooms Approved design flow �/ �� gpd The issuance of th pe it shall not be construed as a guarantee that the system will ctio . s design; Date I Inspector Ow > No. c) t ' 3 Z Fee /UU THE COMMONWEALTH OF MASSACHUSETTS V, PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair( x) Upgrade( ) Abandon( ) System located at O-1 39 t-� 5 TL.C-f, 0.1�b k t u g' /"1 J412 S TO IBIS k4` t"t.S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date 1 f%�///►� Approved by • Town of Barnstable Barnstable Regulatory Services Department .. "' ft'ft • "" NSTABM Public Health Division Q D• 6J9���� 2007 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Richard V.Scali,Director FAX: .508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7014 1200 0001 0358 5944 October 21, 2015 Lois Hirshberg &Janice Hank 239 Whistleberry Drive Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 239 Whistleberry Drive„Marstons Mills, MA was last inspected on 10/01/2015 by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the following: • Distribution-box is deteriorated and must be replaced. You are ordered to repair or replace the septic system within one (1)year from the date ,you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH G.§a's McKean,R.S. CHO Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\239 Whistleberry Dr MM Oct 2015 Town of Barnstable + HARN3rAHLE, KASS Regulatory Services Department Public Health Division 200 Main Street Hyannis MA 02601 Office: 508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6,2007 Rev. 7/6/15 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑Any portion of the cesspool within a Zone 1 to a public well ❑Any.portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool 1 ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation of a driveway due to H-10 components, etc) ❑.Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) OTHER �Ad Repair deadline: l' -em C Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts � �10,:F /,Z w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M 239 Whistlebegy Drive Property Address t�i Janice Hank Owner Owner's Name t�7 information is X., required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection v--.0 Cmfi'I Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information L/# //z D/ �apttutt�fqup on the computer, J I NX\`°ZH of use only the tab 1. Inspector: �����``�' •'•9c�''� key to move your cursor-do not James DSears JAMES :R, use the return Name of Inspectcr bEAKz)key. :r„` �— Capewide Enterprises, LLC ;'. Cl- Company Name 153 Commercial Street ''i ,r�t IFt,�G�``���� Company Address Mashpee MA 02649 City/Town State Zip Code 505477-8877 S 1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority off ' 10-12-15 6spector's Signatire 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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �0� Us t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ° Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated Ibelow. Comments: Conn Pass-Need to replace D Box. The system is a 1500 Gal. Tank D Box and pit. B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �^M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health); ❑ broken 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): Need to replace D Box. ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system-is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in @&@@pEW is less than 6" below invert or available volume is less than Y2 day flow ,0/7— l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 prim, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 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 11 of a public water supply well If you have answered"yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required forevery Marstons Mills MA 02648 10-1-15 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for:every Marstons Mills MA 02648 10-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and pit. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2013-30,000Gals g ( y g (gp )) 2014-29,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 6/16/10 - 10/28/14 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1984 Permit#84 - 160 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 46" 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.): Pipeing is 4" PVC SCH 40 Septic Tank (locate on site plan): Depth below grade: 3' feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500Gal.Precast H-10 Sludge depth: 1" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M s 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level. Tank and out let cover at 3' below grade w/inlet cover at 15'. Two inlet tee's w/outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x21"-34" Below grade w/one line out. Wall's are gone, need to replace box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass; Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,M s•'° 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 precast pit w/1' stone. Pit and cover at 3' below grade 1' water in pit. No sign of over loading or solid carry over. No high stain line. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for eery Marstons Mills MA 02648 10-1-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately fi FiPoNr 13 3-,1A- O i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N© Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1-13-84 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H. on Design plan 1-13-84 no G.W. at 12'+. Bottom of pit at 9' below grade. Bottom of pit at 3'+ above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 usetts Commonwealth of Massach Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 239 Whistleberry Drive Property Address Janice Hank Owner Owner's Name information is required for every Marstons Mills MA 02648 10-1-15 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 q • V LOCATION �"� f SEWAGE PERMIT NO. 'VILLAGE ;~ m , , ��S - INSTA LLER'S NAME i ADDRESS ® UILDER OR OWNER pr DATE PERMIT I1SSUED pDATE COMPLIANCE ISSUED ��� c/ 53 y� h Ie b r:ICY P r, 1 No. �-lcl.a..... Fizs..:f'................... 9 THE COMMONWEALTH OF MASSACHUSETTS 3� ,D BOAR® OF HEALTH Appliration for Disposal Marks Towitrnrtinn Vatnit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....... ........•�1.`....-- --••----------------------------------------------------------•------------------........--------- Location-Address or Lot No. ... � L .�s�a.... ------------------------------- ----t..?.7....5zR!���.H .�sd. Y........t Y11/-r�[�r........ 3 Owner Address a -----••---- ......... -----------------------------------------•-•-• .....•--•--••••.........._.....---...---:............-••--........--•-•--•--------•-------........ Installer Address Type of Building ��--^^ Size Lot............................Sq. feet U DwellingNo. of Bedrooms ....................Ex Expansion Attic Garbage Grinder A) — P ( ;�) g ( Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Othe fixtures ------------------------------ W Design Flow........ __�7.......................gallons per person per day. Total daily flow-----------3 .0.....................gallons. WSeptic Tank—Liquid capacity i.-A gallons Length................ Width................ Diameter--.-.-------_- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..4.-X-9.------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------.----. Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water....................---. ---•------------------------------•-----------------------..----.---------------•------------------------ -... -... -........ ---•------- -....... ----- •.......... ODescription of Soil.....................................................................----------------------------------------------•---•-----------•---••••--------------•-----...-•--- x U ----•••••-•••••---•-•----•-•••......-•-----•--•-----------•••-•.....•-•-•••....................•--•••-•-•--•••-••-•---------•-•---•----•-----•--•••-----••-----••••--••-••-•....-------••--•......••••-- w ---------------------------------------------------------------........................................................................................................................................ UNature 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 TITL a 5 of the State Sanitary o e—The ndersigned further agrees not to place the system in operation until a Certificate of Compliance has be issu by e b r of heal ." ned•••• •. • • ---•...... ........... • . . ------. 9 .... -- e Applicarion Approv Date Application Disapprov f o lce following reasons:.............................................................................................................. ---•-•-•....•---•-•••--•--•-•--------•-•...............•--•-•--•-•-••-•--....-•----------.......•----------•••••--•-•••--•--••••--•-•---•---••••--•--------------------------------- -••--••-•----- Date PermitNo......................................................... Issued....................................................... Date ................ • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 07 .............0 F.....J.3.6..R45T#184X...................................... Appliration for Disposal Works Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ........................... ................................................................................................. Location-Address or Lot No • -------------------------------- . .....(..A Owner ......................... ------------------------------------------ ...... ------- ---------------------------------- ----------"-------------------- ------ Installer Address I. Address Type of Building 70 Size Lot............................Sq. feet Dwelling—No. of Bedrooms________ G#0.....................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons_________.______._.__._____. Showers Otherfixtures .......................................................................... -----------------------------------------------------"---------- Design Flow........./.,Z.'7........................gallons per person per day. Total....daily fl o w---- A-3.0......................gallons. Septic Tank—Liquid capacityl50'*f.gallons Length________________ Width._____._________ Diameter__._________-___ Depth___________._... Disposal Trench—No_.................... Width______._.___________ Total Length_.___._____.._______ Total.leaching area...................sq. ft. Seepage Pit No.4.X-9-------- Diameter____________________ Depth below inlet____._.____..._...__ Total leaching area..................sq. ft. Z Other Distribution box Dosing tank Percolation Test Results Per-formed by.......................................................................... Date........................................ Test Pit No. I________________minutes 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.,___-:____._______.___. 9 ......................................................................................................... ----------------------*--------------------------- 0 Description of Soil_________________ .................................................................. W U ........................................................................................................................................................................................................ W .................................................................................... ................................................................................................................... �ii U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ..................................................................................................................................................................................................... Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in,accordance with the provisions of TITLE 5 of the State Sanitary 10 e—The Wndersigned further agrees not to place the system in operation until a Certificate of Compliance has be issu by e b r,of heal ., . . . .... ....... P;99te .-Application Approv ..... --....------- -- .................... - --- ----------- Date following reasons- Application Disappr7ofofe following reasons:.......................................................................................................... ......................................................................................................................................................................................................... Date PermitNo....................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... up rdifiratr of Toutpliana 'C T25W!,_5�111 . 'CERTIFY,..�'C"IERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired by----- .. . . ... ............................ .................................................................................................................................. Installer at... . .. . . . .. . . ...................I........................................................................................ ....... --- has been insta ed in accordance with the pro ions of TITLE. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------fy. A___..______________ dated_...._____._._._..__________._____..__.._____.._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. & DATE.................................... ........................ Inspector.—_—.--- ft'�............................................................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF.................................................................................... No ..�:4jv FEE..,�................. Disposal rr"patit Permission is here nted- ;..W: 5_ __-_------------------------------------------------------------------------------------------------------- to Construct air an/In i age Disposal System atNo.------ .......... .. ...... .. .. ....................... J Street as shown on the application for � J-- /0� TI/ Disposal Works ucti - Di 9 ks N on Permit No .. ...... . .. ated----- .................................... ..................... ...... .................................................................... DATE--_.... ............................................ Board of Health FORM 1255 A. M. 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