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HomeMy WebLinkAbout0452 WHISTLEBERRY DRIVE - Health M52 WHISTLEBERRY, tV Qi MARSTONS MILLS A = 062 038 -- - - - r ocoa- 0 38 Commonwealth of MassachuseM Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive " Property Address Cynthia&Gregory Rand_ Owner Owner's Name / information is Marstons Mills t( Ma 02648 5/412021 required for every Chy� n State Zip Code Date of Inspection page. 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 A. Inspector Information Sl I S 3 So filling out forms on the computer, Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. � 74 Beldan Lane Company Address Centerville Ma 02632 Citylrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails r- 5/4/2021 Inspector's Signature Date The system inspector s all submit a copy of this inspection.report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of er the inspector and the system owner s 10,000 gpd or great hall submit the report to the appropriate p y ' regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the some or different conditions of use. t5stsp doc-rev.7I28W 8 Title 5 Official Inspection form:Subsurface sewage Disposal System-Page 1 of 18 r y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive_ Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every -— page. citylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. w 1) 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: The property located at 452 Whistleberry Dr Marstons Mills is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 5 Infiltrators.Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) System Conditionally Passes: ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 iniiitration or exfiitiation 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 tail:is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5insp.doc-rev.7f2812018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 2 of 18 C®r�lr��i'�v��at�i>; c►��t��t�s�c6tirilisf��c Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Mistleberr r Drive Property Address Cynthia&Gregory and Owner Owner's Name information is Marstons Mills Ma 02648 514/2021 required for every page. Cityfrown State Zip Code Date of inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due 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): 3) further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7262018 TNe 5 ofrmW Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 1 cry Corkurcoi: -wealet of Wria t.:::. .. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistlebony Drive Property Address Cynthia&Ora gory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every "T page Cityfrown State Zip Code Date of inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within Go foot of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health(and Public Water Supplier, if any) 1 .a � yr .,� n,..„a • c+s• � 's.*,>,'A. ill 9iSt3i�iJ3�;7 a3is,33 I�j L'i�. 1ho public health.i'?'�.1'f'�3i:a.-.'�J 3i's�t�.la.�• uiai 33 .� .ur�{.iaLii.. , 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.70=18 Tate 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every State Zip Code Date of Inspection page. City/Town C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® 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 1/a day flow El ® 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. El ® 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 water supply 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 2000 gpd- 10,000 gpd. ® The system fails.I have determined that one or more of the above failure El criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systewis: To bo cvni,[ cd a large slstlerrL tNQ ss L.,,;; v..IU-i a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ s y t is :`i'..1 100`,; t of�a surf�co d y nkincg water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection ❑ ❑ Area—IWPA)or a mapped Zone 11 of a public water supply well t5 nsp.doc•rev.MWO18 Title 5 Official Impection Forth:Subsurface Sewage OLaf0581 SYstem•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every State Zip Code Date of Inspection page. Cityrrown C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section C-A above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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? El 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) ® ❑ facility Was the facili or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] i - t5insp doc.rev.TOM 8 Title 5 Offlclat Inspection Forth:Subsurtace Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner owner's Name information is required for every Marstons Mills Ma 02648 5/4/2021 page_ Citylrown State Zip Code Date of Inspection D. System Information 1. 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 gpd Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current y Date Mnsp.doc-rev.7050118 rrtle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 ' required for every - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available. Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? -- Reason for pumping: t5insp.doc-rev.7/2812018 Titte 5 Official Inspection Form:Subsurface sewage oisposat System-Page a of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is required far every Marstons Mills Ma 02648 5/4/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution lox, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components,date installed(if known)and source of information: Original system installed 4/26/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage,etc.): Joints in good condition, no leakage, vented through roof. t5inap.doe•rev.71W A 18 Title 5 Official inspection Form:subsuftoe Sewage oisposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whisfleberry Drive Property Address Cynthia&Grego!y Rand Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/4/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 5 Depth below grade: fee Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallons 5rr Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Owned covers and took measurements 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 should be pumped soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. i t5insp.doc-rev.M612018 Tine 5 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistlebe Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet.and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 8. 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 L%W.doc•rev.U 2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand _ Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every _. page. CitylTown state Zip Code Date of Inspection D. System Information (cont.) , 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 011 - 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.): Distribution box was video inspected and found in good condition with no rot.Water level was even with outlet invert. t5insp.doc•rev.7262018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts --- Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistlebeny Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5lrisp.doc•rev.71261201 a Tste 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistlebeny Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/4/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s.was video inspected and found with minimal standing water and no signs of past overloading 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool — ---- — Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev.7126 018 Idle 6 Official Inspection form:Subsurface Sewep Disposal System•Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) 13. 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.): Mmsp.doe•rev.U28120,8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachuseft Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 452 Whistleberry Drive Property Address Cynthia&Gre�c ory Rand Owner Owner's Name information is required for every Marstons Mills Ma 02648 5/4/2021 - -"'—" page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 Q Q o v t �-- Al 2N 6 l �( zs AZ_ 30' R3 Z� t5insp.doc•rev.7/MD18 Title 5 Official Inspection Form:SubsuAaoe Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cynthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cant,) 15. 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc-rev.7/ffiI2t118 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 452 Whistleberry Drive Property Address Cy nthia&Gregory Rand Owner Owner's Name information is Marstons Mills Ma 02648 5/4/2021 required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked 9 ® C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed Z D. System Information: For 8:Tight/Holding Tank Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high,groundwater included i t5insp.doc•rev.7l M018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 y i TROY WILLIAMS P- 38 SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1500 19 Hummel Drive South Dennis, MA 02660 CODA MONWEALTII OF MASSACHUSETI'S EXF,C'UTIVI,; OFFICF OF' ENVIRONMENTAL AFFAIRS DEPARTMENT OF 1.1NVIRONMEN'I'AL PROTECTION � s TITLE 5 OF INSPECTION FORM — NO'I' FOR VOLUNTARY ASSESSMEN-I'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Projwrt) Address: 452 Whistleberry Drive Marstons Mills,MA 02648 Owner's Name: Darlene Scranton-Ashley Owner's Addres,: 452 Whistleberry Drive Marstons Mills,MA 02648 Date of Inspection: September 28,2006 O Name of Lispector: Troy M. Williams LYN Company Name: Troy Williams Septic Inspections f Mailing Address: 19 Hummel Drive r ~t South Dennis,MA 02660 Telephone.Number: (508)385-1300 x CERTIFICATION S"hATEMI:N I' N ; I cenif)•drat I have personally inspected the sewage disposal system at (his address and that the info-mation "C, below is true,accurate and complete as of the time of the inspec(ion. "fhe inspection seas performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP appro,ed sy slem inspector pursuant to Section 15.340 of Tille 5(310 CM12 15.000). The sysicni Passes Conditionally Passes Needs I urther Evaluation by the Local Appuoving Authomn Fails Inspector's Signature: 2J.���_ Date: _ /,z D 6 _ The systern inspector shall submit a copy of this inspection report to the Approving Awhori►y(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has.a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection.certification is not 10 be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. "•"This report only describes conditions at the time of inspection and under the conditions of use at that time. phis inspection does not address how the system will perform in the future under the same or different conditions c•f use. "Title 5 Inspection Form 6/15/2000 pate I or II Page 2 oft OFFICIAL INSPECTION FORM — NQ'l' V'Ojt 'VOLUNTARY Ass Less MNNTS SUIISlilzrACE SI WAGE DISPOSAX, SYSTEM INSPECTION PY)RIVI PA R`I' A CIP011'1111CATION (cortfinued) Properly Address: 452 Whistleberry Drive Marstons Mills,MA Owner; Darlene Scranton-Ashley Dale of Inspection: . September 28,2006 Inspection Slim uary: Check A,II,C,t)or E/ALWAYS con►plete all of Section 1) A. System Passes: 1 have ow lound any inlunn pion which iridicales that any of life Iililure criteria described in 310 CMR 15.303 or in 310 CMR 15.3011 exist. Any failure criteria not evalualcd are indicaled below. Couutleuls: 13. Syslcu►Coudilioually 1'asscs: One of nuxe systcul cofupolleols as dcscrihcd ill the'•Cludilional Pass"section need it )c replaced or repilired.The Sys tcul, upon Col np IL;Iioll of the replacentcfit or repair, as approved by the Ito• (I of llealth, will pass. Answei yes, no or not dcicimined(Y,N,NI)) io life tui file lollowing stalcinc s. 11"'not deterlllined'•please explain. -The septic lank is metal and ovci 20 years or the Septic lank icllier metal of.not) is sliucturally unsound, exhibits subslaulial infilliation or exliiiialion of lank failure imminent. System will pass inspection if the existing lank is replaced with if conlplyiog septic lank its approved life Board ill Ileallh. *A metal scplic lank will pass inspection if it is structurally sou not leaking and if a Cerlilicalc of Colnpliancc indicating that Ills lank is less than 26 years old is available. Nj)explain: Obsefvatlon 01 sewage bachip or break it or high static water level io the dislribulion box due to broken or obstnlcted pipes)ur(rue to a hrokcn, seule(l r uneven distribution box. Syslenl will pass inspection if(with approval of Board of IItalth): -- b en pipes)itie replaced ohslruclion is icnulved distfiblllion box is leveled of replaced ND explain: The systen e(Jlttled pillfilling m7ore Illall zI liples a yea►due to broken of obstructed pipe(s).The system will pass inspcctiol (with approval of the Boat I of lItalth): — broken pipe(s) lire replacc(� obstruction is removed ND explain: 2 1'age 3 of 1 I OFFICIAL. INSPECTION I+OI2iYI - NOT VOR V01-UNTARY ASSI?SSMLN`1'S SUItSURIi'fkCI? SI WAGE L)ISI'OSAI, SYS'fli,Nl INSI't?CI'ION ii'Ol2M PA 11T A CI�I2'Y'II�ICA`I'IQ1V (continued) Properly Address; 452 Whistleberry Drive Marstons Mills,MA Owner: Darlene Scranton-Ashley Dale of lupeciiou: September28,2006 l'valiialiou is ticyuired by (lie Iloal-il ill'Ileallh: Coc"Idilions exist which rquire lilrlher evalualiou by the Boar it Of!leallh in order to deiermine if the syswfn is failing lc prolcel public health, safely ill the Cnvironrnenl. 1. Sys: ecu will pass unless Board of 11calth delervi ices lu accordance with 310 CIVIR 15.303(1 that the syslelu is not functioning in a 111auner which Will protect public health,safely and lie en rounleuL ____ Cesspool or privy is within 50 ow or coke water Cesspool or privy is within 50 teel of a bordering vegewied wetland or a salt me sh 2. SyslCul will fail uulcss the Board ill'116341a (ant! Public Water upplier,il'any) delemlines that the sysieul is functioning in a manner lhat protects the puhHC heal ,safely and euviraumenl: "ITC Won has a septic lank and soil absorption syi in(SAS)and dw SAS is within 100 feel of a surface Willer supply or tributary to a Sul htce water s ply. Hit system has a septic lank and SAS an Ow SAS A within a Lone I of a public water supply. l he syslelu has a septic lank and S S and the SAS is within 50 101 of a private water supply well. 11w sysMn has a septic; lank rid SAS and the SAS is less than IN 141 but 56 feet or more ham a priv,llc water supply well". lhod used to delenuint;distance ."his syslelu passes i 1c well water;lualysis, perlurined at a t)LI'ccnilieil laborataiy, fill caliform �acleria and vc�latil rganic compounds jndicales lhal the well A iee fionl pollution Iron1 that facility and the presence of- unania nitrogen and nilr[lc nilrogcn is equal la ar less than 5 ppm, provided [hat no olher fallm crher arc irygerCil. A c"y of the analysis nlllst he attached io this form. 3. Other: 3 Page 11 of 1 1 (.)91'1�IC:IA1 1NS1'I:C'1'>ON 1t'0RM — NO'4' jeo11 VOVUN'J'ARV ASS CSSIVIENTS SUBSURI-iACE SEWAGE DISPOSAiI SyS`1I'I�lYl 1NS1'I?C'110N CeOIIIVI IlA 10.' A CrAt`IFICE1`r'IION (continue(j) 452 Whistleberry Drive Properly Address: Marstons Mills,MA Darlene Scranton-Ashley Owner: September 28,2006 Dale tit'InspCelum; 1). Syslcni hailtlre Criteria applicable to all sysle!ns; You n►ust indicalc"yes"or"no" lit each of file following !iir;ill inspections: Yes No Ilacktlp orscwagc into facility ur system component tblc to overloalicll or clogged SAS or cesspool _ Discharge of prluding of effluent to the surfi!ce Of,die ground or surface walers title to an overloaded or clogged SAS ill cesspool ___ ✓ Static Illptld level Ill Ills dislrlbt111011 box aI)OVC Oil IICI It1velI title 10 an Ovel lOalded i)i clogged SAS Or - cesspool Liquid deplll ill Cesspool is Icss than 6"below invert or available vollllne Is less Ulan %s day flow Rc,Iui,cd puull)irtg olorc Ihau q limes ill lllc last year N— O'1_thle it,clogged or obstructed pipe(s). Nuolber of tiulcs purupeil__ _. _✓ Any"portion ol'llle SAS, cesspool or privy is below Vigil ground wale,elcvaliou- Auy )ill tion,)fccsspuul iir privy is wilhirl 100 lcct ofa surlacc wailer supply or Iribulury to a surlacc waler supply. Any po,lion ofa cesspool Or privy is within a Zooc 1 of it public well. Any pot tioo ofa cesspool or privy is wilbin 50 I'cet ofa privalc wale,supply well- Any poilion ofa cesspool or privy is less !hall 100 feel but gicaler than 50 Icc! from a privalc wales supply well Willi oo acceptable wale[-yuallly analysis. I"This system passes it(lit! well water analysis, perlilrtned al a 100, certified laboralory, lilt-coliform bacteria and volatile orbaoic compounds indicates Thal Iht: well is rrce from pollulion froze► that facility and flit I)reseuce of arlunouia nitrogen and nilrale nitrogen is etptal to or IC55 than 5 pplu, provided that lit) olber failure criteria are Irigbcred. A copy of lilt:analysis fmisl be atlachcd to this forlu.) _4o _(Ycs/No)The system tails. 1 have dclulloiuetl that out;qi mitre of file above lallure Criteria exist as dcscrihed in 310(:MR 15.303, lhcielolt; the sysleln !ails. The system owner should contact the hoar(] 01 Ilcallh to delcinliue what will lie accessary to Corrtcl the lailurc. L. Large Syslems: '1'o lie considered a 1;►rge sys(en► file system iiiusl serve a facility with a esigu flow of 10,000 gild to 15,001) 6htl- you nwst it-Alieale cilher"yes"or"no" to each ill'tile li)Ilowing: (Tile following criteria apply to large systems ill addition to (lie Cl if `a above) Yes o0 _ the system is within '100 fecl Ora surface th-wkii water supply — _ the syslenl is within 200 Iiet ol'a tributary a surface drinking water supply the sys1e1TI is located ill a nitrogen se !live_ area(Interim Wellhead Prolection Area—IWPA)or a mapped Zone Il ofa public Witter supply I If you Ilave t!nsweretl"yes" to any(file•.ton in Seclipn 1 the sysleln is considered it significant lbi-eal, or answered "yes" in Sectiol) P above lilt large stem Ila$ tailed. i'l!e owner oI.operalor of any large syslenl)considered a significant lllreat untltt Seetiot! ►(ailed unilCr Section l)shall upgrade file syslenl ill accordance Willi 310 CMR 15.301.`file systelll Rw)lel.shl, tl colhacl Ille ahpropflole fealonal office of lilt Drparinlenl. �l Page 5 of 1 I ( 141CIM, INSPII:C'I'ION DORM — NOT IeOR VOLUNTARY ASSESSIVIEN'I'S SUBSURVACE SMikGME I)IS1'QSAI., SYS"1'I?1VI INSI'I?C'I'ION POIiM illsT It �'rtptrly Address: 452 Whistleberry Drive Marstons Mills,MA Owner; Darlene Scranton-Ashley Dale al'lnspectitll: September 28,2006 Check if the lidlowing have been done. You nutst indicale "yes"or"tit"as to each of the lullowiog: Yes No 1'unyping illfoli union was provided by Otte owner, occllpanl, or hoard of I lealth WeIC aoy of the system conyw lie ills pumped out in Ills previous Iwo weeks '? l his 1hC sysicol received uonnal Ilows ilk IbC previous two week perit(l '? (lave laige volumes of walcr been iulroduced to llle syslem recently or as part of this inspection? WCrc as buill plans of ille.system oblaiotd and examill-P (If lbcy wcic nut available title as N/A) _ Was like tacility or dwelling inspected fu(signs of sewage back op'? -._.-- Was the site inspected, fur signs tf bicak out •? -- WerC all system cooyltlncnts, excluding Ibe SAS, localed to silt '? _ Wert; the septic tank manholes ilnctvered, opened, and Ibe interior of Ibe lank inspected for the conditimi of the baffles ti tees, inatcrial of consli uclioti, dimensions, depth of ligklid, depth of sludge and depth of scum Y ,/ -- Was the Iacility owner(and occupants if diffelcnt Iron)owner)provider] wills information on like proper rllaluteuaucC of snbsllrface scw;Igc disposal systelrls '.' The size and location of the Soil Absorption System(SAS) nn the site has been iitteinlined based on: Yes no _ Ex isIing ill loro lit I to] . I"or example, a plan at Ihc Board of I Italth- Deleriniueq in the Iichl(if any 01,111C faiblie crileria I-Clalul 10 Pall C is al issue approximaliou of distance is unacceplable) (310 CM 15-302(3)(b)l 5 f • Page 6 of 1 1 01" I(.IAL INSIT CTION 1,ORIVI - NOT I"OR VOM,UNTARY ASSESSMENTS SUBSUR ACE SEVAGV I)M POSAL SYSTEM INSPECTION I+OItM M'A It'd' C SYSTEM MNM'010"Al ION !'roperly Address. 452 Whistleberry Drive Marstons Mills,MA Owner: Darlene Scranton-Ashley Date of Inspection. September 28,2006 I LOW ItI'S11)I'N"1'IAI, Number of bcdroonls(dcsigu): _ Number o[l)e(h mins(aclilal): DESIGN flow based oil 310 CMR 15.203 (for cxat)Iple ! l0 gpd x 1/of bedrooms): 3u— Numbei of'curicut iesiticu(s: d _ Docs residence bavc a garbage grinder.(yes or no): Aid Is laundiy oil a separa(c sewage systeio(yes or oo): A16 (if yes sehaiate inspcchon required-1 l.auucliy systeol inspected(yes or 11o): i,n/9 Seils011ill usc: (yes or no): A& --- Walcr nlcler readings, if available(last 2 years usage(gpd)): O_$-_=-_/O I,�OIwc��ll s p L= ,ZO 000 y'/Z,h> Sump pony)(yes of on): All = 73 O �6wti S l..asl dale ufuccupancy: V 0o�-`� ��t `j COMIVIEIt(AAIJIN1)USTItIA1, Type of eslablisbotcot: Design flow(based oil 310 CMR 15.203): Basis of design flow(seats/persons/sgfl,ett.) — Grease trap picscnt(yes or no): — — ----------- - -- Iluloslrial was bolding lank present(yes or no): Nall Si1111Ii11'y Wi15tC llI5C11i11'gCC) tl1 1111' fldl 5 sy m(yes of no): — Watcr nleler readings, if available: ------- Last dale of occupancy/osc: Q'I 111.R (t1CSC11bC): GEN1,ItA1. IN1,OItfVLVFION 1'uulpinb Records Source of,iulforulalioll: ��. _�__�._.Q.�_-_s__��.(1-- _- Was sys(cin pumped as pail ot'Ibe iospcc(ion(yes of no): (O If yes, voloirlc pumped: __gallons -- Ilow was rluantily punlpui detei-minul? Reason tur pumping:------- ---- -- — -------- ----- -- Septic Nink, distribution box,soil absoiplion sys(cnl Single cesspool — Overflow cesspool I'rivy _—Shared system(yes ni nip)(if yes, atfacb plevlolls inspec((on iecords, if ally) _Innovalive/Altcinativc Icchnology. AUach a copy of Ills current operation and main(enance conliact (In be obtained frolll sys(enl ownei) _—Tight lank _A(Iacll a copy ol`tbc Dlil'approval \ —Other(describe): -- ------ - --------- ---- \ . Appioximale age of all components, dale installed(if known)and souiee of intiliuwtion: Were sewage odofs detected when ariiving at the site(yes oj-no): A a 6 Page 7 of I ! OIi'FICIAM- INSPj C jON F01M — NOT IeOlt VOLUNTARY ASS LSSNII NTS SUIiSUR ACE SEWAGJOI: I)IISPUSAI SYST NI INSPCCI'ION li'ORIVI PART C SYSTEM YNVORIVIATION (continued) Proven" Atllll-ess' 452 Whistleberry Drive Marstons Mills,MA Owner: Darlene Scranton-Ashley Date of I IIsl'ee lit)II: September 28,2006 OUILDING SLWI"It(locale on site plan) Depth below glade: _ ttS't� _ Malc;,iah of coosti action: __cast iron -Z'!0 I'VC_--olber(explain): --- Dislance bunt private water supply well or suction line: Coninlenls(till c1ontlitiou ofjoirlls, venting, evidence of leakage,etc.): SE 1"FIC•1•ANIC: (locale on site plan) Depth below giade: 18--_ Material •:If cousinlctiun: _,/conciele--metal---libeigiass polyelhyleue olher(explaio)_ If lank is.ntetal list age: — Is age coufinued by it Cerlificalc of Collipliauce(yes or Ito):--(attach a copy of ceililicate) Dimensions: _-_ C��clo_1�K�_� �SOv�4Glo" Sludge ticplb:-----`L'' — --- ----- - --- Dislance front top of sludge to botloin of outlet Ice of baffle: Scion thickness: �J�t Distance Irons lop of scorn to till)ofoullet tee or battle: 6 Distance ?rtilll bollotll of sclllll Ill bollool tit oullct Ice of baffle. ly h flow were ttililcnsions delerluined: Collulieuls(till pumping recommendations, inlet and oullct lee of baffle coodilion, slrocluial inlegiity, liquid levels as ielaled Ill oullct iuvei(, evidence of leakage, etc.): _�L 7�t.�.—�f6��---'-`-a--.t.�LQ.r_>�%S9�-_._or_.+�±�v.-__L�C��_✓.._'u�.���—`----�--��G—u�c.r, ` of 1 (yltl!ASL`CItAI': _(locale on silt plan) Depth below gratl.e: _ Material of collstiuction: -_-_coucf0c;__metal_—fibeiglass _ 11yethylene _olhei (e x p l a l n): - ---------- ---—Di tile --- X, (L -- — Scoot thickness: -- Distance fionl lop of seutu to loll of oullle:Date of last pumping:Commenls(on pumping recornloendalioe nr baffle contlitiou, structural inlegrity, liquid levels as lelaled w nullel invert, evidence tit' aage, etc.): 7 . Page 8 of 11 Ul�li'ICIAI� XNSI'1i�C11ON I�()121V1 — N()'1' ��()1t VQi)..UN`l'AIiY ASSI?SSIVII?N`l'S SUBSORFACC SEWA(y1' 1)jS1'OSA1. SYS`1'Ery! INSPECTION 1�ORM 1'A 10' C SYSITM jNF'O11k1A`110N (continued) Properly Address. 452 Whistleberry Drive Marstons Mills,MA Owner: Darlene Scranton-Ashley Date of Luspeclion: September 28,2006 Tit-JI'1' nr I101.DING'1'ANIC. ___(lank iiiust be pumped at lime o1 In' ection)(locate on stte plan) Depth below grnlc: — - Malcrial of construction: —concrete_--metal_--Cibergla polyethylene other(explain): Dimensiuus: _ _ __ --- ---- --- Capacity: —-- — — — gallons Design Flow: Alar in jw:;sent(yes or Ito): _ Alain level: _ _ Alain io working tier(yes or no): .-- Date of I«st pumping:— _-- Coll iuieu..s(condition of itlarrn ant oal switclies, etc.): DISTRI1 UTION BOX: ✓ (if present must be opcned)(locale tin site plan) Depth of liquid level above outlet invert: _ Comments(note if box is level anti distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,Cie.): --8-_=icyy"-�-t-,-,-�1`��-�✓..^.c'—���/_._.�-�'---��_—`�-�t_��.._�_k..�--���—s..�-'rJ1._��mow!__ _ -.-��_�L.�!-K.t<_J7V��___OS1_�'Ls�f_-_..(.'/�1_�..�_-.-,.L'S�CSZ.v,.�_.__._.��-�f�_-_(�-..+✓..CiL�'✓5..--____ PUNIP C1IAIVIIlE R:___(locate on site plan) Pumps in woiking order(yes or no): _— Alarnis in working order(yes or no):—— Coiivaients(note condition of like ip chamber, condi ii of pumps and appurlenances, etc.): 8 • Page 9 of"1 I O1�!<�ICIAI lJNS)'I?C'!r'IIQN ��QI121y1 — N()'1' 1�()!t VOLUNTARY ASSE SM?NTS SOBSUR ACE SE WALE 0181,0SAI S'YS`CM INSPECTION +O12M SVS`ilTM I(NFORIVIATIION (continuc;l) Propu ly Address; 452 Whistleberry Drive Marstons Mills,MA Owner: Darlene Scranton-Ashley Date of Inspecliou: September 28,2006 SO11, ABSUItI'TUM SYSTCM (SAS): --,/ (luc;llc olisjlc IIIau, cxcayaljon uol lctlujrcd) II-SAS not locate;l explain why: Type -- leaching pits, ouulbei: leaching chambers, number: % (], r� 5��� 3Z _ leaching gallciies, m n�ber: --- leaching iicuchcs, ouo;hei, length: - -— leaching fichls, nuruber, dinlcnsions: --- --- - --overflow cesspool, nunlbci: --- -------- _ innovative/alternative system Type/name of'►echnology: _ -- --------- - Conitne1115(oole conlili.00 ofs.oil, signs ol'hydiaulic lailurc, lCvCl ofponding, damp soil, condition of vegelalion, S4h_ _c �-- ✓,.� CESSPOOLS: - (cesspool !oust be Ixouped as bait of iospectioo)(loc. c on silt phill) Nuniher and configuialioo: Depih-- lop of liquid to inICI invert. Depth ofso ids layer: — — Deplli of scum layci' -- - .._.__..-------- Dimensions of eesspool: __----- -- Malerials ofeonstinclioo: luilication:,f grounilwalei inflow(yes or i;o): _ ---- ---- Comitacnls(note condition of soil,signs of draulic f idule, level ofponding,co,ulilion of vegela(ion,etc.): PIOVY: __(locale oil silt:plan) Malerials o!f coustroclion: Dimensions: _ Delhi of solids: Comments(vole condition of'soil, signs ill'hydral e failure, level ofponding, condition of vegelalion, Page Ill Lit'I I OFFICIAL INSITCTION VORIVI — NOT FOR VOIAWIARY ASSESSMENTS SUBSUItFACI' SCVVACE' I�I VOSAI, SYS'I'CM INSPECTION I-i-OI2M JIAll' C SYSTEM INf'(VIVIATION (couliuued) 452 Whistleberry Drive Property Address: Marstons Mills,MA Darlene ScrL-nton-Ashley �)IV IkCI-I September 28,2006 Date of Inspecliou: SKETCH( II OIL SI!WAGE' DISI'(ISAI.SYS l FiVI Provide a sketch of the sewage disposal system including ties to at least two priniancul rcfercnce landmarks or bencluuarks. locate all wells within I00 feel. Locale where public Willer supply eaters [lie Imilding. wo- v j D : Z� ��.. 60 O Q Cl I-t = IL HZ ye . G H lot W1. ' P 1. Page I I of I I OH ICIAL, INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SLJBS )IZPACL� SEWACIP, DISPOSAL SYSTEM INSPE.CI'ION 14)iavI PART C SYSTEM INVORIVIATION (conlinuc(l) I'roperly Address: 452 Whistleberry Drive Marstons Mills,MA rtwnL1: Darlene Scranton-Ashley Dale of luspeclion: September 28,2006 SITE EXAM Slope ✓ Surface water Check celli:r ✓ Shallow WAS Islinialed depth to ground water Z�_,6 lecl Atliuslcrl high ground water clevalion2 y'I 'feet Please indicate(che(:k) all methods used to deleiniine the High ground water elevalion: 01)(aincd lions syslciu design plans oil record - 11 checked, dale ol'desigo plan reviewed: 7/z-/_56 Observcd site(ahultiug properly/observation hole within 150 leel of SAS) clkccked with local Board of IIeallh-explain: Checked Willi local excavalors, installers- (allacli ducuuiculaliou) �- Accessed 11S(;S dalahase explain: 50-..—_L y---3-___Z v,ti�_L3.._._. r/�. S, You umsl describe how you established the high ground avaler clevaliou: ----wµ�--�✓s.�__✓Lo E' .-=�--�•�___t!o Lu-t��-''--� h---'Lh�-.-�;.. �._._..5�✓s�wc.:fw ��✓.y G I a This report rl has been prepared and ilia system Inspected as of the dale of inspection. Tills report is not a warranty or guarantee that the system will (unction properly In the future. There leave been no warranties or guarantees, either expressed,writlen or Implied, relating 10 the system, the Inspection and/or this report. Il - IR ST FRONT ELEVATION it ELfVATioiy ..,. 9 ...... R/ HT [EFr nrwrtoms ?-YAP - Y W d-9 c i 7 ahet.t�� cJd.�� G 10 'T7Z c .. YO 't I �-I 9 .�„ • ;o.r .�, ._ Lmvl- SkC`Ir'/ t7 `� 1�5fa/r l<dnu� .r:.E.. o<t.,.,;.cs o� _.•ram =� = I i i i nr ry {,l/4 • � ��OOr TOWN OF BARNSTABLE 'FCa LOCATION J lV 401. SEWAGE # /f-51�?� \ p�: VILLAGE �C2'�5��.�.�l��s ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.��rY'dG� y��.�vr, 7 7/.JW� SEPTIC TANK CAPACITY ffo—o LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNS / �<Srle-51 { PERMTTDATE: `®/�Sf/�� COMPLIANCE DATE: o© ... Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r 'C Z,0-791, 6. 1' I ` &C K O o. 9 /— Is n 6 r FEE COMMONWEALTH OF MASSAC14USETTS co Board of Health, APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(v-�'Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location Owner's Name Ld "Map/Parcel# -3 6 Address Lot# L4 Telephone# 2 Installer's Name C Designer's Name Address Address Telephone# -7-7 ( � 1 3 Telephone# Type of Building no uua Lot Size sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow min.req.Vired) gpd Calculated design flow Design flow provided gpd Plan: D }e Number of sheets Revision ate ph*a�Pd Title Description of Soil(s) Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to' the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and urther agrees c sys em' operation until a Certificate of Com 'ance h been issued by the Board of Health. �^Signed Date ntA lzibL Inspections 0`4 .•. r _, #ice: ?, o r if FEE�V COMMONWEALTH OF MASSACHUSETTS ,� Board of Health, &ie-n S l l3 Lip MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct("rRepair((.) Upgrade( ) Abandon( - ❑Complete System ❑Individual Components f -LoGationaLOVU 'j "ho be Owner's Name fV F Map/Parcel# "Cl�& —3 6 9 Address Lot# 4(�, Telephone# / Installer's Name �g f To(C g4)' Designer's Name v L 1 h9 Address , Address [V^t Cl x 1l�(,.'�(�sj Telephone# -7 7 ( �) 3`-'7`) Telephone# Type of Building Q i� ! (t b �.k �Q Lot Size �T I gyp sq.ft. Dwelling-No.of Bedrooms 3 Garbage grinder (' ) Other-Type of Building `—�/ No.of persons Showers (),Cafeteria ( ) Other Fixtures f' Design Flow Imin.re,(q,. iQred) :)Q gpd Calculated design flow Design flow provided gpd Plan: Date r d �Numb.-er of sheets ,,.(�` (Revisionate Title ^ Description of Soil(s) f` Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation : C �.. DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees . t laascell system' operation until a Certificate of Com 'an e h i been issued by the Board of Health. Signedn ! Date '�''"� S t,nc� � 1 f/Inspections ' No. 1 — �' FEE C®MNlONWLALT Of MASSACHUSETTS Board of Health, �r� �/ _ , MA. CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System Tiw un,d signed hereby certify that the Sewage Disposal System; Constructed ( '),Repaired ( ),Upgraded ( ),Abandoned ( ) by: 6 6er ;- 60 r �0 E O at has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to _ application No. 9 -94 1 dated Approved Design Flow (gpd) / Installer 14 f9<� 1 1 Designer: Inspector• v /( / . Date. f it �t V 1 V ,/`` The issuance of this permit shall not be construed as a guarantee that the system will function as designed. ) Al No.� �/5—1 FEE 00 0 COMMONWEALTH OF MASSAC14 SETTS Board of Health, ,MA. ➢ ISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(L-<Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at Z (,kI S � _rrA as described in the application for Disposal System Construction Permit No; 5 dated F 1 H �7 Provided: Construction shall be completed within three years of the date of thispermit. All local conditions must be met. Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date*r Board of Health`"(� TOWN OF BARNSTABLE LOCATION '7 7 Z K/�j �/• SEWAGE # VILLAGE h'1l1'f 5y71r7j'/l�j��S ASSESSOR'S MAP & LOT LOTJQ& & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 600 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNE / A--5 e PERMUDATE: COMPLIANCE DATE: b o Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by.. OF p // / �� f NOW, THEREFORE, V 4,tDRJE,vE A 6SM4d4es hereby place the (owner's name) following restriction on his above-referenced land in accordance with his a grement.wWiAbe_.Town.a Heatth whiefh�-fest�ictioshait run with the land and be binding upon all.successors in title: K 7q 1. �S� GU isr�E�3 E k5 ro 105 Ki Lk-,5 may have constructed (address) I . upon the lot a house containing no more than;Tn! RFC L--3) bedrooms. S h1 L agrees that this shhll be.permanent deed (owners name) M A Os-To rU S H i f.I- S t restriction affecting E r located onysa wgisrLC_687-141Ke, //, V4 and being shown on the plan recorded in Plan Book JIV �, Paged _ S j Or on Land Court Plan For title of see the following deed: Book 123 9- Page 167 . Or Land Court Certificate of Title Number — Executed as .a sealed instrument D day of 6LiL ?001 Owner's signadure Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS ss 20 09 Then personally appeared the above-named known to me to,be the person who executed the foregoing instrument and acknowledged the same to be o-� free act and deed, before me, P Notary oa J _AS h s R � My commi�ssi(�o/nn expires: N ( Public qA 4 1;� om f or-e:clttl of Cu sachusetis (date) r bAGa"� My C'ofnmissio f Expires BARNSTABL E REGISTRY OF DEEDS Bk 22821 PS258 019122 ��•--1�-2�+�E: of 12 � 4�R DEED-RESTRICTION WHEREAS, of (owners name) V �rIcts MA �' �� �'� (Address) is.the owner of S G� ISfL- c located (address) at 6`J�9 D2 5 TD /t- S f`7/ C M 4, Y R— , MA(hereinafter referred to as and being shown on a plan entitled "Subdivision of Land in MA, Property of et al, duly recorded in Barnstable County Registry of Deeds in Plan Book 3 , Page ep" 3 ; Or on Land Court Plan Number A4 �Ys 6-LEY WHEREAS,)WRR y N, 69 N LeV Y 1/q k i,ew - as the-owner of said lot has (owners name) 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 as a pre-condition to obtaining a disposal works construction permit 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, as a pre-conditionlo granting a disposal works construction permit for a septic system in compliance With 310 CMR 15.200, 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 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, du* :X A REA PLA N,,,, PROFILE S YS TEM CALE., 30 ' S _41 FINISH GRADE A10 r ro scALE APPLrCA rXaV AV. )M-9187, -,AX Y �2. 1_999 'G4ADE - SLEW HARRXNerON BARAISUBLEMEALM MDT. , 0 FINISH SAADE FIA17SH 0.0 ER' RENCHES r-ilo OVER ,TANK OV �-r T', yp,�tj, 12�,q` TOP Fi AV TE& r I Nt�b X !"7 SCH 40 PVC .1. EL EVA 71WS BASED 'ON OWS OR 70W M j R ON S.177E A rE CA S T IRON I EES " ,ZOW &C .:. 1 57.34 3. 4- BSAf 7' F*L R r 00 GAL, EGUA L12ERS -ED REINFORC GAS DrS T.Box CONCRETE ' BA FFL E TO BE 'INS TA L L ED ON A LEVEL 'STABLE BASE, SEP rIC TA W LE H RENCH NGT TO BE INS TALLED ON A 1ME BEARIA06 DXSTAACE op X WOO 100 IN 25.00 LEVEL :STABLE BASE mIN.',HErGH 7' NO TE: DO VO r RUN HEA V Y EaurpmEN T 0 VER S YS TEM .,;.ABOVE''OBSERVED �':'�':GROUND,-!#A T LEACHING INFIL TPA TOP SECTION SOIL* ND,� -A T DA TA EASgXOVr NOT TO ,SCALE A PERCOL -ION kAftXCA TrZW AV. P FOR FINISH'GRA Dt LOT 45 SEE YS TEM'PROFILE MIN -1/8 -112 OE qA T E 20 SHED 'S TONE TA kEV'r (I P*AfIlv a Yr "SFX4X 'a. CW Y r r Tss. A re &AL Y 2. JAW DIA PIPE TEST PIT V-4111*T 7M'AXE MXEr I ''0 IVA TVPA L kr AFFFEC TI VE A A 'JOY kVY LaW R` sAmr,taw �,Yow'4* �IEP TH LOT, 46 31 11�2 amw x4m YR La4my WASHED S TONE SWO �16VR 44 EFFEC TI VE_ WID TH -ED SIDE; 10 1-jo EXCA VA 7 VA LL PEW'D A r 2 #14 :�to YR AwdJaw-cm-sip #and 4'-0' 4'--�O TAf L ESS 2Xq1_ c TRENCHES om 4 NUMBER OF sand SAAV JOYR Z 4 INFIL TRA TORS NUMBE R OF : DESIGN�,,DA 7*A GALS. ' DR, Oms. MENA LL AEA --. 74 GAL�51 :5F .'OF-BE 90' 71 S. S1' AID yp L :DrSPOSA 346 'S. F. BOTTOM AREA . 7-4 GA L SISF GA L S.. Y &FL UEV T OA ES T. To 7' AL P TIC TA NK, I" AL �SE 517 AL_ A 'GA L SISF 382 GALS.' � S. Fi T6T :_ARE 7w 1 OENERA L NO rIlEs #A 7M A10 TE.' IN I ALL S YS TEM COMPONEIV TS !�HA L L 8b TH TI T� A CCOR0,4 OF:�,THE S TA TE AftIARYI lip 4 I NCE,,'WI 0_00X EXCA VA TE TO OR L ONER A S REOUIRED .0 ELEv. 51 D MARCH 1995 AND .ANY LOCAL 'ROLES A- DA TE 0 / TO REMOVE ALL LOAM AND CLAY CONWAUNG 0 HA TERrA L BEA1EA TH THE L EA cHrNG AREA EPL A CE 2. ,AI\IY CHANGE.�IAI ,,THIS PLAN ,MUST 'BE A PFR6 IIED 0 EXCA VA TED NA TERIA L WITH CLtAN, CLAY FREE GRA VEL 8 Y ' THE BOA PDr 'OF HEA L TH r r -FERQEI AND A Ci. 15W RAL MECHANICALL Y COMPACTED IN PL A CE PRIOR -;BA FILLING s9)mTXc rioly C6MPL E TED, C 3. wHEA1 coNsrpuc ',,rs 7AW �TAJSPEC WOTIFY BOARD' 0Fr FO TION HEAL TH V. MU.!�T, BE CHECKED 4. FND. EL E COMPLETED' 5., THESE ELE V.'MUS T r PROPOSM LEACRIM NOT.�BE.o CHANGED WIT ramov Iam f4) LEGEND. 90A RD OF HEAL TH bWrL"M 7VW #1r7N HE A PPRO VA L, UL AR~ WHEN 4* ZFVW A-job x S, jwl 101 .6. BOARD OF A L TP, INSPEC rlcf/v,:REO D �EXCA 7 EXIS T-GROUND,EL E V. FINISH GROUND EL EV. SYSTEM.;�PLAN,­ SEWAGE - DISPOSAL" VER PIPE IN T tL E V.. 0) PREPAED:r FOR L OCA rroAl' rEsr Pr7 RIC W -ASHLEY ' HAROLD,' SEPTIC 'TA .179.80 13 ­46 HIS TL EBERR Y DRI VE Al 7.9 42'36 k/ DIS TRICU rr01V BOX LOT E4 4"C.I.OR SCH 40 ,PVC �MA SS BA RNS TA BLE, V"k OF S? 47BIr.F18ER PIPE-TIGHT OIN TS LOT,,52 GE-RGE gM SCRUTON 'FROPERTe LrXES DESrGIVED DA No 1�4�7 FtAREIRA �'A SSO&'I TES TBACK DtS;rAjVCE 5E DRA WN SCALE-AS BARS.,ROAD 62� 46 452 ALMOU 050em 14SE CHECKED.AIAP-, SEC'� PCL"" L07 1 0 0 7