HomeMy WebLinkAbout0460 WHISTLEBERRY DRIVE - Health (2) 460 WHISTLEBERRY DRIVE
Marstons Mills
A= 062 -053 - — - - - - --- - -
TOWN OF BARNSTABLE
LOCATION 460 W iM-I b,=%SEWAGE# JQ 3,..
VILLAGE h''. I`'(_ ASSESSOR'S MAP&PARCEL �.
INSTALLER'S NAME&PHONE NO. 0
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size), X a e �
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: 3
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility $— Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) 9.[ Feet
FURNISHED BY mfd 61t
I�RIo�re
O
ss 6°
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in compu er:
/ Yes
O PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplitatlon for Disposal 6pstrut Construction VPrtnit
Application for a Permit to Construct( ) Repair/Upgrade( ) Abandon( ) ❑Complete System eindi,idual Components
Location Address or Lot No. Y&O i !y' , Owner's Name,Address,and Tel.No.6_0$-r290-quo Flo
Assessor's Map/Map/Parcel &1/5_3 7_e.rr1 O'Shea, {Qo-(�0--b9S
r
Installer's Name,Address,and Tel.No. - - Designer' Name,Address,and Tel.No. 5 08- G -ZjSy/
Type of Building:
f-
Dwelling No.of Bedrooms -3 Lot Size Y40 /QL 1 - sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(_min.required) � gpd Design flow provided_ ��� gpd
Plan Date A4,1ICh /;9 pT 'ZD j 9 Number of sheets f Revision Date
Title 'T,�1 s� �; p/air -I q&o ",gdo� rru r l'
Size of Septic Tank>uXj��i rle imp :&n�C Type of S.A.S.a 6410)L6-Mq«C -;Ls
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Co nd n o place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
ed Date
Application Approved by i Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
- i No. Fee, I a
THE COMMONWEALTH OF MASSACHUSETTS Entered in com u er: ,
/ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes r
O4plitation for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(t/j Upgrade( ) Abandon( ) ❑Complete System ,Zlndividual Components
Location Address or Lot No. Cj(PU W 11 i S.qeLer j`I . Owner's Name,Address,and Tel.No.,5 U8_r'f 90-q(,F&
-Terri
Assessor'sMap/Parcel (,1 5-3 t�tLifS�Ul1S i�i�ilS D�Sf1PA �o (3ax'�9S
Installer's Name,Address,and Tel.No. ,IFS—W 9- $9 a(o Designer's Name,Address,Iand Tel.No.
1?br �ott�Ctvn�{Svc-l-�on;gar �('S'ZndusF�-J/� , OW) rc� �r� :n��riry�,�i�r. 9.0 it-la � 5�
41. / -
Type of Building: C/ i
DwellingNo.of Bedrooms Lot Size f
3 y� ��� - sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �3 � gpd Design flow provided_S y 9 gpd
Plan Date /2 ,, p (� Number of sheets,, ! Revision Date q
Title s . Ie P,Il 7 6'� c T�t t ( r l^ /1 l •1✓ f ,G :fl� �l'��t
Size of Septic Tank )�M, �� �,.r�� Type of S.A.S.;
Description of Soil
ti
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: `~
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code rfd not b place the system in operation until a Certificate of
Compliance has been issued by this Board of Health. n
e J r/C` Date .' f _
Application Approved by Jh (A '
/ /� Date
9 v
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
v r j
THE COMMONWEALTH OF MASSACHUSETTS µ �
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( .)'f Upgraded
(n� ( )
Abandoned( )by f"f%r' � E 7� t-
at 1(P U has been coast cte/d' accord ce Q- j
with the provisions of Title 5 and the for D1 isposal System Construction Permit No. .
/� v /
Installer l'Yir ' e Z�G ! Designer 0. jr,,
#bedrooms Approved design flow ;l gpd
The issuance of this permit hall not be construed as a guarantee that the system wil Efuncti i as designed.
Date InspectorC� , 0
--- --------- - --------------------------------------------------------------------------------------------------------- �
No. I Fee
8THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon
S ( )
stem located at ( j i y . i .�/�; n.��i. a r tlJf
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/compt6ted within three years of the date of this permit A
Date / Approved by
PP
I _
027-2019 05:41 From: To:15087906304 Page:1/1
Town of Barnstable
rnstabale
Replatory Services
Thomas F.Gdler,Director
]Public]f[eaitth DivisiOu
n °e Thomas McJKem,Director
Zoo Maim Street,Hyauuiis,MAC 02601
Office: 508-8624644 Far 508-790-6304
bstaHer&Desigger Certificatiora Forme.
➢ate: Z sewage]Permit'# -- 1 Aasessop's 1V�aplPcel (02 53
Designer: DOWN Ne, GAIN=h]6 hastoler. *QV1-bM COWWITM
Address: CIE MAI ,!rr t1l�l Address: . �► �5 ri�1�M f D
IWAo11IIt Mal. MA �Pl� t�tlu.��J 0?lo�fl
On 3 a-e /`� �br as issued a permit to install a
•(date) mst er
septic system at 40 WNIVL996UVkK,, MAgUNilloasedonadesigadrawubY
(a ss
t: dated_ MARCH �aiALA lo ZD_ (q
•(dedgaef) —
_j/_ X certify that the septic system referenced above was installed substan.tially according to
the destgu,which may-include ruinor approved chmgea such as lateral relocation of the
distribution bog and/or septic taus.
T cer fy that the septic system referenced above was installed with major changes (ie.
• greater than 10'lateral relocation of the SAS or any vertical relocation of any componet
of the septic system)but in accordance with State &Local Regulations. Pfau revision or
Ze
as- ' designer to follow-
. � OF
DANICLA
OJALA �
e) " CIVIL N
No.46502
0' QI 5 T eR�O����
ss/OIVAL ECG
esigner's Signataze ( es�gner's Stamp Here)
pPIXMM M URNLTO 13ARN E MB]LXC HEALTH ]D][ 20N. QZRTIFTCM OF
CoMMXAMCM VM,,IL NoT gg IMM UNM BOMTM FORM AMAS-' ARE
Rta gryM AT ZBM RARNSTAWM gPMjCAX. DIVTSIOPI. IVANK YOU.
Q:Healtb/sp-pde/ caper Cerdficationporm 3-26-04.doc '
Town of Barnstable P# l 5 qC6
oFT�
�y` o Department of Regulatory Services -11
tri
trI
_ : BARNSfABLE, Public Health Division Date
y MASS. ,.
i639• `0� 200 Main Street,Hyannis MA 02601 4�z�
oDate Scheduled 5h� � Time Fee Pd. `Q�•�� .-�,
Soil Suitability Assessment for Sqmale Disposal 85
Performed By: ��i!.t- ' •,� ��C[�c-i Witnessed By: PC.
4 !L .CATION;&. : ENERAL-INFQRMATI0N
vocation Address d�0 w�)46 r Owner's Name O
� �W
f.l�.P -
Assessor's Map/Parcel: (0 53 s Eng ineer' rJ-0
e
2
NEW CONSTRUCTION REPAIR `/ Telephone
l
Land Use es, I&I Slopes(%) J/d 1��� Surface Stones
Distances from: Open Water Body
/��G-ft Possible Wet Area�_ft Drinking Water Well GP) ft
Drainage Way ft Property Line ft Other 1 ft
SKETCH:(stre name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
;;4 �'-
-r 6O
V
Parent material(geologic) 41 d� � 'J Depth to Bedrock
Depth to Groundwater: Standing Water in Hole: IV(Y�✓t� Weeping from Pit Face
Estimated Seasonal High Groundwater r
DETERMINATIONYOR SEASONAL HIGH WATER TABLE
Method Used:
�11-
Depth Observea standing in obs.hole: in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft.
V Index Well# Reading Date:_. Index Well level Adi,factor Adj.Groundwater Level_ __ -
PERCOLATION.TEST. Date Time
Observation �J
He le# .y Time at 9"
Depth of of Perc ,�_ Time at 6"
Start Pre-soak Time @ fU Time(9"-6")
En3 Pre-soak - w
Rase Min./Inch wN 4 !�✓1
Site Suitability Assessment: Site Passed Site.Failed: Additional Testing Needed(Y/N)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
***If percolation test is to be conducted within 100' of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC
DEEP OBSERVATION HOLE LOG Hole#.= —
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Mansell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
loyv
11Z �'_ A/Gs 10/R w
DEEP OBSERVATION HOLE LOG'
Depth from Soil Horizon Soil Texture Soil Color 'Soil` Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
7
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
Flood Insurance Rate Man: /
Above 500 year flood boundary No Yes ✓
Within 500 year boundary No V_/ Yes
Within 100 year flood boundary IQo V/ Yes
Death of Naturally Occurriny-Pervious Material
Does at least four feet of naturally occurring pervioo material exist in all areas observed throughout the
area proposed for the soil absorption system? k 'S
If not,what is the depth of naturally occurring pervious material?
Certification 0-1
I certify that on Z« (date)I have passed the soil evaluator examination approved by the
Department of Envi'onmental Protection,and that the above analysis was performed by me consistent with
the required training,expertise and experience described in 310 CMR 15.017.
t
Date 3 ,
Signature
Q:\SEPTIC\PERCFORM.DOC
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cO Certified Mail Fee
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$ t \aypN�. yam.
Extra Services&Fees(check box add tee as prate
r-1 El Return Receipt(hardcopy) $
C3 ❑Return Receipt(electronic) $' 0.,•, ,�- t,
0 ❑Certified Mall Restricted Delivery $-
[:]Adult Signature Required $
O ❑Adult Signature Restricted:Delivery$
O Postage
Total Postage and F s
O SHEA, TERENCE As&'LAURIE T �>'
� sent to PO BOX 695
o St�eetendApi ivo.; WEST BARNSTABLE, MA 02668
Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail label). for an electronic return receipt,see a retail
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for gpcified period. ►K ry` delivery to the addressee specified by name,or
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ntReminders, H' -Adult signature service,which requires the r37i
may purchase Certified Mail service with Iit signee to be at least 21 years of age(not U
Class Mail®First-Class Package Service®, available it retail).
Priority Mail®se,e: t gv1 -Adult signature restricted delivery service,which
rifled Mail serviali notavailable for O" requires the signee to be at least 21 years of age,
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riffled Mail service:However,the purjr (not available at retail). _
o d Mail service does not changrt�i' ■To ensure that your Certified Mail receipt is
in automatically included. accepted as legal proof of mailing,it should bear a.]
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of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply w-,
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.C t
electronic version.For a hardcopy return receipt, l(
complete PS Form 3811,Domestic Retum
Receipt;attach PS Form 3811 to your mailpiece; IMPORTANT:Save this receipt for your records.
Ps Form 3800,April 2015(Reverse)PSN 7530-02-000-9047
■ Complete items 1,2,and 3. A. sig lure _
■ Print your name and address on the reverse ❑Agent
so that we can return the card to you. Addressee
0 Attach this card to the back of the mailpiece, e• Received by(Printed N e) C. to of elivery
or on the front if space permits. _4z ldl
1. Ar D. Is delivery address different from item 19 ❑Ye
If YES,enter delivery address below: ❑No
Q'SM€ TERENCE A&LAURIF T
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'- PO BOX 695
-�tl. EST BARNSTABLE, MA 02668
II I IIII�I IIII(�I I II II I I III II I I I I I�I ,I 3. Service Type ❑Priority Mail Express®
❑Adult Signature El Registered MaiITM
❑Adult;Signature Restricted Delivery ❑Registered Mail Restricted
9590 9402 4798 8344 8587 63 9�Certified Mal® Delivery
d Certified Mail Restricted Delivery eturn Receipt for
❑Collect on Delivery Merchandise
❑Collect on Delivery Restricted Delivery Signature ConfirmationTM
o—n.�7,.]n_n4ic„F,cr_rCransfer from_service_IabeD - ._.—..__..il ❑Signature Confirmation
7 015 1730 01101 4987 9545 iil Restricted Delivery Restricted Delivery
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PS Form 3811,July 2015 PSN7530-02-000-9053 Domestic Return Receipt
USPS TRACKING#
First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10
9590 9402 4798 8344 8587 .63
United States F
Sender:Please print your name,address,and ZIP+4®in this box°
Postal Service
Town of Barnstable
Health Division
200 Main Street
Hyannis,MA 02601
I
Town of Barnstable Barnstable
Inspectional Services °" caC'
ty
HARNSTABLE,
MAS& Public Health Division
prFO��s 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508.790-6304
CERTIFIED MAIL#7015 1730 0001 4987 9545
March 5, 2019
O'SHEA, TERENCE A & LAURIE T
PO BOX 695
WEST BARNSTABLE, MA 02668
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 460 Whistleberry Drive, Marstons Mills, MA was
inspected on 01/29/2019 by Frank Nunes III, certified Title V Septic Inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Backup of sewage into the house due to an overloaded or clogged SAS or
cesspool.
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Th , R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\460 Whistleberry Drive Marstons
Mills.doc
oF�
Town of Barnstable
�� 3AHN8fABLE, •. 1"9.�, ' Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1)YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2)YEAR DEADLINE CRITERIA
❑ Single Cesspool
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
-U
Q:\S:EPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M . 460 Whistleberry Dr. {
Property Address
O'Shea
Owner information Owner's Name '
is required for every page. Marstons Mills V/ MA 02648 1/29/19
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 64 /3Cel(O
1. Inspector:
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
Citylrown State Zip Code
508.272.6433 13010
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
1/29/19
InspecWs 81gfigt 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 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
everypage.for Marstons Mills MA 02648 1/29/19
every g
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owners Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM , 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—1WPA)or a mapped Zone 11 of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Engineered plans were not availble at BOH
Number of current residents: 3
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: Occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
460 Whistleberry Dr.
Property Address
O'Shea
Owner informawn Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: No recent pumping per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1985 per compliance
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: >10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
6"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
H-10 tank appears to be structurally sound
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500g
Sludge depth: undetermined
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle n/a
Scum thickness trace-1/2"
>211
Distance from top of scum to top of outlet tee or baffle
�2
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
lug
460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Poly d-box is 2' below grade, cement cover to 3"of grade
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
l
Commonwealth of Massachusetts
ROM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M s 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for
a every page. Marstons Mills MA 02648 1/29/19
Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit is full beyond its leaching capacity, effluent level is above the last row of leaching holes, pit
is 2'6" below grade, no riser
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I�
Commonwealth of Massachusetts
Title 5' Official Inspection Form
el Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , Y 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
Citylrown 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
A �
" r
Q 3S� as
I � \v S�s�
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>12'
Estimated depth to high ground water: 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:
No engineering on file
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
TOPO mapping puts the site at 80'msl and nearby surface water is at 40' msl
You must describe how you established the high ground water elevation:
See above
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 460 Whistleberry Dr.
Property Address
O'Shea
Owner information Owner's Name
is required for every page. Marstons Mills MA 02648 1/29/19
CityrFown 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
L_
L E G E N D SYSTEM DESIGN: SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES
MARKED WITH MAGNETIC TAPE OR
COMPARABLE MEANS FOR FUTURE LOCATION. o
gg PROVIDE MIN. 20" DIAM. WATERTIGHT (NOT TO SCALE) 1. DATUM IS NAVD 88 '",r
EXISTING CONTOUR Q
GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE �9a (D2" PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING ��
X 99•1 EXIST. SPOT ELEV. TOP FOUND. EL. 83.1 FILTER FABRIC OVER STONE
�a
EXISTING 3 BEDROOM DWELLING 2% SLOPE REQUIRED OVER SYSTEM 78.8'— . 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. \� Mystic Lake
—[991— PROPOSED CONTOUR 82.3 MINIMUM .75' OF 775 COVER OVER PRECAST a
(ga 4 DESIGN FLOW: 3 BEDROOMS @ 110 GPI = 330 GPD NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS 0
] PROPOSED SPOT EL. PRECAST H-to THICKNESS REQUIRED BLOCKS OR TO BE AASHO H-LQ
TH1 USE A 330 GPD DESIGN FLOW RISERS (TYP.) 4"0SCH40 PVC MORTAR ALL PRECAST RISERS
, = 2'0 6" MIN. SUMP
TEST HOLE ,.: 12" MIN. INT. DIM. PIPES LEVEL 1ST 2' FENDS
4' COMPONENTS 5. PIPE JOINTS TO BE MADE WATERTIGHT.
: � . . .SEPTIC TANK: 330 GPD (2) = 660 INSTALL TEE SIDES 75.83' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH j
,a E y. ➢o�oI....
,o e o a o•o•0 0 11 310 CMR 15.000 (TITLE 5.)
2% SLOPE OF GROUND to" 14" ° >" XISTING TEE �I�®En ElMM® —U®®� 'EXISTING TEE *802t ° ° ° ° °**RE—USE EXISTING 1500 GAL. SEPTIC TANK SEPTIC TANK °°° ®®®®®®®®®®� ���®�®®®�®® >°°°°°°°° Middle
UTILITY POLE o ° O ° ° ° ° ° ° °GAS BPIFFLE °o°o°o°o°o°o, WATERTEST D BOX o °o i o 0 0 0 °o°o°o°0 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
LEACHING: CV ;°°° ®®�®®®®®®�� ®�®�oao®®a ;°°°°°°°°FOR LEVELNESS ° ��®®�®����� ®®®®®®®®®®® °°°°°° LocusBE USED FOR LOT LINE STAKING OR ANY OTHER Pond
FIRE HYDRANT 75.Z7' 75.10' ° °°°°°° °°°° °°°°°°°° 73.0 PURPOSE.
Y SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD - ` ' $. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING '%: '` c`o Hamblin
BOTTOM 25 X 12.83 (.74) = 237 GPD 3/4" H-10 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL.-1-1/2" DOUBLE WASHED STONE 4 MIN. a � Pond
(2) UNITS REQUIRED 9. COMPONENTS. NOT TO BE BACKFILLED OR CONCEALED
ALL AROUND PRECAST STRUCTURES WITHOUT INSPECTION BY BOARD OF HEALTH AND
TOTAL: 472 S.F. 349 GPD 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: -25.00' X 12.83'
*THE INSTALLER SHALL VERIFY THE LOCATIONS PERMISSION OBTAINED FROM BOARD OF HEALTH. o
COMPACTION. (15.221 [2]) 00
OF ALL UTILITIES AND ALL BUILDING SEWER USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) OUTLETS AND ELEVATIONS PRIOR TO INSTALLING 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
DIGSAFE
WITH 4' STONE ALL AROUND ANY PORTION OF SEPTIC SYSTEM (1-888-344-7233) AND VERIFYING THE
LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES LOCUS MAP
**INSTALLER SHALL CONFIRM MINIMUM SEPTIC TANK SIZE AT PRIOR TO COMMENCEMENT OF WORK.
1500 GALLONS AND ITS SUITABILITY FOR RE-USE. REPLACE 67.2' BOTTOM TH-1 SCALE 1"=2000'f
WITH 1500 GALLON SEPTIC TANK APPROPRIATE TO SITE NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
CONDITIONS IF NOT SUITABLE REMOVED BENEATH AND 5' AROUND THE PROPOSED ASSESSORS MAP 62 PARCEL 53
LEACHING FACILITY.
MA ( 9 5 % SLOPE) ( 1 % SLOPE) 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND LOCUS IS WITHIN FEMA FLOOD ZONE X
APPROVED DATE BOARD OF HEALTH REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. (AREA OF MINIMAL FLOOD HAZARD) AS
LEACHING SHOWN ON COMMUNITY PANEL 25001 CO541 J
FOUNDATION— EXISTING SEPTIC TANK 52' D' BOX 12' #
FACILITY DATED 7/16/2014
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down cape engineering Inc
civil engineers
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\ \ // 939 Main Street ( Rte 6A)
DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675
DCE # 19-034
19-034 BORTO-O'SHEA.DWG