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0538 WHISTLEBERRY DRIVE - Health
538 WHISTLEBERRYr� A=061-052 - J TOWN OF BARNSTABLE -LOCATION Lo- t0 a km e- wh�'sflebCr�y SEWAGE# 98 '3/8 VILLAGE Ma.r"s-Lns JW05 ASSESSOR'S MAP& LOTQj /-0���- INSTALLER'S NAME&PHONE NO. Joe ck y e u SEPTIC TANK CAPACITY 5 0 0 q a o h LEACHING FACILITY: (type) (size)3a`� X /01/6"W - d' a�e eP heh NO.OF BEDROOMS % BUILDER OR OWNER S CO &W'lanal a TT d o-F s fone�vrs PERMITDATE: �Y / / 9 COMPLIANCE DATE: ®' 9, 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 ASI =aa' A5 A = 50' i BA 23 ' ' F�-a Y.r Or .. � xa i�Y s e --3h.l.�a+ .✓•..n�v. . - s .� - ' B4 =37 ` 85 - qlo 87=37 ' TOWN OF BARNSTnnABLE LOCH"r'lON �3g (,J{�l Sl2LeLr�j I`� SEWAGE # VILLAGE 11r1 .. .,,,,,,��S ASSESSOR'S MAP & LOT Ow 0fa-- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY SUU LEACHING FACILITY: (type)' 1At,Yrp ,l (size) SVAC NO. OF BEDROOMS BUILDER OR OWNER_ i-f-0 S�e�/�nZ1q PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of aching facility) Feet Furnished by L- 'Zi1�Ocq 10n �O/� AI- a3:(0 AA 31 ' Q,q 10 � `Q Qa- a3 I�tck_�- . . 02 133- 4 3 } n�-O COMMONWEALTH OF MASSACHUSETTS ' U- O� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ' U/ DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 538 Whistleberry Drive FREvMarston Mills, MA 02648 Owner's Name: Leo Speranza 2 0 Q 1 Owner's Address: Same TOWN OF-BARNSTABLE Date of Inspection: September 5, 2001 HEALTH DEPT, Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford Mailing Address: .P.O. Boz 49 4 Osteryille.MA 02655-0049 ' `-• �i-" ''Parcel:052 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: September 6, 2001 The system inspector shall sub 4acopyy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing.this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority: - T Notes and Comments ****This report only describes conditioat -on escri ns lithe time of inspection and under the conditions of use at that .;time. This inspection does notjaddress how the system will.perform in the future under-the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,CERTIFICATION (continued) Property Address: 538 Whistleberry Drive Marston Mills. Owner: Leo Speranza ti Date of Inspection: September 5, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes:` ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):h broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 538 "istleberry Drive- Marstons Mills. MA Owner: Leo Speranza Date of Inspection: September 5, 2001 -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 System will fail unless the Board of Health(and Public Water Sapplieki4f,any)determines that the system is functioning in a manner that protects the public health,safety and environment: _i _ '_`_ •3 \ ..°° .`_ f.'._� .t.. .. ,_ J~ ..'G..�.z, _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.' The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for.coliform. bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 _ Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM : .: . .: PART A CERTIFICATION (continued) Property Address: 538 Whistleberry Drive '- Marston Mills MA Owner: Leo Speranza Date of Inspection; September 5, 2001 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS'or cxsspooi' ✓ 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 '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or'privy is within a Zone 1 of a public well. _ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy'is less than 100'feet butt'greater than 50 feet from..a private mater supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia ' nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E.. Large{System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B Property Address: 538 Whistleberry Drive r" ,•} :', ;r ,,; ,,•.. Marston Mills, MA Owner: Leo Speranza "- Date of Inspection: September 5, 2001 < 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 facilityor.dwelling inspected for signs of sewage back up?;(The owner was not home) r.;.;<.✓ _r r Was the_site_inspected,for,signs. break out ✓ ,__� Were all system components,excluding the SAS,located on site? 1 ✓ 71 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? I ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? ?'he see and:Iocation of the Soil Absorption.System(SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. `"`-' ,2 ;it i-c "�.ii:'.C,=<.a. :: ...L ..�".'... t. . . ... .�"'t.. 1T"V.. h ti ,.�.. 'f'<_11[_ 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �L •` ' W ""' •+�$SYSTEM INFORMATION Property Address. 538 "istleberry Drive_ Marston Mills, MA Owner: Leo Speranza Date of Inspection: September 5, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): : Yes Is laundry on.a separate sewage system_ (yes or no) No _-[if yes separate inspection required] Laundry system inspected(yes or no): Noµ Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2000-128,000 gals.;2000-207,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALIMUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_. . gpd. Basis of design flow(se afs/persons/sgft,etc):-';�' #£ `�' '' - •. Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no):.. Water meter readings,if available: h� Last date of occupancy/use: OTHER(describe): ' GENERAL INFORMATION Pumping Records Source of information: Pumped in 2000-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: gallons--How was quantity pumped determined? "Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool , Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach•a copy of the current operation and maintenance contract(to be obtained from system owner) Tight_Tank Attach a copy of the DEP approval _. I Other(describe): .�; t 7 i 7�:._?.ilft.x Is.-r i 1R f.. :r,T "i";r;: ! ;�Z , --Approximaie age of all components,date installed(if known)and source of.information: . _. -August 3 1998--per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 I Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ",!,"'=-`SYSTEMIINFORMATION (continued) Property Address: 538 nistleberry Drive f j `,,,n^�3 Marstons Mills, MA Owner: Leo Speranza _ _"a T^ .-� • . Date of Inspection: September 5, 2001 _ BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron ✓ 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 20" Material of construction: ✓ concrete metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): - (attach a copy-of certificate) Dimensions: 1500 gal. ., , `s, -.,r .. ;.f�,s 9 , Sludge depth: 1„ �., .T.,. Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tees were present The liquid level was even with the outlet invert. There were no signs of leakage. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: , Distance from top of scum to top of outlet tee or baffle: . `...�. .✓i :`pit- •.3 lt��i• �_ Distance from bottom of scum to bottom of outlet tee or`baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid-levels as related to outlet invert,evideace of leakage,etc:): 7 h_ Page 8 of l l ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM i"J i":.1 PART C SYSTEMYINFORMATION (continued) Property Address: 538 "istleberry Drive— Marston Mills, MA Owner: Leo Speranza Date of InsPe A Inspection: September 5 2001 ° r TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal ` fiberglass _polyethylene _other(explain): Dimensions Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): . ''.,xi ... ... .� !i, ..?dA? �.s .•�`.i(..;f,l: ..,.+.rZ..�•S.Y J �..�.. 'f`. r ,t ..� � _. �}„ ._ .. i i ..d ...lrv' ---�`- ' DISTRIBUTION BOX: ✓ -(if present'-must be'opened)`(locafeon site'plan)n Depth of liquid level above outlet invert: Even y 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.): The D-box was level There were no sign of solids or leakage Speed levelers were present. There were no sign of failure or back-up from the leach field PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): . . Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t;•;; �.t{„ 1 -SYSTEWINFORMATION (continued) Property Address: 538 Whistleberry Drive ,_ u ,: Marston Mills. MA t Owner: Leo Speranza Date of Inspection: September 5, 2001 N SYSTEM(SAS): ✓ (locate on site plan excavation not required) ' SOIL ABSORPTION ( ) (1 plan, If SAS not located explain why: Type leaching pits,number: leaching chambers,number: leaching galleries,number: ✓ leaching trenches,number, length: 4 infiltrators with 4'stone(32'L x 10'10"W x 2'D) leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative stem T e/name of technolo - - Comments(note condition of soil,signs of hydraulic failure,level of ponding;damp soil,condition of vegetation etc.): The infiltrators were not duQ up,• ,There were.no siQns.of-failure.in the&box. The bottom-to Qrade.was approximately 5'. s�• _ ,_. :tip-. ._ . ^�:. ��i :. �' CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)^ . Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �' PART C --'r,'1 f 'SYSTEM4NFORMA'TION (continued) Property Address: 538 Whistleberry Drive... . Marstons Mills, MA_ Owner: Leo Speranza ------------ Date of Inspection: September 5, 2001 - Map: 061 Parcel. 052 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. 'Locate all wells within 100 feet. Locate where public water supply enters the building. Aa— a3:c� Aa- 31 QA to `Q o 133- 0rc — ' y _ ' 3 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO_ N FORM _ PART C ;t-. =o;;, `SYSTEM'INFORMATION (continued) Pro Address: 538 Whistleberry Drive .; Pew' __. ___._. _ ' s .. � `. .. _._._ :c.�->•aa{', r... :r Marston Mills. 'w Owner: Leo Speranza Date of Inspection: September 5, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20' +/- feet (Ar justed High Ground Water Level is 14.3) Please indicate(check)all methods used to determine the high ground water elevation: ✓ Obtained from system design plans on record-If checked, date of design plan reviewed: 8198 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-.-),' The bottom of the leach field to grade was approximately 5: A test hole was done'when installed, and no water was observed at 101. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 20'+/-to groundwater at this site. Using the Cape Cod Commission Technical.Bulletin the high ground water adjustment for this site(SDW 253.Zone C, 8101)was 5.7'. This report has been prepared and the system inspected and passed as of the date of inspection. This report is , not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. I1 K IGA� �i41� sO I y. 3 / ��i � 6iav�caw�Tei �evc, 9 I �� 56W as3 c to � ,q��usTMc a0.0 G�avhc�w�a`�ci �cv,c n o. A � � %4/ FEE COMMONWEALTH OFMASSAC14USEITS Board of Health, A el) TA 1 MA. PARCEL NO: D APPLICATION FOP DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct(y"Repair( ) Upgrade( ) Abandon( ) - ❑Complete System ❑Individual Components Location �38 W ( Owner's Name F} Map/Parcel# 4 W - G.? 7- Address Lot# �-2.. U. Telephone# Installer's Name -7 Designer's Name �� exfieS Address Address 13, SP r Telephone# �--- �� Telephone# 608 D - Type of Building i Yl�-tl 1 ► X\A i 1A 1�s7) ,i 1 [� Lot Size J� Q sq.ft. Dwelling-No.of Bedrooms Garbage grinder ( ) Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 3310 gpd Calculated design flow Design flow provided 38--7- gpd Plan: Date Number of sheets I Revision Date Title 5a) 6 k -Si SEC y 66A.2 akED S nzi9�q4 Description of Soil(s) Soil Evaluator Form No. G]f 4 Name of Soil EvaluatorJF PA Date of Evaluation "A-Y 7j DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agre the bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further a s t o pla a syste in operation until a Certificate of Yo�mpli c: been issued by the Board of Health. Signed Date v 913 No. / - -- - - - - - - - FEE. COMMONWEALTH Of MASSACHUSETTS Board of Health, MA. CERTIFICATE ®F COMPLIANCE Description of Work: ❑Individual Component(s) 'Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ),Upgraded ( ),Abandoned ( ) by: at �IJ!1!' s has been installe in accordance with the prqyisionrof 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. "°II A , dated ". �" pproved Design Flow (gpd) Installer (� Designer: * Inspector: Date: r T The issuance of this permit shall not be constru d as a guarantee thaqhe system will function as designed. No. / e,7/e T✓`- FEE/ Board of Health, jj STA P,1,.F` MA. APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT, Application for a Permit to Construct(-I'Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location 5315 WH iS T G-ppQ 12. Owner's Name LeD S E R O Z..fc Map/Parcel# a 61 45 Z Address Lot# (0 2 Telephone# Installer's Name Designer' Name ,k g F�c�eE��� ssoclafies Address J Address`'3i Telephone# -- Telephone# Type of Building )n(-ni E 1 nm 1�,t i 1,J �j G CL)1►.l G. Lot Size 45,08 sq.ft. Dwelling-Np.of Bedrooms 3 Garbage grinder ( Other-Type of Building No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow(min.required) 3 O gpd Calculated design flow Design flow provided J0 6r� -- gpd Plan: Date ML(o, )q 9 a Number of sheets Revision Date Title Eu)�a6 )jSR0s iL a .SWA �'40 PFP,-2REO rQ,e �� SMER nfr�� Description of Soil(s) 5� �-- Soil Evaluator Form No. P 9114 Z. Name of Soil Evaluator Qll)(� Date oaf Evaluation M)'y -7 DESCRIPTION OF REPAIRS OR ALTERATIONS•_ The undersigned agree the bove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further es t o o pla etsyste in operation until a Cirtificate of omplia been_issued by the Board of Health. _ Signed 1 Date No. ? FEE/ ./o COMMONWEALTH OF MASSACHUSETTS Board of Health, � ��t�.C�/,� �, MA CERTIFICATE Of COMPLIANCE Description of Work: ❑Individual Component(s) ]`Complete System The undersigned hereby certify that the Sewage Disposal System; Constructed (Repaired ( ),Upgraded ( ),Abandoned ( ) by: at l i i has been install-,I in accordance with they rro 'sions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built plans relating to application No. - dated 4Approved Design Flow (gpd) Installer /0 c 1 Designer: Inspector: \i Date: 3 The issuance of this permit shall not be construed as a guarantee tha the system will function as designed. No. "' / FEE COMMONWEALTH OF MASSACHUSETTS Board of Health, �/U , MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby granted to; Construct(k� Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system at h2� 6- '3/ � iG `.ti�as described in the application for Disposal System Construction Permit No 4/ " I dated - Provided: Construction shall be completed thi th e years of the date of is ermit. All local ditiop ustcbe met. a Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date Board of Health ® (/ F s OFBARNSTABLE LOCATION S3� hu-�-1 hc_r�Gy O�3EWAGE # a 6 VILLAGE—I S ASSESSOR'S MAP &L©� S'�JL ' INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY >0 6 '1 • LEACHING FACILITY: (type) rS (size) 3A X 10 1G r NO.OF BEDROOMS I)UILDER OR OWNER S� PERMITDATE: :5-'—�7^COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by _ p;3:k ft3= 33 A4=a° j As =a7 A-7 SIL i a3 �: 36 aS= �-7 I __________ I I I 11 - _______________-______ _______--------------____-____ ----.------ -------- __ . __ _,�, ,- �-7,'1,-7 ,7�77!7,� - I , - , ", -. , , I I .1 - � - . . -�� ,, -, 1,�"., � i - , , � "_,_ , -�,- -_,", --.1-1� ,.- ., . 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