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HomeMy WebLinkAbout0100 BLACK OAK ROAD - Health 100 Black Oak Road Marstons Mills A= 230-072 Commonwealth of. Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal SyfAem Form N.of for VoWntary Asses*;,nents M /00 oa V Property A -S-4 V4e-rl' b.: Cw qer Cw ner's Nan information is A/ required for every oc�-6 V? f 6 -6 10-6 page. Uty[Town Zip Code Date of Inspedtion qp CA 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. thing Men filling out forms A General Information on the computer, use only the tab 1. Inspector key to move your cursor-do not & use the return key. Name of Inspector H Company fsbme 0 ro Company Address Jaw.. eityfrow eo— 9 0 State Zip Code 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 16.340 of Title "10C 16.000). The system:Passes ,, Conditionally Passes ❑ Fails D Needs Further Evaluation by the Local Approving Authority Inspect is Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design low of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only clescri bes 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. t5ns-3113 Title 5 Official Inspection Forrrr SubSuface Sewage disposal S)SWM*Page 1 of 17 0�? Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage D145saI System Form -Not fbr Voluntary Assessments Property Address 14 4-e QM nef Oar nees Name information is required for every / G r{'7a✓if �lS /� �r� 7� d C page. City/Town State Zip Code Date of Inspection B. Certification (corn.) Inspection Summary: Check A,B,C,D or E/alwayscomplete all of Section D A) :�l m saes: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CM 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 ex0ain. 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 ,ndicatiing tttat the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i. Oro-3t13 Title50ffiaJ lrspectonForm SubsufamSevrageDispOS9 System*Page 2017 Commonwealth of Massachusetts .W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form .Not for Voluntary Assessments /6l0 OG 4 2,j Property Address ✓l h2 tj Om nermi Cw ne?s Name ird information is Al required for every / �/� page. Cdy/Town State Zip Code Date of ifispection 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): ❑ dstribution 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 mannerwhich 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 Mrs,3M 3 Tide 5 official Uapectim Form Subsurface Sexgge Disposal System•Page 3of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /do &,k c Property Address Ory ner Ov / n h information is ner's Name required for every (irrf�Ovtf r ll� page. Ctiyfrown State Zip Code Date of"Inspedtion 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 fleet 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 coliforrn bactela 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 ❑ ,L_�,/ 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 Y2 day flow t9ns-3M 3 Title 5Official Inspection F omc Sunsvface Sexrge Disposal System•Pge 4 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow net Owvt`�YI'e information is ner's Name required for every GYsp�1 //� page. Citylrown State Zip Code Date of Ins.0ection B. Certification (cunt.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or /obstructed pipe(s). Number of times pumped: ❑ 2 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. ❑ 19' Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ny 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 DE'P certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than :c ppm, provided that no other failure criteria are triggered A copy of the analysis and chain of custody must be attached to this form.] ❑ e system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ 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. tars-3113 Title 5 Official Inspection F orm Subsurface SavMe Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments DD 67 �t' pa Iv- Om Property Address I►�r r1`e ner ON ner's Name �1 information's /f J� required for every / ' l�►'f��J S �0 6�(� page. 0 i/Town State Zip Code of Inspection C. Checklist Check if the following have been done. You must indicate'yes"or"no"as to each of the following: Yes ❑ umping information was provided by the owner, occupant, or Board of[Health ❑ :Were any of the system components pumped out in the previous two weeks? ❑ 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 WA) 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? L7 o Was the facility owner(and occupants if different from owner) provided mith information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has n 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)1 D. System Information Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): _ 3o DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): -- �S' f5ns•3M 3 Title SOfficial Irspection F amc Subs<rface Sewage Disposal System•:fie 6 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �l� � Property Address /On � �' � yl`e — 1 Osr ner Owner's Name information is — required for every �I's ✓Lf i. S O�i dG �L page' �01Af" State TIP Code fate of spe lion D. System Information - Description: 4000 I.P /el 2 — Number of current residents: -- 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 'Co Water meter readings, if available(last 2 years usage(gpd)): — Detail: Sump pump? ElYes No Last date of occupancy: _L U y�/�v► Date Commercial/Industrial Flow Conditions: Type of Establishment: — Design flow(based on 310 CM R 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: — Son.-3M 3 Title 5 Official Inspection F am Subsurface Sewage Disposal Systam-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System /Form -Not for Voluntary Assessments Property Address �✓i vl Om na Owner's Ninformation is ame ,p required for every G rs K f page. City/Town State Zip Code Date of spec n De System Information (coat.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: / Source of information: ew —/ Was system pumped as part of the inspection? ❑ Yes Er No If yes, volume pumped: gallons — How was quantity pumped determined? — Reason for pumping: — Type of Sy 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 VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(descri be): t5re•V13 Me50f lelIrepectionFormSubsurfaceSevrageDisposal:IyMfn-PageBof17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address owner Gum information is �neWes Name � — required for every page. ayRown State Zip Code Date of spec n D. System Information (corn.) Approximate age of all components, date installed(if known) Ind�squrce of information: D �s rl .r L o h Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: feet Material of constructi� 40 : El cast iron PVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet — Material construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: year — Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: ✓ Sludge depth: — tins-3M 3 Title 5 official Inspection Form subsurface Sewage Disposal System•Page g of f 7 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o a G Qc R� Property Address 00 � Owner l h NAP information is Owner's Phame requiredforevery / q/'S��f S U/¢ �6g6 page- Cdy/Town State Zip Code Date of Ins pection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness / _ J f u A"� Distance from top of scum to top of outlet tee or baffle — Distance from bottom of scum to bottom of outlet tee or baffle // How were dimensions determined? c'.e 6/1 c.e Comments (cn pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GHj S /� Grease Trap:(locate on site plan): Depth below grade: feet e 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 t5irs•3M3 Title50fticial UupectionForrt[SubsurfaceSe,MeDisposal System,fte 10of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10� �(.7�cr G L, 0G �' AQ Property Address Owner Ow ner's Name inforequired orevery / Gl rj��►f �� f /� Oo26�� 3 o?b / 6 page' Uy/Town State Zip Code Date of Ins pectan D. System Information (coat.) 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 worldng 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 t5i s•3M3 Titie5Official lre tionFom[Subsirface pec Savage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposalSystem Form -Not for Voluntary Assessments /OV 0"G h/ 6. k/ 142G Property Address �114-e Os� Omner's Name �f // �jJ information is �f�p e 1 / "', ( / "/ 4 Oo)6 d 6Arequired for every page. Cltyfrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (f present must be opened)(locate on site plan): 'EV e of Depth of liquid level above outlet invert --�- Comments (rote if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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•3r13 Title SOfficial Inspection Form SutsWwe Sewage Disposal System^Page 12 cf 17 Commonwealth of Massachusetts Title 5 official Inspection Four Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /40 Property Address Q — Ow ner Owner's Name n HofLl information is � �,4 �02 [(-F required for every � �•�l , L % PageT01"n State Zip Code We of Inspection D. System Information (cost.) --- Type: leaching pits number ❑ leaching chambers number. ❑ leaching galleries number. ❑ Teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativetaltemative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 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 fans•3M3 Title50Ftiaal IrepectionForm SufsufaceSexrdgeDisposal Sysoam•Pie 13d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forma -Not for Voluntary Assessments Property Address Ory ner Ow hformation is ner's Name _ required for every f /page. CStyllownZ—Ta State Zip Code Date of Ins D. System Information (coat.) pect,on — 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.): t%ns 3M3 Title5Official IispeclionFomt SuhsWace Sewage Disposal S)SWIn-Pa3e 14 of 17 Commonwealth of Massachusetts -- 02 Title 5 Official Inspection Form Rt Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner 1 .4 14 Owner's Name information is G'lYf�O✓t �required for every -_ A page. City/Town State Zip Code Date Insp coon D. System Information (cont.) A / 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 o� I where p lic water supply enters the building. Check one of the boxes below: I n y�t �-✓� hand-sketch in the area below t`` /�� ❑ drawing attached separately 4JGaG�✓ 3 � � I! 3 "Y 4� 3o 151ns•11110 Title 5 Official Inspection Form:Subsurface Sewage Disp osal posal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Cw ner l H N'e information is LONners Name I _ required for every �Ci�f�Ovtf page Atylfown State Zip Code O Date of Ins pq donn,b D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water. _ feet Please' cats all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design Ian reviewed: r --- g p Date ❑ served 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: !P1 f�4 //101 — i lS 0 _ Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15res•3M3 Ti11e 5 Dffiaal Inspaotian Form Substrface Sewage Disposal SysDsm•Rage 16 of 17 Commonwealth of lftssachusetts Title 5 Ofrocial Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2dProperly Address _ ON nor Ow ner's name l 4-e eifom>ation's 21 ' l JI _f� L / ,p requiredforevey , r j' 9 i (��� O G11 Pa9e Cily/Town State Zip Code We of Ins E. Report Completeness Checklist Fk Inspection Summary:A, B, C, D, or E checked 2 uisp Summary D(System Failure Criteria Applicable to All Systems)completed ::$y !Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Sias-M rMOSoffidd ImpecfionFomc SubsWanS&wWDigxzd System-POp 17d 17 �O-r���' ��!�of � �� LUCATION � SLWAGE PERMIT NO. !off �IHSTA-L-LfR'S ►TAME A ADDRESS l ,J v 3 U I L 0 E R OR OWNER rAh no, � F) ATF PEPMIT ISSUED �_._ i - 2- L DAT E COMPLIANCE 13SUED L3 3S � 3Z ° G 0 ��Z • No..$.q YuB....... .......... THE COMMONWEALTH.OF MASSACHUSETTS BOAR® OF HEALTH Town ......0 F..Barnstable ................ ..:......................------.....---.-----.--•--..._.....-----.._...._......._._..... Appliratiou for ,DiiiVag a1 arks TOnotr ion anti# Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Lot #42 - Black Oak Rd. , Marstons Mills I. IVIA ................—•-r•.............. ............................................. ................. ......•...._..._._...... •-•-•-----•.........•-•••...........---•-- Capricorn Real" ti`izst 765 Falmouth RUa�;°•Hyannis ......................_........................--.. ..--•--•-•-•--------.................... ..........__.............-•••••......----•-... -••-............•--•---•-------•--....--•......... Owneerr r Address W Steve Label Installer Address UType of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedrooms._-•........................................Expansion Attic ( ) 'arbage Grinder ( ) `4 Other—Type e of Building ranch______________ No. of ersons...._....................... Showers — Cafeteria a YP g ------------- P ( ) ( ) Q, Other fixtures .------•................•-----.._...-------•---------------------------------------------•----------- W Design Flow........�� .................1000 gallons per perso �p� day. Total_Jl 16�flow....__.__.___________._._.____.____.__._._ �1Rns. WSeptic Tank—Liquid capacity._......__=.gallons Length................ Width....__.._._._.... Diameter..._.........._. Depth_.__.._..._.. x Disposal Trench—No......:.............. Widt .�_.___......_.._... Total Length..._... __.__._.__.Total leaching area..... sq. ft. Seepage Pit No---_--------------- Diameter.................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin anndk �., Etdr&dAe Engineering 11-25-81 a Percolation Test Results Performed by... __ �_.__-_._.__---------_.... Date........................................ 2.0 i2 Inone encounte�- ,� Test Pit No. 1._.r.......___.minutes per inch Depth of Test Pit..... .............. Depth to ground Ovate S.. ._...._..._.__. e Test Pit No. 1 ........ minutes per inch Depth of Test PitT��A........... Depth to ground water..���............. -•-•-------------------•------------...............--•-------- = ........--------------------------- -------------•-------•------------------ 0 Description of Soil.......... r.___'_..2 1 1 o am & t o s o]l . ----------y-- x 2 - i(5 Nfedium e l ow sand V ................................ i----- --•y------- 6-- ----•-•• 1 w i0 - I� med0 w�iite sand- traces---oi'"graver rio water at" 12 -----------------------------------•---------------------------------•--••------------=------------•-------------•----•--•-----------------------------•---•----------------------------•-•-•--•-----•-- U Nature of Repairs or Alterations—Answer when applicable................................................................................................ --------------------------•--•--.........--•----•---•---......-•---•-------•------•---------•......•-•--...-•-----------------------•------------•-----------------.................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TILL LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance as b en issued by theboarA,2f health. Signed --•-Pre... ... ��A���; n /Date Application Approved BY �-�`- ......_.. •------ --- .......... ...............l-l / Date Application Disapproved for the following reasons-------------------------------------•-----------------------------------------...... ......................... .................•--------.................--•----•----------........---------------....---•--------•--------•-•-•-•----•-----•-•----------•-•------------•••-----------•--------•------------•...--•--- Date Permit No..... ....._ ._.. _.........•...... Issued-............. ............... ate } 1 N................. g.. FEB....,r? a....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ............." .................---.....OF......................................................................_................_.. Appliration for Disposal Works Cn instrurtion Vandt Application is hereby made for.a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Lot #42 - Black Oak 1Ld. , Ylarstons Mills I, IVIA ................___.._._........---.............. -..................................---.... .......................---•---------------------------------------------------- ............. ...._. Capricorn R&Wlt3i d ust 765 Falmouth RPJ t to-Hyannis ...... --....----- -•..............•...........--••••......•-•-•--••-•••••-• •...........------......--•••-•-•--•...........----•-.- ..........----............... W Steve Lebel Owner Address .....---•.....................••-•--•-•------•-•-•-----•--.......---------••--••-•--•--•--•-••••-- •--••-•------------------•-•---••----•••--•-•......................•...._......................: Installer Address Type of Building 3 Size Lot............................Sq. feet a Dwelling—No. of Bedrooms anch...................................Expansion Attic ( ) ,Garbage Grinder ( ) p-I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QIOth fixtures --------------------------------------------------•---.......•-•--•..... --------- d Design Flow...............________________ __ gallons per pers ,p f,day. Tot 1 ��iow...._._..33-........._._........_.......gallons. 8 It WSeptic Tank—Liquld capac>ty.____.__..:.gallons Length................ Width....__..___.._.. Diameter................ Depth____________.._. x Disposal Trench No. .................... Widt _r__..__..._.______ Total Length....... _.•--..____ Total leaching area..... . . . sq. ft. Seepage Pit No�................ Diameter..... ..._._...._. Depth below inlet.................... Total leaching area... �__....sq. ft. Z Other Distribution box ( ) Dosin `r&dke Engineering 11-25-81 Percolation Test Res lts Performed by.......................................... r _._. Date........................................ a .0 i2 hone encountm- Test Pit No. minutes per inch Depth of Test Pit•................. Depth to ground wate .............._. e /A..... Ia/A N/A Gro Test Pit No. ................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................ O 0.V---------2-,-.........loam & topsoil................................ Description of Soil--------- r ...... ----••-------------------------•---.....-••--•--••- x 2 •------•1D Tifediuin yeTTow sand................. W ........................................1.0-.-...: ...TZ"-----me4T8" •whit-e---sand/tr-aces--6f gravel/rio water-at-• 12 ' ................=..................................................................................... ---------------------------------------------••---•---------..........................----------- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------------•••••-••-••••••-•.-•-•---------•••-•-•--•-•••-•----••--.........---.....---••--------••----••••--------•--------------••••-••-•••-•-•---------------•-•••---•-••--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ned ..... Pres. � --....._. ........�................. ., .............. Application Approved B (A y-••--••••..................•••. .. ----------------------....------•-•-•---_... ..................... ................. Date ' Application Disapproved for the following reasons:-----•-------------------------------------------------------•--------------------••......•••...........--••-•- .....................•-----------•-•----.....---......--------------------------..........-•--------•------•••••-•-•-••--•••--------------•--•-•-•-•---•-•••--•--••-•---------•-----••--••---••-••------ ��� Dat e PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town..........................................oF.......Barnstable.............................................. (Inr#ifirate of Toutpliattrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (X ) or Repaired ( ) Steve Lebel at Lot_ 42 - Black Oak Road. . ..........InstalleMarStOnS Mills , VIA -•------- --- ---- -- ---•---•---- ........._......_.._.• . ------....------.-------- ------------- . ----- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CON RU AS A GUARANTEE THAT THE SYSTEM WIL UNCTION SATISFACTORY. 1 DATE.......................... •--•-----•-•--•-----••-••--••-•..... Inspector---------- . .....( --------------------------------------­- THE COMMONWEALTH OF MASSAC SETTS BOARD OF HEALTH $ -(tD$ 2. Town.........................OF....Barnstable r�J No......................... FE ---•-....... Disposal Works Toatu#rttrtiott "an tit Steve Lebel Permission is hereby granted ............... to Construct . , o 2Repair, }ka �rdiviril�l ;Sev�raga� Disposal System at No T Ot�r > Lac _ ,, �t, 1�larstonS Mills , MA---••----•........................_._......._..----•----•--. •--.-••----•-----------• ---•-•-•--•----•---•........ Street as shown on the application for Disposal Works Construction Per it Dated .f ' .....................................••------•-•--------------------......------.....----•••---•-......_ L Board of Health�S DATE------ ............................................. 1 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i �00, ,:, � j a, L j �"-\;6 o N. t ZD� U 2_3 .5 ;F j C Zv Nll� OF � GG t G• i ti 'n SIC S T��yG ToP't,� �!�r/ �� pro SE 9 �,� Q 4 tq v�vl/51 �cFSG/ST 2 /a y`13A-x7-e2. -i- Al yE wl ADD 77D.-iAr. �vQh7.�-5 Jos/(dy 3 g LEGEND ,x� EXISTING SPOT ELEVATION . OxO, A CERTIFIED PLOT PLAN 'EXISTING., CONTOUR — -- p -- N L oT 4c cry n is FINISHED SPOT ELEVATION 1 Ks��tRr `" FINISHED CONTOUR 0 BRUCE u 44A-R570A45 /19/t LS r ELDR4 APPROVED BOARD OF HEALTH � � 1N ,Y 'n DAT E AGENT SCALE, " 30 DATE , LDREDGE ENGINEERING CO. CLIENT w I CERTIFY THAT THE PROPOSED z EGI:STERE REGISTERED JOB td0 3zS4 �. '.BUILOING. SHOWN ON THIS PLAN " CIVIL LAND CONFORMS --'TO THE ZONING LAWS OINEER SURVEYOR DR 8Y= Of .BARNSTIa►BIE MA MAI N STREET CH. BY, yR`•3 ., SHEET.._ OF. .,:. q E -;"` RES. 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