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0380 WHISTLEBERRY DRIVE - Health
380 WHISTLEBERRY 06 .,.2� - -- -'� - q t� t i l i i I TOWN OF BARNSTABLE LOCATION r SEWAGE# ,N LLAGE M , , M ASSE OR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. �� t dmz, 4$0 SEPTIC TANK CAPACITY `, LEACHING FACILITY:(type) (size) 12 5 1 3 y�3f NO.OF BEDROOMS OWNER t PERMIT DATE: 10 COMP IAIVCE DATE: I I Separation Distance Between the: J Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 Feet Private Water Supply Well and Leaching Facility(If any wells exist on f site or within 200 feet of leaching facility) IV/A Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �/0/@� Ll 36, <3 j 5 O' off` W. 'rvrN 9STABLr. OtrA:TiON -77 VILr� fi" F"SF.SSmIt'S IVIAp St LOTS. _ A L,LBI'i.'S NAM&P�(On NO A SlE1''I'LC TANK CAP�hC1TX �� q ( ` LEACH NG 1?ACI.M'. (ti..) NO OFBS[7t.00mS 3 ISMUM OR C38VN R If31tN1�A.'1' -. ._» iT l�i"1LYR►t+iG� I�ATi �.�.� :... Separae�aci�en�unac 8ctv�aeta,t��e� ;., ': MaxiumAdjustedGQutAciwatet"Csblslatitct3�uompfI.eachinIIl��uil�ty ... --7777 . l lva�4�dVat�r'Sapply WON did irtdiag FaceLty �Ca�►y��et9s cxSst �rc�c�9 ate eitc�ac wrlth,n Of (vF Wacwt4 fstc lity) Ecl�r};iy�'�/et�an�!end]..eaattl�tt i~actdi�y(�E»`+y wcUands ex st tivit.��t�30Q fc�t of 1eacUi�g luciia"� �` . .S4 �c n1Ctli5.hR(�. IP�o�- TOWN OF BARNSTABLE LOCATION ✓ ` () SEWAGE# ` � � '1- VILLAGE i +(%✓�/. i�et, 04�_ASSE OR'S MAP&PARCEL ;:k r INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY s LEACHING FACILITY:(type) A0 (size) Li NO.OF BEDROOMS 3 OWNER ( t + i PERMIT DATE: g 0 'Z�l� COMP IANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility J Feet Private Water Supply Well and Leaching Facility(If any wells exist on p //� site or within 200 feet of leaching facility) ,iP d ri Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 6 L4 0 Feet FURNISHED BY /t/� j Ad 1 $ ° (3 . 1 36�� 2 4 ac 4 Ll 6 Lis -Ci 5 6 � 3' i i � � a :�,. JrUD Town-of Barnstable P# ? Department of Regulatory Services y B a Public Health Division Date �vl r�1v 200 Main Street,Hyannis MA 0260I rFt►putt" ` f�- Date Scheduled_ ` 4J' Time Fee Pd. Soil Suitability Assessment for Se e Dispos PIS- Performed By: pta 0j Witnessed By: LOCATION&.GENERAL-INFORMATION Location Address J �, 1 n ��� Owner's Name 0 V`l (If ti � ' Address 8?(D Lo ru cu Cu .. 11.. Assessor's Map/Parcel. 1 t�' V Engineer's Name NEW CONSTRUCTION REPAIR Telephone#t Innd Use Slopcs(9b) 0 la Surface Stones Distances from: Open Water Body _ft Possible Wet Are, }i( ft Drinking Water Weil tt Dmlitage Way ft Property Line —!'C A.Ift Other ft SKETCH:(Street name,dimensions of IoG exact locations of test holes&perc tests,locate wetlands in proximity, to holes) �/ --- o 3 Parent al(geologic) Depth to Bedroek ►v materi • ,I A� //! ' Depth to Groundwater. Standing Water inppHole:_ 1 :r'. c� Weeping from Pit Pnea tV d(1t Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL'HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to sell mottles: In. Depth to weeping from side of obs,hole: In. Groundwater Adludtment ft. Index tiVel{# Rending Datc: index Well I { .Al dj thetor, �.r Adj.Groundwater.Leval.l.e:C*P PERCOLATION TEST Dail) DEEP-OBSERVATION HOLE LOG Hole# 6 Depth from Salt Horizon Soil Texture Sdil Color Soil, Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones,Boulders. Corisi3tency,%'aravel) 0 - 3 Q Vj L, e3aJ� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soli Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency, LV DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.. Consistena. A L 0,S qj • �� 6D C' t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Sail Texture Soil Color Soli Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Scopes;Boulders, Co r'• , j L. v !yf bb G .S y C/3 s Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No= Yes Within 100 year flood boundary No. `✓_ Yes �__ Town of Barnstable P# 7 � Department of Regulatory Servicesa i „,R,raT" Public Health Division Date r 200 Main Street,Hyannis MA 02601 Date Scheduled 45 U' Time / Fee Pd._ Soil Suitability Assessment for Se e Disposal J.�Performed By: Witnessed By: LOCATION&.GENERAL INFORMATION Location Address O� 1 t ) Owner's Name � � uV W 00A I't Address Assessor's Map/Parcel: ' D �— Engineer's Name 4 tJ NEW CONSTRUCTION REPAIR i/ Telephone# 56g Land Use M A11111!'1 �� Slopes(96) 0 6D Surface Stones Distances from: Open Water Body_Li 000 _ft Possible Wet-Area'1_ft Drinking Water Well ft Dralbage Way i ft Property Line T E ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands inn proximity to holes) 3 a Parent material(geologic) ' Depth to Bedrock Depth to Oro mdwater. Standing Water in Hole: 1 1.. Weeping tYa IVA n Pit Rnea ` Estimated Seasonal High Groundwater a 5 DETERMINATION FOR SEASONAL•HIG1I WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mottles: In., Depth to weeping from side of obs.hole: In, Groundwater Adjustment Fr- Index Well# Rending Date. Index Well b 9.f'-7 a1' r ��Iketor, � _ Adj.Groundwater Leval PERCOLATION TEST 167L%2_19 Time t :W Observation � ,�'� Vr Hole# W� _ Tine at 9" Depth of Pere '1"'f Time At 6" Start Pre-soak Time @ 1�nP �o'a® Time(9"4") End Pro-soak ' rP a, Rate Min./Inch Site Suitability Assessment: Site Passed t/ Sito Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observdtion Hole Data To Be Completed on Back-- --- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conseirvation Division at least one(1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP-OBSERVATION HOLE LOG Hole# I Depth from Soli Horizon Soil Texture Shcl Color Sol]. Other Surface(in.) (USDA) (Munsell) Mottling (Stnuchtre,Stones(;Boulders. o zsittency.%'Gravel) L. . e r DEEP OBSERVATION HOLE LOG Hole# Depth from' Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) :Mottling (Structure,Stones,Boulders. onsistency. 0: u . loy R 5!4 3D,-I D6 C C . S. .s*l DEEP OBSERVATION HOLE LOG Hole#. _ Depth from Soil Horizon Sall Texture Soil Color Soil Other Surface(in.) (USDA) (Munaell) Mottling (Structure,Stones,Boulders._ Consistency. A L a5; 6/ 6 'C ?, F. S :i �. T G e ar5 '6 DEEP OBSERVATION HOLE LOG. Hole# Depth from Sall Horizon Soil Texture Soil Color Sall Other Surface(in.) (USDA) (Munsell) Mottling (Structure,S;ones;Boulders, 0 P L , 10VR 4 . 6 oyj �. it7 6a C , f} M . 5 r �S y - CI 1: V r d Flood Insurance Rate Man: Above 500 year flood boundary No— Yes _ Within 500 year boundary No . /� Within 100 year flood boundary No.,� Yes _ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious materlal? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 10 CMR 15.017. Signature Date �� 1 Q:WEPTl0PBRCFORM.DOC a�a -o3s Commonwealth of Massachusetts a= Title 5 Official Inspection Form �. ::--II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y �Si R 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 Lt„n 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. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B., Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b Local Approving Authority 8-22-17 Inspector's 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. t5ins•3/13 _ - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �0erY5 I r Commonwealth of Massachusetts a :a=1 Title 5 Official Inspection Form 4.' I.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `�_;;!✓ 380 Whistleberry Dr III Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 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: . ® 1 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: System is in good working order with no sign of failure. Recommend pumping every two years for maintenance and to prolong 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. 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. p System will ass Y inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑. ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts azl Title 5 Official Inspection Form .r-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •�.,§ 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Ma.stons Mills MA 02648 8-22-17 page. City,7own State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts ia=1 Title 5 Official Inspection Form f �I Subsurface Sewage Disposal System Form Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts :a=1 , Title 5 Official Inspection Form Pq f �H Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l a�� ?.J,!% 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City,Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool.or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 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 dunking 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 Disposal System-Page 5 of 17 Commonwealth of Massachusetts � Title 5 official Inspection Form i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 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? ® ❑ We're the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ®• ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information t Residential Flow Conditions: Number of bedrooms (design).. 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City.Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 8-2017Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts ,a=�l Title 5 Official .Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments `�P;?!✓ 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 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: Owner--pumped 2yrs ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: ' gallons How was quantity pumped determined? 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts :,^ f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f.4� a 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 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: 1985 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12"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.): Good condition. Septic Tank (locate on site plan): Depth below grade: 6"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 gal Sludge depth: 12" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts :a=l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) , Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 611 n Distance from bottom of scum to bottom of outlet tee or baffle 1 How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): g 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 t5ins•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City'rrown 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts aal Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. 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 Ian excavation not required): p Y ( ) ( P If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `W ! 380 Whistleberry Dr � Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1-1000 gal ❑ 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.): Leach pit in good condition and holding 18" of water with stain lines at 18" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a,!, 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts a=1 Title 5 Official Inspection Form W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. Citv/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately � - J ff3l , t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts ,a=1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments AW 380 Whistleberry Dr Property Address Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 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: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: . ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f - - Commonwealth of Massachusetts ^+ f+ Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,_��;.✓ 380 Whistleberry Dr Property Address —_-- w Joanne Regan Owner Owner's Name information is required for every Marstons Mills MA 02648 8-22-17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 g LP 0 BORTOLOTTI CONSTRUCTION, INC. `'� '�99 AM 45 INDUSTRY ROAD,.MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A i CERTIFICATION r < Property Address: -1(146�>'O Date Of Inspection Insp ct Name: Owner's Name and Address: Iry f2 CERTIFICATION STATEMENT: I Certify that I have personally,Inspected the Sewage Disposal System at this address and that the informs- tion reported below is true,accurate and complete as of the time of Inspection. The Inspectioin was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.,Tlee system Passes Conditionally es Needs Fur r va us n By the Local Approving Authority Failure / Inspector,'s.Signature . Date: TheSystem,Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or bass Design Flow of 10,000 gpd or.greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Offie of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,.if.apphcable and the Approving Authority. r, INSPECTION'SU MARY: A) SY$T PASSES. ,,, I have not found any Information which i ndicates that the System violates any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not,evaluated are indi- below. B) SYSTEWCONDITIONALLY PASSES: One orrmore System Components need to be Replaced or Repaired. The System,upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined",explain why not. t' The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is iimminent. The System will Pass Inspection if'Existing Septic Tank r ,=aispReplaced•with!.a conforming Septic.Tank as Approved by-the Board Of Health. 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): - 1 - li s� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)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). t _ ' The system will pass inspection if(with approval of The Board of Health):, Broken pipes)are replaced 1 ..< Obstruction is removed 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 the public health, safety and the environment. ;1),SYSTEM WILL,PASS UNLESS BOARD;OF HEALTH DETERMINES THAT•THE SYSTEM IS NOT FUNCTIONING.IN,A MANNER WHICH WILL PROTECT.THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:. Cesspool or privy is within 50 Feet of a,surface water Cesspool or privy is within,50 Feet of a bordering vegetated wetland,or.a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM•IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: —The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or,tributary to a surface water supply. The system has a septic,tank and soil absorption system and is.with a Zone I of a public water supply well.' The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than'100 Feet but 50 Feet or more from a private water supply well,unless a well water:analysis for coliform , .bacteria and volatiie organic compounds indicates that the well is free.from pollution from' the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less N•,.1 y{..f iy.. ' .. �n,.'f. . , l n T :.'tlan'S`PPm ' .. `D)SYSTEM FAILS:z I have determined that the system violates one or more of the following failure'criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health' `s should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge orponding of efluent to the surface of the ground or surface waters due to an, overloaded or clogged SAS or cesspool. �� x Stati61iq4id-level�in ihe'distribution box above outlet i4nvert due to an overloaded or clog- ged SAS of cesspool: (Liquid depth'in cesspool is less than G"below invert-or avaitable•volume is less than 1/2 day flow: -,Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is,a'significant threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet,of a tributary to'a surface drinking,water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water.supply well. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health , _None of the system components have.been pumped for atleast two weeks and the systpm has, been receiving normal flow rates during that period. Large volumes of water,have %.- 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: 7The facility or dwelling was inspected,for signs of sewage back-up. . The system does not receive non-sanitary or industrial waste flow. ._.W/ The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site ,.v,, _�'fhe septic tank manholes were uncovered,opened,and the interior of the septic tank was m- ; spected 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 existing information or approximated by non-intrusive methods. -3- vt f{ n SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) V .The facility,owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS RESID .NT Ai.•_ " Design Flow: loos Number of Bedrooms: Number of Current Reside is Garbage Grinder: Laundry Connected To Systeu4,& Seasonal Use: Water Meter,Rea . gs,if fable: O Last�Date of Occupancy, �- CO MF.R AL11ND ST IAI a' /J U Type of Establishment Design Flow:` sallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present. Non-Sanitary Waste Discharged To The Title V System: Water'Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System Pumped as part of inspection:w If yes,volume pumped: gallons Reason for m ptunp; g: TYP�'iOF SYSTEM: V`Sc tic Tank/Distnbution Box/soil Absorption System .,_�'Single�Cesspool ar. . . z Overflow Cesspool Privy . . Shared System(If yes,attach previous inspection records, if any) Other(explain): ROXIMA , GE-o all'Components,date installed(if known)and iource of jnformation: Sewage odors detected`wlten arriving at the site- -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) N SEPTIC TANK: Depth below grade: Material of Construction:—Ie!!�C'Oncrete metal ther (explain), ,Dimisions: Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 3Q Distance from bottom of scrim to bottom of outlet tee or baffle: /1 /' Comments: (recommendation for pumping,condition of inlet and outlet tees or. Iles„de th of.liquid level in relatio outlefinvert,slructt ral inte ri evidence f leak etc. ri GREASE TRAP: Depth Below Grade: Material of Constriction: concrete metal FRP Other ... (explain) — — —' — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle:, Comments: (recommendation for pumping,,condition of inlet and outlet'tees or balfles,depth,of liquid level in relation to outlet invert;stnictural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: NU Depth Below Grade: Material of Construction:_—concrete_metal_FRP_Otiter(explain) Dimensions: Capacity: gallons Design Flow gallons/day Alarm Level: Comments: (condition of inlet tee, condition of alann and float switches. etc.) DISTRIBUTION BOX: Depth.of liquid level above outlet invert: Comments: (note if evel-and dist ibution is_equa evidet o solids carryover,evidence of I ge i to or out o box,etc.) PUMP.CHAMBER: - Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) S i 3.• ' ?. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOLL ABSORPTIO14 SYSTEM(SAS): ✓ (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,nwnber: Leaching chambers,number: Leaching galleries,number• Leaching trenches;:number;length: #, Leaching fields,'number,dimensions: Overflow cesspool,number: Co nts;`(note condition of il;si of hydraulic f 'lure level f ponding, ondition Qf vegetation . � ~• l U • 1 CESSPOOLS• Numbei and'oonfiguration: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction:—' Dimensions: Depth of Solids: Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) -G- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent r ferences, landmarks or benchmarks. to all wells within 100 Feet. ` 1 1 a a DEPTH TO GROUNDWATER: Depth to groundwater: 7-1 Feet Method of Determination or Appr ximavon: ' wlwl0 v ( i ep� I" t2l0 S -7- No. �v T Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ` 01pphtatlon for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade(�) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. .3$o Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 6 oZ 13 5 U D" Installer's Name,Address,and Tel.No. fjO$ _ 3(� Designer's Name,Address,and Tel.No. t)©$_ ;j 6 9 Type of Building: Dwe_ling No.of Bedrooms Lot Size 9 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �j gpd Design flow provided 14 H o I gpd Plan Date Number of sheets Revision Date ®, 5 Title Size of Septic Tank 11 ;00 Type of S.A.S. Description of Soil le—Q, Nature of Repairs or Alterations(Answer when applicable) WQ A4 JU � 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 ` Date (� Application Approved by L. Date Application Disapproved by Date for the following reasons Permit No. (� O Date Issued 6 I y-No. C?I r7 4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer- i PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for MispoBal 6pstem (tonstrUction 3permit Application for a Permit to Construct( ) Repair( ) Upgrade.( ) Abandon( ) i Complete System ❑Individual Components Location Address or Lot No. ,Q,Qi L)/%, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Instal'Name,Address,and Tel.No. 50% ..3 6;1 (Designer's Name,Addres,and Tel.No. Cam©%- i3 6. u�14 ot tl'D d� 49 4 a Type of Building: Dwelling No.of Bedrooms Lot Size S L1 i 509 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) t A Other Fixtures Design Flow(min.required) gpd Design flow provided (4 !R q « H gpd Plan Date Number of sheets Revision Date I n f I Title v i Size of Septic Tank l (' Type of S.A.S. I L • y y a Description of Soil Ae R, � 4 a 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 CAe and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed • 1 n Date Application Approved by ,, Q, Date /o P � Application Disapproved by Date for the following reasons Permit No. d D Date Issued (b— I ` le THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(e�) Abandoned( )by r-j AAr at 3 © I A has been constructed in accordance Y r � s 4 with the P p provisions of Title 5 and the for Disposal System Construction Permit No. 0 dated r Installer t � � �, Designer 14 W #bedrooms Approved�gn flow v - � I, gpd The issuance of this pe/rmif shall 'of a construed as a guarantee that the syst will fu,cti n as e7l necI Date _ { l Inspector- ----------------------------------- .... ..,, -- �UI � '� �-.- - �------ ---- ------ -------------------------------------------------------- --- No. Fee ("� ----- - THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS bisposal *pstem Construction 3permit Permission is hereby granted to Construct(� ) Repair( ) Upgrade Abandon( ) System located at _0 toaw ,P l 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 co m leted within three years of the date of this permit. Date ' _f Approved by LO l ..._... _........_ Town of Barnstable Regulatory Services - Richard V. Scali,Interim Director Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: >3v/ Sewage Permit# Assessor's Map\Parcel Designer: Ak�7-Installer: Address: f 0 i5e>k /4- Address: On A( Iyc 2� -d41`h was issued a perinitL to install a (date) (installer) UL septic system at 990 W 01 S7Z--6-6&a-P--e DA- • based on a design drawn by (address) /4,4 fif� dated e-J j be.) (designer). +� I certify that the septic system referenced above was installed substantially according to the design, which may include minor_approved changes sucbLaSL lateral relocation of the. distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I. certify that the septic system referenced above was installed with major changes (i.e. greater than 10' latera: relocation of the SAS or any vertical relocation of any component of the septic'system) but in accordance with State & Local LRegulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructedAli � liance with the terms of the I\A approval let.ers(if applicable) (Installer's Signatur Z , 01 .p .rivet� (Designer's Signature) (Affix Designer's Stamp Here)' PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION.' CERTIFICATE OF COMPLIANCE WILL NOT BE. ISSUED UNTIL BOTH' THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH VVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 8-14-13.doc L-O-CAVIOIt AS���sv SEWAGE PERMIT NO. TIC e,n y2 VILLAGE 71 I N S T A LLER'S NAME i ADDRESS All c 1,,e C,2 R U I L D E R OR OWNER i� C o,r�E�r.a / ��d/_� ��.� �.,.�; O DATE PERMIT ISSUED ge _ DATE COMPLIANCE ISSUED 1 1 4-- �r No.. '.`�z°l FRim sb.6 b..... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ...................... ....................O F............................._...........------------.....-----------..................... Appliration for 11ispaii al Works Tontrnrtion ramit , Application is hereby made for a Permit to Construct or Repair (�<) an Individual Sewage Disposal System at: WkAl.30 ..._ .. ..... .................................................. L(�oca�tio�ni-Address g7y� or Lot No. .�.. .....---^-•............... A.:h�. � �Q .... � Owner Address a ` •-•............. ....-----_^_..............:...........__.. Installer Address Type of Building Size Lot.....6..._t. 9. ..Sq. feet U Dwelling—No. of Bedrooms____________ ___________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------------------------------------------ W Design Flow..............5�..._.....................gallons per person per day. Total daily flow.................3 ................gallons. WSeptic Tank—Liquid capacity_./A gallons Length___l0�(!'Width_ �+���._ Diameter-_-- Depth................ x Disposal Trench—No..................... Width.................... Total Length............`... Total leaching area....................sq. ft. Seepage Pit No..___ ........... Diameter.__��!.. Depth below inlet..ta..: Total leaching area. I� Z Other Distribution box ( .4 Dosing tank ( ) '_4 Percolation Test Results Performed by./_}�4W_6 _;6���_llf e. Date...7.W. 14 Test Pit No. 1.....A......minutes`per inch Depth of Test Pit.................... Depth to ground water__ e4wz fLj Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ o ............................................... ...... �!"....._._.�`..... Descrl_t• n of Soil....0 '"�!..44 f.IoZk l!� 4 � ��� �d�� L U ......_.yQ_. ...O. A----------------------------------------•----------------------------•------•-------------------••------.._..---•---- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------•----------...--------------------------------------•------•-----------------------------------------------------------------------------------------------...--•••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has 1�5ued by boa- of heal Signed.....`' D4te Application Approved By----- rz' _-cl.:_. yl[r-- -- --- ------------------------- ------- 10J/p/ss --------___- Date Application Disapproved for the following reasons---------------••----------------------------------------------•-----------------•---•-••--•-•--•••---•----•-- ---••............••••--•--•--•-••..............••--•••--••••-----•-••--••-••--•-.............------•..._..••••-•-•...--•.._..._._....-----••-•---...------. .......................... Date Permit No........ _�_ 2.` ----•--------------- Issued.........to ----� .............. ate . Nod°'�?.?''L��, � � F�$...�.•..�••-t...���...... F= THE__COMMONWEALTH OF MASSACHUSETTS BOA FZ® OF HEALTH pliration for Disposal Works Tonitrttrtion ermtit ,Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: -------------------------•--•-•------------•---- • " _ Location-Address or Lot No. ---- ------- -- -------------- Owner / Address' ................................................:............................... Installer Address Type of Buildir_g Size Lot___Vgt.60_9...Sq. feet Dwelling—No. of Bedrooms..........._15____________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons___________________________ Showers — Cafeteria Other fixtures .. '•---------------------------------------------------------- Design Flow............_J5.........................gallons per person per day. Total daily flow................3..�_;7.................gallons. WSepiic'Tank—Liquid capacity/"e_gallons Length____P!'6" Width_5��"___ Diameter__ __ _�___ Depth ___.. Width___________________ Total Length Total leaching area______:_______......s ft. x Disposal Trench—No_______________ g g q. Seepage Pit No....../_------------- Diameter__/a- !__. Depth below mlet_�_ i_�...:. Total,leaching area__�� __.___gq/?w Z Other Distribution box (f) Dosing tank ( ) \ Percolation Test Results Performed by ,�'!� Date__ ?7t GL, '•minutes per inch Depth of Test Pit.................... Depth to ground water!1�40&Z'� .d Test Pit No. 2__ . -• Test Pit No. 1-- minutes per inch Depth of Test Pit____________________ Depth to ground water........................ �+ 1----------------------------- --••-• ..._._._...__....-•------------.............--•---..._.._�....---------... _.`.......--• .•--- ODescri nf oil..__ � ( � - �..S � ------ag W Answer when applicable................................................................................................ Nature of Repairs or Alterations . w .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the prod sions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in z ' operation-until a Certificate of Compliance has been > sued b boa of hea tli 1 ' ..---•••........... ......I.......................••.e _.Sign Date - ----------------------- ---•Application Approved BY Date Application Disapproved for the following reasons______________________________________ ... ....................................................-- ---•--------•---•-••----. -•----• .•-••----••-----......... . ' ....................................Permit No.. • Issued. .. . - ._ tr ate •� THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ....:..!..` . ...V.................OF.... rl J `l .................................. Tatifilrate of Toutplianre THIS IS TO CERTIFY, That"thervidual Sewage Disposal Sy tem constructed ) or Repaired ( ) by -= :.:!� ��, c/ ..t------� �-�.. ,y Installer at l-cJ.!__. �:_,_ L!1__.............s� _ . . ......................................... has been installed'in accordance with the prov1s�ons of TITLE 5 of The State Sanitary Code as described. in the application for Disposal Works Construction Permit No. ...... ____________ dated......fc �lc:f.s'z................ _ _ THE ISSUA CE OF THIS CERTIFICATE SHALL NOT BE CONST UED AS A GUAR NTEE THAT THE SYSTEM WI UN TI N S TISFACTORY - r DATE........ A. Inspector._.... .�__..._. .. ..__••............... ----____-. _. ................... k r THE COMMONWEALTH OF MASSACHUSETTS rdd f BOARD `OF HEALTH v ..........................................OF..................................................................................... ,�-.. L+cU No......................... FEE._SP._-..__....... Disposal Works (rvonstr ion rr it Permission is hereby granted---- ----------- to �t.l to Construct ( ) or Repair ( ) an Individual Sew a Disposal bSystem ft - .................. - ••:ZAtreet as shown on the application for Disposal Works Construction Permit No H__.92.41___:__ Dated...�.D/lkglvf............... ....... ?" ^ Board of Health DATE............................................................................... FORM 1255 A. M. SULKIN• INC.. BOSTON - TEST HOLE LOG DATE: 67/25/18 BM ® T.O.F 95.72 SEPTIC SYSTEM PROFILE TEST BY: MIKE O'LOUGHLIN �- NOT TO SCALE WITNESS: DON DESMARAIS COVER TO WITHIN 6" PERC RATE: < 2 MIN OF FINISHED GRADE TEST HOLE 1 TEST HOLE 2 TEST HOLE # 3 TEST HOLE 4 �� 88.05 EL p° 88.3 EL 0„ 90.29 EL 0„ 89.13 EL 18 COVER TO GRADE # # # 66° 90.0+- F.G. F.G. 90.0 PIPE TO B E LEVEL 0 p q LOAMY SAND A LOAMY SAND 89 6 / FOR 2' OUT OF D-BOX 3. 87.8 EL 88.05 EL 6 10Y 4/1 89.79 EL 10Y 4/1 88,63 EL f A LOAMY 4/AND A LOGY 4/4 MY SAND BW LOAMY 5/8 SAND BW LOAMY 5/8 ND 10" INLET TEE TOP ® 88.34 8" 87.39 EL. 6" 87.8 EL 36" 87.29 EL 36" 86.13 EL F n LOAMY SAND LOAMY SAND o 0 0 0 0 o a o a o o MEDIUM SAND MEDIUM SAND 88.6 oa000aoaoao BW 10Y 5/8 BW 10Y 6/8 C 2.5Y 6 4 C 2.5Y 6/4 4 0 0 0 o a o a a o o a 36" 85.05 EL. 32" 85.8 EL 60" 1 / 85.29 EL 60" 1 / 84.13 EL 90.2 14 TEE AND 88.35 0 o a o 0 o a o o a a 87.8 87.51 oaoaoaaaaao FILTER SEE � ooa000aaoao C C o a a o 0 o a o 0 0 FINE SAND FINE SAND NOTE 4 87.97 C C H-20 1 68" 2 2.5Y 7/2 84.63 EL 68" 2 2.5Y 7/2 83.49 EL °-Box DRYWELLS H-10 BOTTOM 85.5 (3) 500 GALS 12.5 X 34' EXISTING 1,000 GALLON H-10 SEPTIC TANK TO WITH STONE 2'-3" ON ENDS AND 4' ON SIDES BE REPLACED WITH 1,500 GAL.SEPTIC MONO TANK 6" COMPACT STONE COARSE SAND COARSE SAND C 3 H-10OR COMPACTED BASE 5 2.5Y 6/8 2.5Y 6/8 COARSE SAND MEDIUM - COARSE 2.5Y 6/4 SAND „ 2.5Y 6/4 80.51 EIL 112 WATER i 109" WATER WELL SDW-253 ZONE B ENCOUNTERED ENCOUNTERED NO WATER NO WATER 79.'01 EL 120" 79.01 EL 78.05 EL. 126" 78.3 EL 120" ENCOUNTERED 80.29 EL 120" ENCOUNTERED 79.13 EL 1.5 ADJ. WATER 5/4/18 . WATER 79.01 EIL BOTTOM OF BOTTOM OF PERC 40" BOTTOM OF PERC 44" #2 TEST HOLE 78.3 EL PRESOAK < 2 MIN./IN. PRESOAK < 2 MIN./IN. II 83.85 S 83.1� >= 83.96 GENERAL NOTES Aw 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALL UTILITIES, OVERHEAD & 83.84 UNDERGROUND, PRIOR TO ANY EXCAVATION OR CONSTRUCTION. 2. SEPTIC SYSTEM IS TO BE INSTALLED IN COMPLIANCE WITH 310 CMR 15.00: TITLE V. w 3. THIS PLAN IS NOT TO BE USED FOR PROPERTY LINE DETERMINATION. 4. IF AN OVERDIG IS REQUIRED, DESIGNER TO INSPECT & CERTIFY THE OVER-DIG BEFORE B AC KFILL. 5. DESIGNER TO COMPLETE FINAL INSPECTION FOR CERTIFICATION BEFORE B AC KFILL. 6. CONTRACTOR TO PROVIDE 48 HOUR NOTICE FOR ANY REQUIRED INSPECTIONS. 7. THIS SYSTEM IS NOT DESIGNED FOR THE USE OF A GARBAGE DISPOSAL. 8. THE TOP OF ALL SYSTEM COMPONENTS SHALL BE MARKED WITH MAGNETIC MARKING TAPE OR A COMPARABLE MEANS IN ORDER TO LOCATE THEM ONCE BURIED. 9. IF SOILS ARE FOUND UNSUITABLE OR DIFFERING FROM THOSE FOUND IN SOIL LOG, 9391 �. CONTACT DESIGNER AND THE BOARD OF HEALTH. 52 8425 10. IF AN OVERDIG IS REQUIRED, OR IF UNSUITABLE SOIL FOUND, CLEAN GRANULAR SAND GB NODH 98.44 MEETING 310CMR 15.255(3) SHOULD BE USED AS FILL MATERIAL, 5 AROUND AND 99.00 1=ND s4 �, UNDER S.A.S. 11. ALL 4" PIPE CONNECTIONS AT SEPTIC TANK AND D-BOX SHALL BE MORTARED 95s1 $ m fiq IN PLACE. IF USING 18' PLASTIC RISER PIPES, THESE TOO SHALL BE MORTARED 9� IN PLAC E. Garage 94.-1 84.16 9 .89 95.26 100.00 x A ` 84.60 MAG SET 98 �VQ Dock r DESIGIN DATA r 100,15 95.85 � ttl I DAILY FLOW: 3 EXISTING BEDROOMS X 110 GPD = 330 GPD 100,43 - O 95.19 Garlage ( ) 100.16 -- o\ \ CB DH FND 84.49 SEPTIC TANK: 330 GPD X 2 = 660 '6Pb v (- END BERM \ ' i 8568 USE: 1,500 GALLON H-10 SEPTIC TANK x 85.19 m i I NAIL SET DISTRIBUTION BOX: �i100,1� 95.08 USE: DB-6 H-20 9® ,' SOIL ABSORPTION SYSTEM: m / w3so USE: (3) 500 GALS. LEACHING DRYWELLS H-10 WITH DOUBLE WASHED STONE. A �� 95.1 tOF=95."f2 /�� LEACHING AREA REQUIRED: 330 Q GPD Q �t r90 �� 95,0 (Assumed) 93. 6 > / ro° 440 GPD _ .74 = 549.59 SQ/FT o l00.31 `. 5.4z PROPOSED SAS: BOTTOM AREA 12.5' X �34' = 425 SQ/FT q ss SIDEWALL AREA 93 X 2 = 186 SQ/FT X8 TOTAL AREA 611 SQ/FT mL s O %?o F TOTAL GPD 611 SQ/FT X .74 = 489.14 GPD s o s o- 915.04 95, 99.56 95.35 DeG1C 9.16 NOTES E SHOW \ 92,60 E 7 OA 3.5' X / ,84 89 00 85 1. SOIL REMOVAL OF UNSUITABLE SOIL BELOW ELEVATION 87.6 BE INSEC TED BY 99.13 8�.32 Lot 36 TOWN OR ENGINEER BEFORE INSTALLATION OF DRYWELLS IN S.A.S.. 95a IFT OA� E FT OAK , �4,�✓C�9+/- S.F. 45 98.1 IFT OAK ,� +/_ �G� 2. PUMP OUT AND REMOVE EXISTING PIT, STONE AND CONTAMINATED SOIL. IFT OAK ,ti l 1 Stone ! n - - - 2 E i® �'� `, �. ` gyp, � Map t 3�J 3. INSTALL A ZAB EL A 300 8X18 VC FILTER WITH ALARM. '' 4. REVOME EXISTING 1,000 GAL. TANK AND REPLACE WITH A 1,500 GAL. MONO TANK. 91.86 8.03 IFT OAK /Area o 9 .6 91.53 96.3 O q O SEE NOTE •1 - g@ 6,$3 3FT OAK OYERDICt -� 96.9 tl O 9O X LOCUS o 96.69 T H. 9� 6 5'1 5,12 T 2 X.. j . RAC E LANE 96.10 9414 MA G SET ' �' SO' 5.88 v E �1 88 216.31, 9L51 nT O TURr�EegC 94.10 s 89.46'So" w 91.51 DATE HEALTH AGENT APPROVAL K Rp 95.04 C5 DP FND ECT SEE NOTE •2 wH'ST�E� PEDS TRANS EXISTING PIT TO IBE REMOVED Scale: 1"=20, Off' 'L 0 20 40 roO SURVEY BY: SEPTIC REPAIR PLAN ENGINEER: TERRY WARNER STEPHEN HAAS #38o L°°AT'°N: # 380 WHISTLEB ERRY DR. o MARSTONS MILLS MA. 02648 rTE sNOf�sasePREPARED FOR: DAVID AND ANNE CURLEYY as o DATE: 8/1/18 . 0 > WARNER N SCALE: 1 = 20 Z No.38721 s JOB NUMBER: REVISION: 10/15/18SHEET , +1i MAP:NUMBER: t PARCEL: 35 0 �� 1 Rid J. O'LOUGHLIN INC. Ro 714 MAIN STREET, YARMOUTH PORT, MA 02675 q10 (508) 362-4942 f a� ------w � ,. I I � I I �11 1-1-,-1--l'. � I I I � -, ------' ," I .I .-----""-- � - ��, . I I I I I I � I I � - ... I I I k, I , � - I . I � � . . I . 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