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Home My WebLink About0251 WHISTLEBERRY DRIVE - Health 251 Whistleberry A= 0 IS 1 I i t Commonwealth of Massachusetts F Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Whistleberry Drive Property Address e Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 Company Address Centerville Ma. 02632 Cityrrown State Zip Code (508)428-4028 S14454 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 to1.Section 15.340,of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fail''s = 9 1 ❑ Needs Further Evaluation by the Local Approving Authority b / 8/13/2008 r Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approvi g 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. 251 Whistleberry Dr.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma 02648 8/13/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Septic system is in proper working order at the present time. 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. Answer yes, no or not determined (Y, N, ND) in the ❑ 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. ND Explain: ❑ 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 ❑ obstruction is removed 251 Whistleberry Dr.-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Whistleberry.Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: . 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 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. 251 Whislleberry Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form I m - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. GityTrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 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: r 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 cesspool is less than 6" below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 251 Whistleberry Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 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 II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 251.Whistleberry Dr.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 r Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is Marstons Mills Ma. 02648 8/13/2008 required for every page. City/Town 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)] 251 Whistleberry Dr.•03/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. City/Town State Zip Code Date of Inspection 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 Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d unavailable 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) I 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: Last date of occupancy/use: Date Other(describe): 251 Whistleberry Cr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is Marstons Mills Ma. 02648 8/13/2008 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? measured Reason for pumping: Maintenance , Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 251 Whistleberry Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts (0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 4' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition'ofjoints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank (locate on site plan): Depth below grade: 4 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------= ------------------------------------------------------------------------------------------------- Dimensions: 1000 Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle na Scum thickness 0 Distance from top of scum to top of outlet tee or baffle na Distance from bottom of scum to bottom of outlet tee or baffle na How were dimensions determined? tank pumped at inspection 251 Whistleberry Dr.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two tears.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from,bottom of scum to bottom of outlet tee or baffle Date of last pumping: . Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 g El polyethylene ❑ other(explain): 251 Whistleberry Dr.-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s••`'v 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box not present. 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarm working s in order. ❑ Yes ❑ No 251 Whistleberry Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000gl LP ❑ 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.): Sandy soil.No signs of hydraulic failure.Pit was dry at time of inspection.Stain line is 36" below invert in pit. 251 Whistleberry Dr.-03/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System Page 12 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 251 Whistleberry Dr.-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Map Page 1 of 2 Town of Barnstable Geographic Information System a Parcel Viewer Ma Custom Map Abutters p Size Zoom Ou.tMIMM1111JIn 5 2 � a a v :. i;. 0. i. is ,.r:,'' a•':_ tt' r rb• I. .. Set Scale 1" = 20 I 'Aerial Photos I MAP DISCLAIMER r.nnurinhf 9MF_9MR Trnun of Rnmefohle KAA All rinhfe raconn http://www.town.bamstable.ma.us/arcimsiappgeoapp/map.aspx?prover ylD=062013&map... 8/14/2008 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 251 Whistleberry Drive Property Address Jeff Taylor Owner Owner's Name information is required for Marstons Mills Ma. 02648 8/13/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of LP 50' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. 251 Whistleberry Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 i Town of Barnstable *'THE Tp�� Regulatory Services BARNsrABLE, ; Thomas F. Geiler, Director 9 MASS. �p i639. Public Health Division lFD MA'S Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report, the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System 'Inspector who conducted the inspection. QASEPTIMisclaimer Private Septic Inspections.DOC 1..�.d...�:�........ !r/l✓ �.J /�� t COMMONWEALTH OF MASSACHUSETTS r , 0` BARNS T�,OLE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS L DEPARTMENT OF ENVIRONMENTAL PROTEC��0IF � P : (�� 61V1§1ON TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 251 Whistleberry Drive Marstons Mills. MA 02648 Owner's Name: Leon Brill u Owner's Address: Date of Inspection: May 30, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 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 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: June 6, 2005 The system inspector shall 4iaof 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. Notes and Comments ti ****This report only describes conditions,at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 t Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 251 Whistleberry Drive Marston Mills. MA Owner: Leon Brill Date of Inspection: May 30, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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. Answer yes,no or not determined(Y,N,ND).in the 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 indicting that the tank is less than 20 years old is available. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 1 I Page 31 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 251 Whistleberry Drive Marstons Mills. MA Owner: Leon Brill Date of Inspection: May 30, 2005 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 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 251 Whistleberry Drive Marston Mills. M4 Owner: Leon Brill Date of Inspection: May 30, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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 cesspool is less than 6"below invert or available volume is less than'/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 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 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,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well 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. 4 ` Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 251 Whistleberry Drive Marstons Mills. MA Owner: Leon Brill Date of Inspection: May 30. 2005 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: Yes No 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(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 251 Whistleberry Drive Marstons Mills, MA Owner: Leon Brill Date of Inspection: May 30 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESI`3N flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was system pumped as part of the inspection(yes or no): 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) Tight Tank Attach,a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed in 1986-per owner Were sewage odors detected when arriving at the site(yes or no): No 6 • Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WhistlebeLa Drive Marstons Mills. MA Owner: Leon Brill Date of Inspection: May 30, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Dept'-i below grade:, 4' Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage. The inlet cover was 2'below grade. Recommend pumping. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 ' s Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 Whistleberry Drive Marstons Mills. MA Owner: Leon Brill Date of Inspection: May 30, 2005 TIGHT or HOLDING TANK: None (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: R-allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): t 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 Whistlebera Drive Marston Mills. MA Owner: Leon Brill Date of Inspection: May 30, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I -6'x 6'(1000 gal.) -per design plans 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.):: The pit was dry and clean. The scum line was approximately 6"up from the bottom. There did not appear to be any signs of failure. The bottom to trade was 10. The cover was 12"below grade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 Whistlebera Drive Marstons Mills. MA Owner: aeon Brill Date of Inspection: May 30, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. GA(A 4 Q ProA a � � 3 � J s a3 3 Ca 3 yo a! 10 7 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 251 Whistleberry Drive Marstons Mills, MA Owner: Leon Brill Date of Inspection: Me 30, 2005 SITE EXAM Slope Surface water Check cellar _ Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 25'+/-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report. 11 1 TOWN OF BARNSTA.BLE LOCATION'':ATION �S�I i�trr R�• SEWAGE # r � � S VMLAGE /0• M.11s ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY OM R LEACHING FACILITY: (type) (o (size) UUV NO. OF BEDROOMS-3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 leac�'ng facility) r Feet Furnished by 1/1SAG�Ti„n F�i� GSA t 1 I a �s a3 3 3 yo as TOWN F BARNST LE LOCATION SEWAGE # Y `l \� AID Va,LAGE 1 ASSESSOR'S MAP &'L T 6 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �o�� i � �� - � ,, . . - .. � � o o - y a i _ ��a�e_ �� s i ASSESSOR'S MAP NO. PARCEL / J ` 1 , IU CAT ION 1� SEWAGE PERMIT NO. re- VlLL.AGE ` sTo,.✓s .walls INST A LLER'�SS / NAME i ADDRESS c. �eod w d U I L D E R OR OWNER -5±,t U,E Avwgis- J-ul� a3 Ti9p�. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � 1 d G N 3=fig. /,loos 01.5 7_ Bo,Y S 31 Setp-05-01 14:26 BARNSTABLE HEALTH OEPT 5087906304 P.03 �SME Toys Town of Barnstable Regulatory Services BARPWABLE, KAM Thomas F.Geiler,Director ECG` Public Health Division Thomas McKean,Director 367 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 DATE: 7 /3 O, ��v+ 4'✓-kGr �. (2'11X 7,1/7 rLj�c4�p-.t f CL1-36 RE: Zs' / �vL��1��6,rrrYy�ly� The Barnstable Health Division has reviewed the Title 5 septic inspection form for the above referenced property. The following comments listed below are deficiencies according to 310 CMR 15.300 and the Town of Barnstable Health regulations. Please re- inspect the system, if necessary, complete a new report form or revise the pages pertinent to the deficiencies listed and resubmit the report to this office within fourteen(14) days: sepdef.dcc Wage 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 Check if the Hollowing have been done. You must indicate "yes" or"no" as to each of the following: Yes No X _ Pumping information was provided by the owner, occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,excluding the SAS, located on site? X _ 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? X _ 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: Yes no X Existing information.For example, a plan at the Board of Health. X _ 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(3)(b)] S !Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a I R i +Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6' X 6' leaching pits, number: 2 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 6"' OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 6" OF WATER IN IT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): n/a 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS, MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. " I GC,P. cl 0 6 I � o a AID ;� an Ac AE 6C ov as bE 3S' C C 3`1 CE 35 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ^' F n � � I Y�J TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner's Name: LEON BRILL Owner's Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Date of Inspection: 4/20/01 Name of Inspector: (please print) JOHN GRACI RECEIVED Company Name: SEPTIC INSPECTIONS Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 MAY ® 9 2001 Telephone Number: 508-564-6813 FAX 508-564-7270 TOWN OF BARNSTABLE HEALTH DEPT. CERTIFICATION STATEMENT I certify that.l 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: :n X Passes _ Conditionally Passes _ Needs Furt Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4/20/01 The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspe ion. 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. Notes and Comments THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. ****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. :i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System,Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. 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. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. n/a 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. ND explain: n/a n/a 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 _ obstruction is removed _ distribution box is leveled or replaced ND explain: n/a n/a 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 _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 251 WHISTLEBIERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 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 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 n/a "This system passes if the wel-water analysis,performed at a DEP certified laboratory, 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,provided that nc other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: n/a z Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 D. System Failure Criteria applicable to all systems: You muss indicate"yes"or"no"to each of the following for all-inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. i _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)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. E. Large Systems: To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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 tiny large system considered n 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. i A f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection '? _ X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS, located on site? X _ 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 '? X _ 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: Yes no X Existing information. For example,a plan at the Board of Health. X _ 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(3)(b)] S Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents:2 Does residence have a garbage grinder(yes or no): NO Is laundry on G separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1986 Were sewage odors detected when arriving at the site(yes or no): NO f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 BUILDING SEWER(locate on site plan) Depth below grade: 54" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 48" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10"" Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP: _(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: _(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n/a 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.): n/a PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a e Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 1000 GAL 6"X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a innovative/alternative system Type/name of technology: n/a etc.): Comments(note condition of soil,'signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 611'OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 6" OF WATER IN IT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a 4 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 SKETCH OR SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or-be rich in arks. Locate all wells within 100 feet. Locate where public water supply enters the building. �n) L A C SIG � a3e in I Page l 1 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 251 WHISTLEBERRY RD MARSTONS MILLS,MA 02648 Owner: LEON BRILL Date of Inspection: 4/20/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET II No.._...�Q-:5..... � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH W.(A.1 ....................OF.... A. ia:��. ........................................... Appliratiun for Uhip sal Works Cnnnotrudion ram'd Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: - ......................................... � � n � Location-Addre {� o..Lot-No. .._.. ............ ....•.... .......... Ow j>d$ Ci (p l,V )4%ess a ...............•••.0 ....::...�! 1. ° ............ ........._._... ..'lit?. 2 v Z!I.... �.:........ .... M Installer Address V Type of Building /� Size Lot.. g(�.......Sq. feet .-� Dwelling—No. of Bedrooms..............--"-'-..........................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures ................•---......---...---.........-•-•--.............................................................----..........:....•--•................ d W Design Flow..............��..s,...................._g,�11eon�s per person per day. Total daily flow..........��.d.......................gallons. WSeptic Tank—Liquid capacity.hS ?_ I&s Length....®........ Width:....._..... Diameter................ Depth.'UZ—r..�F x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft. 3 Seepage Pit No... '...... Diameter............... Depth below inlet.....6.......... Total leaching area.A�Z....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) GDdI+J- v Gi-1 ,C,, Percolation Test Results Performed by--M:_M.............6..................�..f........•--•-••---. Date..�� .�;/.�¢.:�.----......... ,.a Test Pit No. I...............minutes per inch Depth of Test Pit....11A....... Depth to ground water....Az-2"�'._.. Li. Test Pit No. 2...G4.......minutes per inch Depth of Test Pit.... Q'.._.._. Depth to ground water...N...�..... O 0 .. TOp SUS 3 CJ /1'l�n 7Q G6�2 ... S�►✓rJ - Description of Soil.....-•-•---...--•----•--......._..�_....---•..............�:.�__....._._�...----------.._...._..........---•--•--............ ....._............-•--•--•--•• Q1P-_C.6._418...........:3........ '2 s�4rvO W ......................•••--•-•••-••-•-••--•--••••••----•-•••-••-••-...---••-••......••--.....--•••-......--•••--••••-•--••••••. -----•-----•-••---••-•--..............•-•............-•--•-•--•_.... VNature 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 TIT I.:; 5 of the State Sanitary Code— The undersigned further agrees not to place th system in operation until a Certificate of Co fiance has been issued by the bo )d of health. �� Si ned........... ��'� �d '....'. �u,(J C:.. > .. .. Date 7 Application Approved By......................... - • I .._. .'.... ......... Date Application Disapproved for the follow n r reasons:............................................................................................................. .... ....•---••-•--•-••••••....... . ...........•--.....--•--•--•---• •.........••............................ ...._...................................._.........--••----.. . .......... Date _ PermitNo..................................................._.... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTSi. BOARD OF HEALTH ..70 LvJa...... z.......OF.... A, TA6 l E ' ............................................................. 'A p iration for Dis o ttl rrk,s Tonstrur#ion Permit Application is hereby made for a Permit to Constru& ( ) or Repair ( ) an Individual Sewage Disposal System at: # ` .,H.Ls rLg Y M�a2�sTons mart_ . ...�". I : .... .. . . ... .................... Locatroi�A ddre ,i� �L--_ j .. 4 or Lot V IV ................_ _- ..t................i— �._`..... Q..... ... `� -.`Y �. .�..... ...... ......lp............»........ .» ... ... oW 'PdIa C /(o w 3g a ............ ..... ! ..::. '�-----��- ........_ = .............. Installer . M Installer (, Address R7i Type of Building - /��"I �,�-tL� � t :Size Lot..121� -l�-.......Sq. feet aEf" Dwelling—No. of Bedrooms............................................` Expansion Attic ( ) Garbage Grinder ( ) 04 � Other—Type of Building ............................ No.- of persons..........._+:............... Showers ( ) — Cafeteria ( ) W ; 4 Other fixtures ........................f t i1 .(. . ................ PF l Design Flow..................��.......... ;n...gallons(per•person per day Total daily flows' `__..__.. .... gallons. g�jC - 'I 1, Septic Tank—Liquid'capacity.1,5 l&i's Length._......... Width..�........_ Diameter................ Depth.�.&..� Disposal Trench—No................ Width.................... Total Length.................... Total leaching area..._................sq. ft. 3 ; Seepage Pit No...)...`...Z...... Diameter............... Depth below inlet................ Total leaching area. Z....sq. ft. z Other Distribution box ( ) A, Dosing tank ( ) ' MGDtVbvGN 'G, / /S� Percolation Test Results Performed by..! �............... .. ..--..--..- $4 Test Pit No. 1... Z....minutes per inch Depth of Test.Pit....Mtl........ Depth to ground water....AJOW .... 44 Test Pit No. 2... L'..._..minutes per inch Depth of Test Pit...1!44 Depth to ground water.../V0� O Description of Soil.................... TA U .�k� i min 7b GOt�?s S�dn!rJ `..'- i° a-----....._ ct. 'n i►%ao �t ...GO.o2s sirv+� ..........................•................ Uw ..... ------------••------•-------- -----•-•-•--•-••---•-•••--••-••-......----•---•----•-•--......--•...----......••---------......-•----...............•-•-........-•--- Nature of Repairs or Alterations—Answer when applicable............................................................................................... •...............•----••----••--•-•--•--.............-------••--•----•-...........---...............-•---------•-•-----------------•-------•-•------.........................--=--ti.................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T I T L Z 5 of the State Sanitary Code—The undersigned further agrees not to place th system in operation;&Z=i ' _ ce has been issued by the board of health. C _ p4 ned.......... ...... .... ...... Application Approved-B .-._. .._.. sky Date Application Disapproved for the follow reasons: ..............:..... .... ......................... ............-•-.................... .......••••-•-•.............................._ .......••..........................._..._..............•Date.............- PermitNo..................................................... Issued........................................................ Dat THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ..........................................OF............5 ................ ............................. Ter#if iratr of Tomplittnrr THIS ISjIFY, That the. Individual Sewage Disposal System constructed ( ) or Repaired ( ) V... 1-�) 1^a--------------....L--!V-1 ..........---.........----•--•----.....................................................:... by...................... .........- -- ` -::...I.` III" (. has been installed in accordance with the provisions•of TIT , xf The State Sanitary Code as described in the application for Disposal Works Construction Permit No....................../..�7 .. dated..... ..: :(.s. - ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTII%OrN SATISFACTORY. DATE..................... _,e!�_ . )-;�;`�............... Inspector...-- ... ---.......-------.. ........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ....... .. . .........OF......... ..�.....�...:=�...................................... No... ............... FEN........................ Disposal �orko TonStrur#io rrm' t f�(, ,d -A Permission is hereby granted.......................-=�-t-�.�...... .-•---................................................................. to Construct ( ) or $epair ( ) an Individual ge Dispo System (� at No.................. .. ...1:: ....... .�af ree �.514.....11-:a ................................... as shown on the aDplicatlion for Disposal Works Construction Permit pat ....Z... .... T.�............ ........................................... ................._ and of Health DATE............. . ......... ... ��1. �a s. r u L ,J --- - _ e r _ is 21 Living room ---------------- ----------------------- Garage Co -------------------- g room Kitchen :\ First Floor -. v ..........�. Hallway open to below e roo e ------ Bedrooms rf� Bathroom 4�2 r utility room 133 Stud rs P". .. - - Family room th Playroom Ba room /21 r (proposco e m kO S } « r r, q ,.- L(Y• 1.: \. j '� � � �..�?•c �� :� it i,:a .�� t�jr�t.� - "' ell t 7 _..._ ,•ti ��,/ -��'' I - �>`.� �'P\��1 F��. �`y-� r �� E �F. ;r.ini�-'( I " -- - --- 71, 40 I 1 � t � . . SUBJECT I i L��" i Gl ,�� l .- � •\ �'' � -ate�' --_...�.�--.—+4—_�___. __ !,.� r� � '� � ; f �\I L,,3+ � k$�l �.�j> c:_tv-�g.C" -�r 'L- { �A.�.�'�'T•f-.i'�`-'� __ — �i""'}?.Y1'aTC>l ,. ;.t:�r i••. -� ,;� C_ _ ` JECT !44-/ -_"_—'�". - _�--�— �'� -i\/! r", �:.h.t L r..i F'Cy,kc ®►b)f i+l ri )....,� u ",� �.,� •1 "` �.,e�f;,y� rr of "-, y '�� a�r ,:�,,7.-�j�:fj�'!.'T::iJ 1,/�,�' 33' '(1•� �'t��'•tC�i ±C.-[^ .�!'Y �r'�.e. ad";p'-:. � ..�{» ��,�� r �tsC� c'L �. d�j �/1 11•, ! '� ._�� 1 y. l�/ `�� r i ?» A.cA, LZ�j .1. `l .. •r•:�'+v� �.!-, '�{� i�l i 'Yi ) {� ✓ 1 � ` _,�: t1r, r,ie- %aa . ......._. _..._._._,.». __ __._.._--_.._.___�__---- ----_,-.___--_._ _.._�—___ _w...._..r......._,..._.,_..�..._._.._. _.._._ -:—_._r-- ----•-- — _.___.-_.____�..�,- ;fir