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Home My WebLink About0261 WHISTLEBERRY DRIVE - Health 261 WIIISTLEBERRY - - - - - - - - - A = 062 015 - i i No. �Q Fee vv THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpiicatiou for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(X Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. Wt41S'7LEbeM4% OIL, Owner's Name Address and Tel.N . H01-L a �C1 EFTc l�C�gAC Assessor's Map/Parcel 6ba Q1 ' a61 cc; H� Installer's Name,Address,and Tel.No. j p8��j j�$�7 Designer's Name,Address,and Tel.No. eLmaLKtsE� c,LL -Sr Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed 1A Date _ao Application Approved by < Date Application Disapproved by Date for the fbllowing reasons Permit No. ' tJ Date Issued ' No. Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS NplitA:tion for Disposal *pstem Construction Permit Application for a Pert to Construct'( )' Repair)q Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. :Z(p f', Wt41ST LE I f DR- Owner's Name,Address,and Tel.NQ Ho c.cY s dX Et�fT�! Ff C)ISslB-r Assessor'sMap/Parcel 66a o(S M 24.1 (e_W1.Sr M. M M Installer's Name,Address,and Tel.No. j p 8.�'j 1�$�7'� Designer's Name,Address,and Tel.No. <MPE-_ (0G Ef✓ �QlSE'S t,cc p r StMA,5ap6ic. Type of Building: Dwelling No.of Bedrooms 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 Health. w ° Signed; Date �y q—_.Q ( 5 Application Approved by Date ._Application Disapproved by ( Date for the following reasons rl Permit No. G Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned//( )by CA PEw f D U 6 �►sz' Q[�: at ASP W1415'rLah8 NR MM has been constructed in accordance with the provisions of Title 5 and ther Disposal System Construction Permit No.��_2Wdated Installer e' LQ?, Designer #bedrooms Approved design fl gpd The issuance of this pe t shall no be construed as a guarantee that the system ill fun io igned. Date tp 15 Inspector ---------------------------------------------------------- ---------- -- - -- ------------- -=------=-- ------------ - No. O( S _ t*2�O Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Nsposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(�) Upgrade( ) Abandon( ) System located at �� W 10 t S-7 LZ-569 V V Al Ui M499710e..'s /L, . i 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. —�/'� V� Date — r 5 Approved by pug 07 15 08:14a p:1 Commonwealth of Massachusetts �` f ��02 0``� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Whistleberry Drive I�z Property Address I:—j> -------------- Holly Hobart Owner Ownet s Name information is ;! required for every Marstons Mills page. MA 02648 7-31-15 City/i'own State ZipCode . Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, �10/n� \\````N011�"11111 OFA14 ixi use only the lab / c!' ``��Y .�&,,4�!: key to move your 1 Inspector: cursor-do not p��' ••.. ••. •'9�'SG use the return James D.Sears �:: JAMES m key. Name of Inspector CapewideEnterprises,LLC =* = �I Company Name A'•. 153 Commercial Street Company Address Mashpee Cityrrown MA 02649 State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I certify that 1 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 Q Needs Further Evaluation by the Local Approving Authority 8-6-15 Ansctors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system 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. (Sins-3M3 Title 5 Onicial tnspedion Form:Subsurface Sewage bisposal system•Page 1 or 11 Aug 07 15 08:14a p.2 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 261 Whistfeberry Drive Property Address Holly Hobart Owner Owner s Name information is required for every Marstons Mills MA 02648 7-31-15 page. City/Town 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 below. Comments: The system is a 1000 Gal.Tank D Box and field 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): .51ns•3J13 Tille 5 Official Incpeo6on Fomt Subsurface Sewage Dispoad System•Page 2 of 17 Aug 0715 08:14a p.3 Commonwealth of Massachusetts = Title 5 official Inspection Form p Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information is required for every Marstons Mills MA 02648 7-31-15 page. City/Town 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 ❑ NO (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y Q N ❑ NO (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. I. 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 151ns•3/13 Title 5 MUM Inspectlon Form:Subsurface Sewage DisPosal System-Page 3 of 17 Aug 0715 08:15a 0.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments !y 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information is required for every Marstons Mills MA 02648 7-31-15 page. Cilylrown State Zip Code Date or 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 DFP 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 SNOW is less than 6"below invert or available volume is less than %day flow I. -64clll vC t5ins•3113 Tifle 5 Offcial trspedion Fomr.Subsurtace Sewage Disposal System•Page 4 or 17 Aug 0715 08:15a p.5 Commonwealth of Massachusetts /72 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments J 261 Whistlebeny Drive Property Address Holly Hobart Owner owners Name information is required for every Marstons Mills MA 02648 7-31-15. page. CltyrTown State Zip Code Date of Inspedion 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 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. 171 ® The system fails.l 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Olsposal System-Page 6 of 17 Aug 0715 08:15a p.6 Comrnonwea[th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments " 261 Whistleberry Drive Property Address — Holly Hobart Owner Owner's Name information is required for every Marstons Mills MA 02648 7-31-15 page. Clty(rown Stale 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 Feld (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): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15,203(for example: 110 gpd x#of bedrooms): 330 15ins•3113 Title 5 Official Inspection Fami Subsurface Sewage Disposal System•Page 6 of 17 Aug 0715 08:16a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information S required for every Marstons Mills MA 02648 7-31-15 page. City/Town State Zip Code Date ofInspection D. System Information Description: The system is a 1000 Gal. Tank D Box and pit. Number of current residents: 0 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 years usage(gpd)): 2013-151,000Gal 2014-135,000 Gal s Detail: Sump pump? ❑ Yes ® No East date of occupancy: _Present Date Commerciallindustrial 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: / [Sins-3f13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal system•Page 7 or 17 Aug 0715 08:16a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information is required for every Marstans Mills MA 02648 7-31-15 page, City/Town 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: 5/19115 Was system pumped as part of the inspection? ❑ Yes 0 No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system I ❑ 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): 154ns•3H 3 TWO 5 Official Inspection Form Subsurface Sawege Disposal System-Page 0 of 17 Aug 0715 08:16a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 261 Whistleberly Drive Property Address Holly Hobart Owner Owner's Name information is required for every Marstons Mills MA _ 02W 7-31-15 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: NA 8-2015 New D Box. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 28" -- - 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 & SCH 20. Septic Tank(locate on site plan): " Depth below grade: 18 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) It tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: --- 15ins-3/13 TiOe 5 Official I rspeollon form:Subsurface Sewage Disposal System•Page 9 c f 17 Aug 0715 08:17a p.10 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information is required for every Marstons Mills MA 02648 7-31-15 page. Cityrrown 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 0. Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-TapeSludge 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 outlet cover at 18"below grade w/inlet cover at 6". Inlet tee, outlet baffle. No sign of leakage or over, loading. Note:outlet cover under brick walkway. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: i 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 i5ins.3N3 Tine 5 Otrrdat Inspection Form:Subsurface Sewage Dtpasd System•Page 10 of 17 Aug 0715 08:17a p.11 , Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name inr uiretJ fo >s Marstons Mills MA 02648 7-31�-15 required for every 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•3r13 Tile 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 11 of 17 Aug 0715 08:17a p.12 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information Marstons Mills MA 02648 7-31-15 required for every page. Cityrrown 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 new 8-2015. Box is 35" below grade w/cover at 6", one line out. D Box is under brick walk way. 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: 15ns•3113 Title 5 official Inspection ram:Subsurface Sewage Disposal System•Page 12 of 17 r Aug 07 15 08:18a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart Owner Owner's Name information is required for every Marstons Mills MA 02648 7-31-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number. -- ❑ leaching galleries number: ❑ leaching trenches number, length: -- ® leaching fields number, dimensions: (1) 10'x 25' ❑ 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 field 10'x 25'. Camera out. No sign of over loading or holding water. 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 15ins-3f13 Title 5 Official hispetlion Form:SuWLKfaca Sewage Disposal Syslem•Page 13 of 17 I Aug 0715 08:18a p.14 'N' . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart Owner Owners Name information is Marstons Mills MA 02648 7-31-15 required for every page. Cityrrown 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.): 15ins.3l13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Aug 0715 08:18a p.15 Commonwealth of Massachusetts _ Title 5 Official Inspection Form - Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 261 Whistleberry Drive _ Property Address Holly Hobart Owner Owners Name information is MarStons Mills MA 02648 7-31-15 required for every page, CitylTown State Zip Code Date of Inspection D. System Information (cons.) 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: M hand-sketch in the area below_ CARAUE 13 i 15im•W13 T18e 5 Of cal Inspection Form:Subsurface Savage Disposal System-Page 15 of�7 Aug 0715 08:19a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 261 Whistleberry Drive Property Address Holly Hobart - Owner Owner's Name k,VW information is Marstons Mills MA 02648 7-31-15 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N0 2 Estimated depth to hhi h round water. t r 9 9 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 propertylobservation 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: Lot and site high 204 no G.W.. Bottom of field around 4'. _ Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3113 rills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 l Aug 071508:19a p,17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 261 Whistleberry Drive Property Address Holly Hobart Owner Oinformatwners Name required on is Marstons Mills MA 02648 7-31-15 required for every _ page. Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 8, 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 15ins•303 Title 5 Official Inspection Form:Sutrsurfooe Sewage Disposal System-Paige 17 of 17 Bk 18424 Po 120 25059' 04-07-2004 & 03 z 235} DEED RESTRICTION WHEREAS, the Creighton Hobart Realty Trust u,/d/t dated April 30, 2002 of 261 Whistleberry Drive, Marston Mills, MA is the owner of 261 Whistleberry Drive, the land together with any buildings situated thereon in Barnstable (Marston Mills), Barnstable County, Massachusetts,being shown as LOT 19 on a plan of land entitled "Whistleberry Subdivision Plan of Land in Marstons Mills, Barnstable, Massachusetts, Scale 1" =200' November 1980 Bohannon Land Survey Co., 99 Pleasant Street, West Bridgewater, Mass", which said plan is duly recorded in the Barnstable County Registry of Deeds in Plan Book 349,Pages 53 through 63, inclusive. Subject to a Declaration of Protective Covenants set forth in an Instrument dated April 1, 1981 and recorded in Barnstable County Registry of Deeds in Book 3262, Page 185. Further subject to and together with the benefit of easements, right, rights of way, restrictions and condition, all as set forth in a deed from Daniel C. Hostetter et ali dated July 3, 1985, duly recorded in Barnstable County Registry of Deeds in Book 4612, Page 59. Subject to and together with the benefit of a driveway easement as described in an Instrument to Douglas R. Levings, Trustee et ali dated November 5, 1985 and recorded in Barnstable County Registry of Deeds in Book 4791, Page 91. For source of title see deed dated October 14, 1998 and recorded at the Barnstable County Registry of Deeds at Book 11766,Page 21 and deed dated April30, 2002, and recorded at the Barnstable County Registry of Deeds at Book 15139 Page 185. WHEREAS, the Creighton Hobart Realty Trust as the owner of said lot has agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS,the Town of Barnstable Board of Health, in compliance with 310 CMR 12.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of an addition and alteration to a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, 1 NOW, THEREFORE,the Creighton Hobart Realty Trust does hereby place the following restriction on its above-referenced land in accordance with its agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 261 Whistleberry Drive, Marstons Mills, Barnstable County, Massachusetts may have constructed upon the lot a house containing no more than three (3)bedrooms. The Creighton Hobart Realty Trust agrees that this shall be a permanent deed restriction affecting the land and any buildings situated thereon at 261 Whistleberry Drive in Barnstable (Marston Mills), Barnstable County, Massachusetts, as described above and duly recorded in the Barnstable County Registry of Deeds in Plan Book 349,Pages 53 through 63, inclusive. Executed as a sealed instrument this d day of April, 2004 . WITNESS the hands and seals of all of the Trustees of the Creighton Hobart Realty Trust. A&-' i n Hobart Realty Trust, 'e eth D. Creighton, Trustee rjeighton H bart Realty Trust, Dolly Hobart, Trustee COMMONWEALTH OF MASSACHUSETTS Barnstable, ss April _, 2004 Then personally appeared the above-named KENNETH D. CREIGHTON and HOLLY HOBART before me and acknowledged the foregoing instrument to be their free act and deed. Notary Public My commission expires: JESSICA LYMAN NOTARY PUBM, Commo moM of Waschoodk USA My Commission Ev t ITV.2k 2009 2 COMMONWEALTH OF MASSACHUSETTS S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE HINTER STREET. BOSTON. MA 02108 617-292-5500 y Sv•y� t WILLIAM F.WELD TRUDY COXE Governor Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 261 Whistleberry Dr Property Address: Marstons Mills Address of Owner: Sam Pires Date of Inspection:;--X7-9 5 (If different) Name of Inspector: Wm E Robinson Sr I am a DEP approved system inspector pursuant to Section 15.340 itle 5 (310 CM 0) Company Name: him E Robinson Septic Service Mailing Address: PO Box 1089 , Centerville , MA 0 632 Telephone Number, 5 0 8 � 7 7 5—8 7 7(y � _ pG1- D/S CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address a t the information re elow is true, accurate and complete as of the time of inspection. The inspection was performed based on my training an experience in the proper function and maintenance of on-site sewage disposal systems. The system: W Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Zt) i Date: ?— The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SY TEM 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. Indic a yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined' explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection, or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpJtwww.magnet.state.ma.us/dep eJ Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 261 Whistleberry Dr, Marstons Mills Owner: Pires Date of Inspection: ,I —A-7-9 B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a'broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FUR HER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the P4blic health, safety and the environment. 1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER W ICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the' presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) THER (revised 04/25/97) Page 2 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 261 Whistleberry Dr, Marstons Mills Owner: P i re s Date of Inspection: ,2 t—g D] SYSTEM FAILS: You m st indicate ei;!,er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis or this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct e failure. Yes o Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LA GE SYSTEM FAILS: Yo must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 1 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) T owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program r quirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 tt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 261 Whistleberry Dr, Marstons Mills Owner: Pires Date of Inspection: ._—A 1—4 9 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No ✓ _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ _ As built plans have been obtained and examined. Note if they are not available with N/A. i/ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 261 Whistleberry Dr, Marstons Mills Owner: Pires Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design flow: 33 O g.p.d./bedroom for S.A.S. Number of bedrooms:_/-/ Number of current residents:X Garbage grinder (yes or no): v Laundry connected to system (yes or no):44i--s Seasonal use (yes or no): A Water meter readings, if available (last two (2) year usage (gpd): 1996 — 48, 000gals Sump Pump (yes or no):w 1997 — 38, 000gals Last date of occupancy: COMMERCIAUI NDUSTRIAL: Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of informati n: e l— , O � System pumped as part of inspection: (yes or no) o If yes, volume pumped: /6 0 O Qallons , Reason for pumping: /✓lei a r C/„s,,p �,�r� w 4 TYPE Of SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: /6-/.S ✓ems Y3 Q i� Sewage odors detected when arriving at the site: (yes or no)IL C) (revised 04/25/97) Page 5 of 10 I• , \ 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Whistleberry Dr, Marstons Mills Owner: Pires Date of Inspection: a 7— BUI ING SEWER: (Local on site plan) Depth elow grade: Materia of construction: _cast:iron _40 PVC _other (explain) Distan a from private water supply well or suction line Diam ter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on trite plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle3 6 Scum thickness: /' 3 Distance from top of Scum to top of outlet tee or baffle:? Distance from bottom of scum to bottom of outlet tee or baffler How dimensions were determined: b �i'�w e 1 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) f b a U GRE E TRAP: (locate on site plan) Depth elow grade: Materia of construction: _,concrete _metal _Fiberglass _Polyethylene _other(explain) Dimen ions: Scum hickness: Dist ce from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date o last pumping: Com nts: (reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integr ty, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 r . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Whistleberr.y Dr, Marstons Mills Owner: Aires Date of Inspection:,�_a•7-g' TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth Lw grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensi,ns: Capaci gallons Design flow: gallons/day Alarm level: Alarm in working order_ Yes; _ No Date previous pumping: Comme s: (conditio� of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V (locate or, site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryovers, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate on s to plan) Pumps in orking order: (Yes or No) Alarms in working order (Yes or No) Comme s (note con "tion of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Whistleberry Dr, Marstons Mills Owner: P i re s Date of Inspection: g ff- SOIL ABSORPTION SYSTEM (SAS):1/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydrauliS failure, level of ponding, condition of vegetation, etc.) / b 'oL- S Lam'A e bl ,f L Io� es a 67 �� cis 1�a i- i n CES OLS: _ (locate n site plan) Number nd configuration: Depth-top of liquid to inlet invert: Depth of s lids layer: Depth of s um layer: Dimensio s of cesspool: Materials f construction: Indication of groundwater: n`low (cesspool must be pumped as part of inspection) Comment (note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on ite plan) Materials f construction: Dimensions: Depth of solids--- Comment : (note cond tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Whistleberry Dr, Marstons Mills Owner: P i r e s Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) I i 6P� (. a yoo rf (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 261 Whistleberry Dr, Marstons Mills Owner: Pires Date of Inspection: JZ , Depth to Groundwater L Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions /Check with local Board of health , Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) . . II I (revised 04/25/97) Page 10 of 10 SI No.. f0 (. F�s��—tea .._ i THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH .................. --..........OF........................I............... ............. .......I............... .. App iration for Uispniittl Works Tontitrur#ion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at M1 ....... -......:ll `I ` ------------------------------------ Location,Address or Lot No. ..�iW1AkR(1:Di7Ydf�T� t4" _... . ..�4.-` a( A�tL��................ •• � y`/ Owner y Address a S/ !.... // !_ ! w. � 4.1 ..........................................................--..._...... ......---•-------------•--•--- `gwnu Installer Address dType of Building Size Lot.... 4r .r.......Sq. feet Dwelling—No. of Bedrooms......:.............................Expansion Attic ( ) Garbage Grinder Ltd) p., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) G4 Other fixtures ................ ........... W. Design Flow..... ��'!'_ .....................gallons per person per day. Total daily flow........2S.0....................gallons. WSeptic Tank—Liquid*capacity.l.C.Q.Wlons Length................ Width................ Diameter..-------..--.-- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit NoJ.�. Dia eter.................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) `"` 2 Do i g a ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ 1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------------- .. 0 Description of Soil...........��------'-�.rites..��1.�------------------------------------•-----•------•----....--•................................................ x •---------•--•---• .. W ••-•-•----------------------••----•----•-•--•--•-••----------------••---•---• •----••-•.....•-----•--•-•-•--------•-----•---•--•--•---•--••-------•--------••-•--•-•---•-•---•-•......•-•••....-- VNature of Repairs or Alterations—Answer when applicable.........................................................:..................................... -•------•-••----------------•---•--..............-•---------------•-----.---••-••--._............0.....-•---------------•••-----•----------•--•----•-•••--•----•-•••---••-•-•--•----•---.......••••..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TL ITI U, 5 of the State Sanitary Co e—.The undersigned further agrees not to place the system in operation until a Cert'- o c as been sue by e boar f health. '' Date A lication Approved B -•-- /! .. ............. ...-•-1�r----Wiz.(:7..... PP PP Y ' Date Application Disapproved for the following reasons:.............................................................................................................. ••.....••••---••--•--•-----....---•••---•------•----•....................••••............................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date Fim ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ... .... ...............OF Appliratioll for Mqpaaal Workii Tonstrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: .......WAVIiAlAmm #&A�.............................U T kA .c).................................... LOQI.A.ddres 0 or Lot No. ... .......MU$_.V...... .... ... .CU V . ...... . .. Owne Address .......................................... .......................................................... Installer Address 1 Type of Building Size Lot---I"t-00-0.....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder yp Other—Te of Buildin g ............................ No. of persons.____..__.__________.__.__._ Showers sCafeteria Other fixtures Design Flow......................:.....................gallons. per person per day. Total daily flow............................................gallons. W 94 Septic Tank—Liquid capacity_k �?allons Length................ Width....._........._ Diameter__........__.... Depth......._......_. Disposal Trench—No. ...........:._...... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.G(K Depth below inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing'tank Percolation Test Results Perform6d by.......................................................................... Date........................................ Test Pit No. I.................minutes per inch Depth of Test Pit....__............_. Depth to ground water....................._.. C-11 Test Pit No. 2................minutes per inch Depth of Test Pit................__.. Depth,to ground water_._....._............... P4 .............. ........................................................................................................................... 0 Description of Soil.................. ........ W ....1�............................................................................................................ U .......................... ...................................................................................................... . .. .. . .................................................................................... ........... . .................................................................................. U Nature of Repairs or Alterations—Answer when applicable................................... ........................................................... ....................................................................................................I.................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal Systernin accordance with the provisions of TITLE 5 of the State Sanitary Co—.The undersigned further agrees not to place the system in operation until a Certificate of,C l* -6-h be sue b boar of health. .9mp e as bee Signed.._. ..... ...... .. ..... .4r 04�.. w........... Igo 51 ? Date ApplicationApproved By........ ..........5;;Z................................................................. .............. Date Application Disapproved for the following reasons:.......................................................................................................... ......................................................................................................................................................................................................... Date PermitNo....................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF.................... ................................................................. Tprfifiratr of Tantliftaurr THIS IS T04ERTIFY, That the Individual Sewage Disposal System constructed or Repaired by---- . .................................................................................................................................................................... Installer at..........11.AA...... . ............ -------------V. W P----------------------------------------------------------------------------- has been installed in accordance with the provisions of TITfr 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No._.. ......... dated........Y__,at_-S�.......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIPN SATISFACTORY. DATE......... � Inspector........' ector........ ................................................................. ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH N FEE .......... io w Works Tonstrurtion famit Permission is hereby granted ............................................................................................................. ...... rw! to Con struct or Repair an Ir niduajl w. ge Dispel Syst at N ..J.6.(...................................... ............!t.............o....... Street 101 t Dated.___- A� as shown on the application for Disposal Works C6nstfjjt!L4wa- 4=it N4j!4..-.................._f', ,J4. (!:�7" *Z� 71...........................................�49................................................. Board of Health DATE............................... Y FORM 1255 A. M. SULKIN, INC.. BOSTON TOP OF FOUNDATION e" CONCRETE COVER .e CONCRETE COVERS 4' CAST IRON '2M � r E! S7.p OR SCHEDULE 40 MAX. 12"MAX. • ' P.V.C. PIPE 4"SCHEDULE 40 PV.C.(ONLY) ° PITCH 1/4"PER.FT: PIPE - MIN. LEACH PITCH 1/4"PER.FT. PIT ° PRECAST i o' INVERT �' m LEACHING ''a EL.$7.�(S_ , INVERT INVERT o . e� PIT OR SEPTIC TAN K DI ST. INVERT ELJ 1 �. . . BOX EL�F6..✓.... ' ; > EQUIV. /�e00. . .. .. GAL. INVERT '°• a' EL.'S1Jr.� .,' INVERT ww :;: 3/4"TO II/: ELS6Xt�.. EL.A . o° �c . WASHED a �o w STONE , ;f� PROR LE OF R OUND W I- -- -AT E -¢- - GER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE ' DATE ` LS�fB L. TIMEO.C7. . . . . . . . •T• oat WITNESSED BY . . BOARD OF HEALTH TEST HOLE I TEST HOLE 2 �!��psq/ �,dG/��oj�/� ENGINEER ELEV.dYXS.. . . . . ELEV. .. .. . . . . . . DESIGN DATA , NUMBER OF BEDROOMS �. TOTAL ESTIMATED FLOW GALLONS/DAY BOTTOM LEACHING AREA •.7 P•. _ . SO.FT. /•PIT - SIDE LEACHING AREA . . /l�• SO.FT./ PIT GARBAGE DISPOSAL ./✓d; . . .(50% AREA INCREASE) B ld- E -C.4A61 TOTAL LEACHING AREA . . ��.3 y SQ.FT Hi __ _ — — _ PERCOLATION RATE . . . {. Z. ' MIN/INCH i ..., . . jWATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .. SQ,FT, NUMBER OF LE CHING PITS .®�6' t APPROVED . . . . . . BOARD OF HEALTH 3 �y` `s . . . + DATE! 7.'Y?, e/Y. .G,. d %oTo9<< c�r1� he AGENT OR INSPECTOR d OF .40T- A/ . . . . . . . . . . . . . 1 � 6 $14(� PETITIONER �4-. �ll�! . �•��, . . . . . . . �®��'✓!I)'r,�J',;/cis d _ I I i I I dI° I 1 E I J — r -71 d , r 1 e I I x:. I: _ 1 • � I I I ---- G aL ti I i 1 : I { / 1 I I I .. .. .. I 1�. :., ... .. .. '/ <-. .`LIB/ICiG !crr_.I•n_. � .II 1 yQ� ... .. d.n......_ - - .. .. 1.... : n_ .. r .:.. C >.,. .. E 2 -.r_ .. L G� f1r �.�.'- � ...I. ..,. . ...:.. I .. .. . .. - ..... ._.l—.�...y-.,xmo. .,.... . A�. r.. .. .. .• ...,. G N r< P _nA .. .:. Aa.r.�x " 1 .. ... \ : \tl..1.tll' t . I ,.,., N.... N-b..1.E. �F'7F :.. . ... _-_..fir✓ ..-. r_ .. .. . ..:.. ...:�..... ..—:—�:. .. . . , I 1: F7 7 F I .. � I ... ... .. .. .... tie e :. ..�... :..... .., — 75, .Cd-.Y / : �. 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