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0563 WHISTLEBERRY DRIVE - Health
563 Whistleberry Drive, Marstons Mills - -_ A= 061_ oLiL� - - �� l i' NdC / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS Ye ftpfication for misposar *Pstem Construttion Permit Application for a Permit to Construct( ) Repair(11�UpgradeV Abandon( ) ❑Complete System Wndividual Components Location Address or Lot No. 6-63 Wk 4 Q 1 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel D&/ jV I tall 's1N A dress, d-T'el�aal��'TTo. ��//- Desi ,1er's Nai),e,ALddre(ss,-and Tel.No. /� bl� �/ y /I� /l/Y�� A VA ICJ IDS i"l to i IrC1� x V n Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank 4x 4,n!e, (Upp 4 j Type of S.A.S. 02.)0SLnA 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 C not to place the system in operation until a Certificate of Compliance has been issued by this Board o ealth. Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued �• A No � �, Fee sr THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �f PUBLIC HEALTH DIVISIQN-=; QWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Disposal *pstrm Construction VPrmit i 0 Application for a Permit to Construct( ) Repair(� pomade'(;) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. 6j4 j f4- rl�t L Owner's Name,Address,and Tel.No. I lyG1 r {v�^,S a f`5, Assessor's Map/Parcel 0&1 /G Installer's Name,.Address,and Tel.No. ref-1121- Designer's Name,Address,and Tel.No. T�o x O nJ Type of Building: t .� Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building / No.of Persons Showers( ) Cafeteria( e Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Cy, Type of S.A.S. e.)(i d Description of Soil Nature of Repairs or Alterations(Answer when applicable) (I_qolat e kt eL^,.,1N )?n Date last inspected: f 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"find not to place the system in operation until a Certificate of Compliance has been issued by this Board of'.Healthh. Signed l� �t'��--'\ S� --- Date Application Approved by _..._-.-.--' Date Application Disapproved by Date for the following reasons v Permit No. l / -""C f Date Issued , / THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Ceftificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Al Upgraded( ) Abandoned( )by 466r4olo c1v� , l_n L t_ , - at (��� t r,� ¢.. n nhrC [ I)f, has been constructed in accordance / /� with the provisions of Title.5 and the for Disposal System Construction Permit No��7 7- `dated / �/ Installer 36 Y'�IC�(�t.A. ..Cloy Designer 11J M I- Coy,.y,. On /c°t #bedrooms t V' Approved design flow /(, I 1 1j d gP The issuance of this permit shall not be construed as a guarantee that the system will fufnctiona "designed. /�i� Date / �a d// Inspector / `c, j,n,_ t� , =-------------- - - - -----V------ cf- No. �/ 7 1 - Fee / W THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction j9erm[t Permission is hereby granted to Construct( � ) tt Repair(F� Upgrade( ) (Abandon System located at �C© . (�ls t 1 to'A t'if'[ rDE A,I/, 0 1 !rs and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed wiithijthree years of the date of this permit. Date Approved by Assessing As-Built Cards Page 1 of 2 LOCATION ' S SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME A ADDRESS �sr Ai, ,l�vaa Ic /UILDER OR OWNER n-4 cj;,d Ce s DATE PERM!FERM11 ISSUED DATE COMPLIANCE ISSUED Q p. f.AL i3;�ck Di' h1ous G P �K a yrf 3 rt http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=061044&seq=1 12/19/2017 J lZ fair (,o)-npl vs t Town of Barnstable Barnstable Regulatory Services Department (9`''M `E ` Public Health Division i6 39• �� F16 ova 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7015 1730 0001 4987 6650 December 29, 2017 MCKAY, VINCENT & CLARE G TRS 67 CANTERBURY RD NEWTON, MA 02161 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 563 Whistleberry Drive, Marstons Mills, MA was last inspected on 11/27/2017 by James D. Sears, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Distribution box needs to be replaced. You are ordered to repair or replace the septic system within two (2)years 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 my cKean, R.S., CHO Agent of the Board of Health Q:\SEPTIC\Title V Inspection Report Letters Mail ing\Conditionally Passes Letters\563 Whistleberry Drive Marstons Mills.doc . T lime T� ~ "* Town of Barnstable . , ,ARxsTAxrr, . Regulatory Services Department Public Health Division 200 Main Street,Hyannis MA-02601 Office: 508-8624644 — P ichard ScA Dircctar FAX 508-790-6304 Thomas A McKean,CHO Feb 6, 2007 Rev. 5111116 DEADLINES T.O'REPAIR FAILED.SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ 'An`Y'marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑Discharge or pending 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 q Single Cesspool ❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation " of a driveway due to H-10 components, etc) d Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code §360-9.1) ❑Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER 1 Repair deadline: WSEPTIMI)EADLINES TO,'REPAIR FAILED SYSTEMS.doo �L\ Commonwealth of Massachusetts Title 5 Official Inspection 1 p on Form r,, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -.a 563 Whistleberry Drive pay Property Address Vincent Mckaa Owner Owner's Name r information is required for every Marstons Mills ✓ MA 02648 11-27-17 rary page. Cityrrown 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. Important,When A. General Information filling out forms S/ / �t 2C''1 \`�tttttnliurgr/rr use onlon the y tab ✓ eC T Q a—� \�0�����SN OF4141 Y `� key to move your 1• Inspector: . cursor-do not 'ate JAMES James D.Sears ;�; key.�A.eturn Name of Inspector — -' Y Ca y Na Enterprises ,0y Company Name • 153 Commercial Street o�%,,Frsf iNSpGV�`````` Company Address Mashpee CityfTown MA 02649 State Zip Code 508-477-8877 S1623 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 6(310 CMR 15.000).The system: ❑ Passes Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12-4-17 Ip ctor's Signature Date The system inspector shall submita 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.6116 Title 5 Official Inspection Form:Subsurface Se'image Disposal System-Page 1 of 17 abed xeJ dH 6EU LI.OZ g0 XI0 /_0 Vs Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistl berry Drive Property Address Vincent Mckay Owner Owner's Name information is required for every Marstons Mills MA 02648 11-27-17 page. C5yy own State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E l 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; Conn. Pass- D Box.The system is a 1000 Gat Tank D Box and pit 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): 15ins.doc•rev.WIG Tllle 5 official Inspecrian Form:Subsurface Sewage Disposal Systam•page 2 of 17 Z a5ed xed dH 6EU LtOZ 90 �aO Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent MckaV Owne., Owners Name inforrr:ation is Marstons Mills required for every MA 02648 11-27-17 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below): ® obstruction is removed ❑ Y ❑ N ❑ NO (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below): Need to replace D Box ❑ 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 ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ISins.doc-my.6116 Title 6 Official Inspection Form,Subsurface Sewage Disposal System•Psge 3 of 17 £ a5ed xeJ dH 6E:EZ L[0Z 50 �e0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mckay Owner Owners Name information is required for every Marstons Mills MA 02648 11-27-17 page. City[rown 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 SA septic tank and SAS and the p S 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 IMEM is less than 6" below invert or available volume is less than '/Zdayflow Pa- Nns.doc-rev.06 Title 5 Official Inspection Form`.Subsurface Sewage Disposal System-Page 4 of 11 b a5ed YPJ dH K£Z LI.OZ 90 3a0 Commonwealth of Massachusetts rwi-r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form• Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mckay Owner Owner's Name information is required for every Marstons Mills MA 02648 11-27-17 page; City/Town State Zip Code Date of Inspection B. Certification (cost.) 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—IWPA)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.6116 Tide 5 Orfida4 Inspection Form:Subsunaee Sewage Disposal System•Page 5 of 17 S a5ed xed dH 6£:EZ L60Z go o20 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mckay Owner Owner's Name information is required far every Marstons Mills MA 02648 11-27-17 page. City(Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no-as to each of the following: Yes No ❑ ® Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 15ms.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Oisposai System•Page 6 of 17 9 a6ed xeJ dH 6£U L ME 90 Da0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistieberry Drive Property Address Vincent Mckay Owner Owners Name information is required for every Marstons Mills MA 02648 11-27-17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank D Box and pit. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2015-30,000Gais Detail: 2016-47,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date CornmercialAndustrial 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.6i16 Title 5 Official Inspection Form_Subsurface Sewage Oisposei System•page 7 of 17 L abed xPJ dH Ob:£Z L60Z g0 aa0 L Commonwealth of Massachusetts Inspection Form Tale 5 Official p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mckay Owner Owners Name Information is Marstons Mills MA 02646 11-27-17 required for every page. UYrTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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 IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins doe-rev.E116 Title 5 Official Inspection Form:Subsurface Sewaga Disposal system•Page B of 17 9 a6ed xe j dH Ob:EZ L 60Z SO D-)G Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mckay Owner Owners Nome information is required for every Marstons Mills MA 02648 11-27-17 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1982 -Permit*82 -347. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 68" feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Pipeing is 4"PVC SCH-40. Septic Tank(locate on site plan): Depth below grade: 58" feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) [],�''Ye.s, ❑ No Dimensions: 1000 Gal. Precast; Sludge depth: 2" lbins.doc•rec.6/15 Title 5 officisl Inspectian form:Subawfece Sewage Disposal System-Page 9 of 17 6 a6ed xed dH 6bVEZ L 60Z go De0 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address -- Vincent Mckay Owner Owners Name information is required for every Marstons Mills MA 02648 11-27-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 1., Distance from top of scum to top of outlet tee or baffle 12 Distance from bottom of scum to bottom of outlet tee or baffle 1 How were dimensions determined? Asbuilt-Plan-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural Integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank at 58"below grade wloutlet cover at 32"and inlet cover at 4". Inlet tee-outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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.8/16 TIUe 5 Otrclal inspection Form:Subsurface Sewage Disposal System•?aae 10 of 17 o l, a6ed xed dH WU L 1.0Z 90 Da(] Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address _Vincent Mckar Owner Owners Name Informrequired is Marstons Mills MA 02648 11-27-17 required for every page. City/Town 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 y ❑other(explain); Dimensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Yes ❑ No Alarm lave': 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.dcc•rev.6116 Title 5 Official Inspeclio'i Form:Subsurface Sewage Disposal system-Page 11 of 17 66 abed xed dH l,'VU L1.0Z 90 Z, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mckay Owner Owners Name information is MarStOnS Mills required for every MA 02648 11-27_17 page. CRyrTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D Box is 16"x16"-6-6"below grade w/one line out.Wall Is pone on box. Need to replace box. 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: 15inadoc•rev.W16 Title 5 Official Insw0an Fore Subeufeee Sewage DlSposaa Syuer•Page 12 of 17 z i, abed xed dH WEZ L 1.02 SO DaQ L Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistleberry Drive Property Address Vincent Mcka Owner Owner's Name reg fired for is every Marstons Mills required for eve MA. 02648 11-27-17 page. CityrTown state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 1 ❑ 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.): Leaching is a 1000 Gal. Precast pit. Pit at 7' below grade wlcover at 4'. Pit is dry w/clean wall's. No sign of over loading or high stain. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins.doc•rev.6116 Title 5 Official Inspection form:Subsurface Sawege 0j$po5al Syslem Page 13 of 17 £l a5ed HA dH 2VU L W0 90 Oa0 Ak Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments •� 563 Whistleberry Drive Property Address Vincent Mckay Owner Owners Name information is required for every Marstons Mills MA 02648 11-27-17 page. City(rown State ZipCode 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 Inspecfion Form:Subsurface Sewage Disposal system•Page 14 of 17 tq a5ed Xed dH Zt7:£Z L 60Z 90 mG Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 563 Whistlebera Drive Property Address _. Vincent Mc Owner information is Owners Name required for every Marstons Mills MA 02648 11-27-17 page. Citylfown 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 144 g-g ; 4i y' 0 -3 - /+-s/, 0 o�5f O O i t5lns.doc rev.6(ts Title 5 Otficial Inamcion Farm:Subsurface Sewage Disposal Srslem Page 15at 17 S 6 abed xeJ dH ZIVU L 10Z 50 :)aa Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments • 563 Whistleberry Drive Property Address Vincent Mcka Owner Owner's Name infom-.ation is required for every Marstons Mills MA 02648 11-27-17 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t high ground water: 50, 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: U.S.G.S.well SDW 253 AT 50'. You must describe how you established the high ground water elevation: U.S.G.S. well SDW-253 AT 50'. Bottom of pit at 15'below grade. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t8jns.00c•rev.6.%6 Tice 5 official fnspeUlon Form:Subsurface S"a Disposal System•Page N of W g t a5ed xe j dH E�:EZ L I.OZ 50 m0 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 563 Whistl erry Drive Property Address Vincent Mcka Owner Owner's Name information is required for every Marstons Mills MA 02648 11-27-17 page. Qijr own State ZipCode 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 h Gins.doc-•re,.6116 Title 5 Official rrupection farm:Subsurfaos Sewape Disposal System•Page 17 of 17 L6 a5ed X2J dH £'V£Z LI.OZ 5o :)aa Commonwealth of Massachusetts ,John Grad Executive Ottice of ErMorimntal Affairs D.E.P. Title V Septic Inspector Department of P.O. Box 2119 Environmental Protection Te 108) 5 MA 02536 � (508) 64-6813 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR PART A CERTIFICATION WIVEO � c� r Property Address: 663 Whistleberry Dr. Marstons Mills Address of Owner: FEB $ 1997 Date of Inspection:217197 (If different) Name of Inspector:John Gracl Kathy Cassidy TOWN OF BARNSTAl3LtE 41 T+ DEPT Company Name,Address and Telephone Number: m 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This Inspection Is based on criteria defined In Title y code 310 CMR 15.303.My findings are of how the system is _ Conditionally Passes performing at the time of the Inspection.My Inspection does _ Needs Fu her Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fells septic system and any of its components useful life. Inspector's Signature: Date: 2113197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C,or D: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.) _ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/15195) One Winter Street a Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT A CERTIFICATION(continued) Property Address: 563 Whistleberry Dr.Marstons Mills Owner: KathyCassldy Date of Inspection:X7197 _ Sewage backup or breakout or high static water level observed in the distribution box is due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 1V15195) 2 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 563 01hlstleberry Dr.Marstons Mills Owner: Kathy Cassidy Date of Inspection:V7197 D) SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information. (revised 11115195) 3 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 563 WhlsdeberryDr.Marstons Mills Owner: KathyCassldy Date of Inspection:717197 Check if the following have been done: X Pumping information was requested of the owner,occupant,and Board of Health. x Nona of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system.recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened, and the Interior of the septic tank was Inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11115195) 4 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 563 Whlstiebery Dr.Marstons Mllis Owner: Kathy Cassidy Date of Inspection:217197 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available: nla Last date of occupancy: n►a COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:6 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: n1a Last date of occupancy: n►a OTHER: (Describe) rda Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last two years. System pumped as part of inspection:(yes or no)_Yes If yes,volume pumped: tt56 gallons Reason for pumping: Maintenance. TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) Other(explain APPROXIMATE AGE of all components,date installed(if known)and source information: 1985 Sewage odors detected when arriving at the site: (yes or no) No (revised 11115195) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 563 Whistleberry 0r.Marstons Mills Owner: Kathy Cassidy Date of Inspection:711197 SEPTIC TANK: X (locate on site plan) Depth below grade: 6' Material of construction:X concreate_metal_,FRP_other(explain) Dimensions: L 8'8-H 5'7"W 4'ill' Sludge depth:5" Distance from top of sludge to bottom of outlet tee or baffle: 22" Scum thickness:3" Distance from tap of scum to top of outlet tee or baffle:6' Distance form bottom of scum to bottom of outlet tee or baffle: 15' Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound Recommend pumping system every year for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: n1a Material of construction: _concrete_metal_FRP_other(explain) Dimensions: n1a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n1a Distance from bottom of scum to bottom of outlet tee or baffle: n1a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of Ie6mge,etc.) n1a I (revised 11115195) ti I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 563 whlstleberry Dr.Marstons Mills Owner: KathyCassldy Date of Inspection:V7197 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: Na Material of construction:_concrete_metal_FRP_other(explain) Dimensions: Na Capacity: n1a gallons Design flow: n1a gallons/day Alarm level: Na Comments: (condition of inlet tee,condition of alarm and float switches, etc.) n1a DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: uquidlevelwith bottom ofpipe. Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.) Distribution box is structurally sound. PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Na (revised 11115195) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 563 Whlsileberry Dr.Marstons Mllis Owner: KathyCassldy Date of Inspection:W7197 SOIL ABSORPTION SYSTEM(SAS):x (locate on site plan,if possible; excavation not required,but may be approximated by non-intrusive methods) If not determined to be present, explain: nla Type: leaching,pits,number: 1-leach pit leaching chambers,number:nla leaching galleries,number: nfa leaching trenches,number,length: nla leaching fields,number,dimensions:nfa overflow cesspool,number:n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The leach pit is structurally sound and functioning property it was 314 full at the time of the Inspection. CESSPOOLS: (locate on site plan) Number and configuration: n1a Depth-top of liquid to inlet invert: nfa Depth of solids layer: n1a Depth of scum layer: nfa Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool must be pumped as part of inspection) nla Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n1a PRIVY: (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: nfa Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) nla (revised 11115195) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 563 Whistleberry Dr.Marstons Mills Owner: Kathy Cassidy Date of Inspection:217197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' I � 31 �g 3-7 AC y� AD ion IS DEPTH TO GROUNDWATER Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11115195) " g LOCATIOPI SEWAGE PERMIT NO. [T t4Ais7/C beApy VILLAGE .11 s � � A INSTALLER'S NAME R A 0 0 1 E S S j3A U I L 0 f R OR OWNER dA DATE PERINI f ISSUED DAT E COMPLIANCE ISSUED. C7 s P• Ae- �� � - ',, ,� � �, `� � � � �� � �Y �� �°� �� i. r i °� - 3- 9Yoy No......62�z-ay;", !!;Z� ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ------7. .----.....OF..... .................. Appliration for Uhipatial Workii To witrurtion Permit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: r ....... .. ..... ............. ..... .... ...... ;'Ro------------------------------*----------- Location-Address or ....DA.VIM ......"........ An.............. Owner fV�C! Address ........................................................................ Installer Address U Type of Building , Size Lot..9'4.aoL?...Sq. feet �4 Dwelling—No. of Bedrooms.........%3..............................Expansion Attic ( ) Garbage Grinder (Ak) PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ..................................................................................................................................................... Design Flow............1,TJ.......................gallons per person per day. Total daily flow.............3.a.42..................gallons 04 Septic Tank—Liquid capacity/OWgallons Length.9.1.C.... Width..V../9__ Diameter.... Disposal Trench—No..................... Width........._...._.... Total Length-' Total leaching area...................sq. ft. Length_._.._.__._:._.__._ ..0..... Seepage Pit No......./........... Diameter.._............. Depth below inlet_............... Total leaching area_X.1;�.Q.sq. ft. Z Other Distribution box (4-) Dosing tank ( ) 4 Percolat-on Test Results Performed ..................... Date...'-6/2an/:K02...... Test Pit No. I...42....minutesperinch Depth of Test Pit...../A., Depth to ground water------IJ. .......... k-.4 I 4A Test Pit No. 2_4Z.....minutes per inch Depth of Test Pit-----112........ Depth to ground water'.-_&j0ME----- P4 ............................/...................................................................................#t.4.................................. 0 Description of Soil....0. 0.eZ---------------0. Z,OA. 70.1 0.-'s.0 cxj ................../Z.. ... . ...IA. V/*---------------------------//Vt:41-V...... ------------------------------7-a--'n,1 .....IZZ,W. ...... U Nature of Repairs or Alterations—Answer when applicable...__........................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed rhdividual Sewage Disposal System in accordance with. the prov:sions of TITLE LE 5 of the State Sanitary Code—Thgundersign further agrees not to place the system in operation until a Certificate of Compliance has be ss d by the and health. Signed.-. ... . ......... ......... .... . .. . .................. A....'7..... .. .... .. . . . .. ........................ .......... - Application Approved --- --- Y1........... Date Application Disapproved for the following reasons:.............................................................................................................. ...................................................................................................................................... .................................................................. Date PermitNo......................................................... Issued_....................................................... Date 0_ No......0.. !.?Y7 FEs....!!e.: ............... NN THE COMMONWEALTH OF MASSACHUSETTS w , BOARD OF HEALTH �`" ,�'.. = Appliration for Digpnsul Workii Tnnstrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ......... .. . .J._..-' ... .. .......................................... pl- 6� Addre s t, or No............................................ i ,_..._ rr"Ir ..... sr�1:AI� Rr .. '+, Owner {� Address r- a ...........m ?5)-A. ..__ Mir2 ?_ 9shl�.......••.......--^--- ..................•-------•--- Install r Address U Type of Building Size Lot... feet Dwelling—No. of Bedrooms........-5.............................Expansion Attic ( ) Garbage Grinder (�' aOther—Type of Building ________________•__--__.--.- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ............. W Design Flow............sA_.,17..................... per.person per day. Total daily flow •�. Q gal - ----------- - -----------•--•-•--- Ions. R: Septic Tank—Liquid capacity./42 allons Length__F.:. ... Width.."' e. o Dlameter_.. +__ Depth._ gallons.,, W ... x Disposal Trench—No. .................... Width......`:........... Total Length.................... Total leaching area....................sq. ft. _Seepage Pit No......./,...........Diameter_______ ________ Depth below inlet........ .___ Total leaching-area...!? �. .sq. ft. Z`. Other Distribution box ( 4«- Dosing tank ( ) Percolation Test Results Performed by..--e56 '► ._ ! !.1.. f .................... Date....` _ ....._ Test Pit No. 1...G._,_.-_-_minutes per inch Depth of Test Pit------ Depth to ground water...._../r-____•--_-.-. Gi, Test Pit No. 2..Z._i?.....minutes per inch Depth of Test Pit------1,2....... Depth to ground water----A✓1:4 __... '.......................................... D Description of Soil--- ................. ✓l �•. G. ab..S -.. J V -----------------------•-- >� � �'S �_7 ''S?/?/� ✓roc" r��/ 9.!vrlddc'.!rL?e✓/ �.^ '� ��`��'�r !^. ..l�-fx/t�i°rr b f7T !lJ UW •-- -•- Nature of Repairs or Alterations—Answer when applicable---------------------- --•----- -..:....................................................... Agreement: The undersigned agrees to install the aforedescribed I di 'al Sewage Disposal System in accordance with the provisions of T ITL E 5 of the State Sanitary Code— Th undersigne further agrees not to place the system in operation until a Certificate of Compliance has bee ' ued by the oard ealth. Signed � 1 t f;..... 1 -------------- t Application-Approved BY _z:. ! ....................... •---•--- �L.--------- Date Application Disapproved for the following reasons.__... .................................. .............................•---•-------•-----...........__ ................................................................................................................................•------------------------------------------------------------------------ Date PermitN5........................................................ Issued-.................. ..................................... Date THE COMMONWEALTH'OF MASSACHUSETTS "wy1y ±' BOARD . OF HEALTH crr ...... ..oF...:...C3 � ,5 ' �''f. ..................... i � �p�#ifirtt� ,af faunt�li�nrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (/-<or Repaired ( ) ----....... ' Instal er at. ' -- ......�r7• --------------------------------•--------------- has been installed in accordance with the provisioof TITL, 5 of The State Sanitary Code as described in the:.,.. application for Disposal Works Construction Permit No.__.. 2.._.. `l.� dated................................................. ;` PP P ----" --- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE : SYSTEM WI FUNCTION SATISFACTORY. ....................................................... Inspector ---•------•-----.._..---------.._.....--=............. 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD "OF HEALTH .......2 ?!V..........OF..._. ' . + _ ....................... Dispont IV rkii Ton r erMit Permission is hereby granted-------------•--•-- ---..... ............ ........................................................ to Constr Y or Repair ( ) an Iddiv al Sewage Disposal System r .- Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... Oa ... .............•-----------• ---__---/ /� of Health DATE::--= �-------- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS / I 00 G L, 01- 0 rl' 1 ri �\ Gar Gb ,. l> f^i:.Y�.rr"w:�n"..�-�`,T::; r??'i C • c".G A,/+i.� GJ r�/i 7l�Cv N \ � r O 12 C-, T 5 7- CAPI 7`-0 4 �ryO G-�N ON `l ce7vSC- 34� 9 R'C c o,ct�t.� i•.r .o�.o..i f Woo o I $�XS +� �� 2c®.eG LO,AYN �.N ODD L�.4 iM \ I E t� � r� - �cpGr�C� Of—lss.�'l.Qs7'a7�rs/s1iL G.s 4 i2 /Trvb FG4I/y4�. �� � y� — 59 x� ... � •O �Ur',z--��.�..-�-,Pre Tr t�-�.. 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