HomeMy WebLinkAbout0105 BLACK OAK ROAD - Health 105 Black Oak Road
Marstons Mills
A= 101-071 /
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector: I
key to move your
UM
cursor-do not Robert Paolini
use the return
key. Name of Inspector
Robert Paolini Septic Service
r� Company Name
17 Playground Lane
Company Address
Yarmouthport MA 02675
City/Town State Zip Code
508 362-3555 S 14454
Telephone Number License Number.
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information rep$*ted 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:
0 Passes ❑ Conditionally Passes ❑ Fails
❑ ;Ne;e,7/dby the Local Approving Authority
� 1/25/14
Inspect is Slgna a 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 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•3113 Title 5 lei Form:Subsurface Sewage Disposal System•Page 1 of 17
' � ' Commonwealth of Massachusetts
Rmwo Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑x I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fort
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
•'" 105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well*".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes ;No
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Z 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.
❑ X Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public-well.
❑ ❑x Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ❑x 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.]
❑ FZ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ M 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 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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
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
❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
❑ 0 Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
❑x ❑ Were all system components, excluding the SAS, located on site?
0 ❑ 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?
0 ❑ 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:
❑ 0 Existing information. For example, a plan at the Board of Health.
❑ 0 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
t5in3•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ❑x No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑x No
information in this report.)
Laundry system inspected? ❑x Yes ❑ No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available last 2 ears usage d na
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes 0 No
Last date of occupancy: NA
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forums
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Robert Paolini Septic Service
Was system pumped as part of the inspection? M Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? measured
Reason for pumping: maintenance
Type of System:
❑x Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection- Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
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:
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
Building Sewer(locate on site plan):
Depth below grade:
2'
feet
Material of construction:
❑ cast iron 0 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10'+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.System vented through the building vents.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
0 concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gl.
Sludge depth:
2"
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
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
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every 2 years.Inlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 official inspection Foam
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town 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 No
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.):
Box is Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑x leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,-length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy soil.No signs of hydraulic failure. Leaching pit was dry at time of inspection .
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer — —
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection,i_on Form-
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t51ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
i itee o umcoaa inspection i gym
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is
required for every Marstons Mills MA 02648 1/25/14
---
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
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
�� zY
0�
1/2
t5ins•3113 Title 5 Official Inspection Toms:Subsurface Sewage Disposal System•Page 15 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑X Check Slope
❑X Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 11'
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:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED;.USGS observation,well,data_USED:Technical bulletin 92-0001 annual ranges of groundwater
elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Tf"e 5 O•ftofaF inspection Form
9 -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
105 Black Oak Rd.
Property Address
Matt Mitka
Owner Owner's Name
information is required for every Marstons Mills MA 02648 1/25/14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspectioi Summary: A, B, C, D, or E checked
N' Inspectio-i Summary D (System Failure Criteria Applicable to All Systems) completed
❑x System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
cx/e>�01,-y �/ 99? ✓.
O W IOa S E C9 A C E PE RCIIT p0•
2�lxcie
VILLAGE
INSTA lER"S 0A ADDRESS
QUILDER OR OCypER
DATE PERMIT ISSUED
DATE COMPLIANCE ' ISSUED
1
31 zy
-rower t�>a
// � '► Fes$....... .s
.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
....................o ...........................--......-....---.--------.--------........--....... .....
Appliratiun for Uiupuual Works Ton.otrnrtiun amit
Application is hereby made for a Permit to Construct x( ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot # 9 - Black Oak Rd_, Nlarstons Mills !, MA
........................... ._.... ...... ____....._.....---•...._.__...•----••---....-•---•-•_-•---
Capricorn Reholat
y"` rest 765 Falmouth Rod&;" ffyannis
......................_.......................................................................... ............_........._._......._.._..................---.........-•--..................--.--...._
W Steve Lebel owner Address
Insta3ler Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms 3.........................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Buildin ahCh No. of persons........................... Showers
a YP l -----••-_- P - ) — Cafeteria ( )
dOther fixtures ..-"-"""---"---...--"""""-""""""-"""-"""""-"""-"•-"-"".-"-""""-"-"-""""---""-"""""""-"---"""""""""•"""""""-•"••---••-"-_.____"________________________
Design Flow______55...._............................gallons per person per day. Total daily flow......3N........................._._.gallons.
W Septic Tank—Liquid capacit�y+000 gallons LengI�_6..-__.___._ WidtNi'_1"0_-�._..- Diameter________________ Deptfi
_�..............tS
x Disposal Trenc}t—No. .................... Wicjtl;.................... Total Length ........... Total leaching area__2b6.........sq. ft.
Seepage Pit N ..................... Diameter...... Depth below inlet-___-_.____......... Total leaching area_____._..._.__....sq. ft.
Z Other Distribution box ( ) Dosing tank (�
EldreW Engineering 11-25-81
Percolation Test Results Performed bY -"___________________•--------•---•.......
.._...._.... Date.
Test Pit No.,i1?' "_--"____minutes per inch Depth of Test PitJ2�______ Depth to ground watrie erlCCunter—
Gi, Test Pit No.IY/_A__.____._._minutes per inch Depth of Test P� jA______________ Depth to ground wate�!�ti....____.__._... e
t4 _-._______._•••-----••-•..............................................................•--:_.._....-•.........................................................
0 Description of Soil.......O i.__._._21 i~ loam &- topsoil
" ----_-• -- "-----------------------------•-------- ---------••"___-•-------------
x 10 I�.edium yellow sand _ __ _
------ ---- -_---
0 - �2 med. while sand races of ravel no wader a� 12
W ".._..."------- --------------------------------•-•----•------•-••. ..._----•--•---____-_-__.__-..._._-________...._..--..__.._"._-__...__.__-�._____________._---___._....______.____--------......
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
"""-""-"""-.--"______________________________________________________________________________________________________________•--._._____-__________.____..._----._._-_._.___-___________.._........____.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accord ce w'
the provisions of TITLE 5 of the State Sanitary Code— The undersign further agrees t t e th syke in
operation until a Certificate of Complianq�has e n issu d by the oar Health. '
Signed Pre.....• .$--3..a. .
Date
ApplicationApproved BY-"• c --""""""""-"""•.............."-"-".........._._.._..---•-•--".............---•-"-•-"----
Date
Application Disapproved for the following reasons:..............................................
..............................................................••--________...__._____...---•-..._---....-..___-•------........_________-___.._._....__._.___•---__________•---___._.._____-____-••••-••--
Date
PermitNo.._., 1K- y.r.............................. Issued_.......................................................
Date
L" JYi
Now.......::....,..... FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
....................................I.....OF..........................................................................................
Appliration for Ui,ipnsttl Work,i Tomitrurtion "rani`
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot # Black Oak Rd. , Yiarstons Mills!, MIA
......................�.._-....... .. ....._ •-•--•---•--------------••-•-••---•-•_----- ••-•••---.._..-----------•--•---..._--•---
Capricorn Re'd7ttiAl'i-Ust 765 Falmouth Ro`ah-;NHyannis
......................-.......................................................................... -••-•-••-••••---•------•....----•-•...----•--.._..•--••--------•--•-------•--•-----------.........
W Steve L e b el Owner Address
Instal Ier Address
Q Type of Building Size Lot............................Sq. feet
04U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building. :??�h............... No. of persons............................ Showers Cafeteria ( )
a' Other fixtures ---------------•••••--•••--••-------•-. .
W Design Flow......55.................
000 'gallons per perspr�i per day. Totl�diy�flow....................................... . bons.
## 6 lj((II�� 99
W Septic Tank—Liquid capacit,._..._.._.__ga]lons Lengt ________________ Widt ........._..._ Diameter._._.___..._.... Depth...............
x Disposal Trencl —No. .................... Wid 1 ------------------- Total Length..... _V---------- Total leaching area.... sq. ft.
Seepage Pit Nd.................... Diameter-_-�__---_-----__- Depth below inlet........_.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosiri�ltaik
re de Engineering 11-25-81
Percolation Test Results Performed by......................................... . . Date.._-........._...._.._..................
� y--•---•------••--- -
2.0 12 one er-countec-
,� Test Pit No. 1...............minutes per inch Depth of Test Pit ............. Depth to ground watt:_._ .___.._..__......
Li, Test Pit No. ��A___...__._niinutes per inch Depth of Test PiP WA
Depth to ground water`���._.._____.__... e
O0-i-----_---�-(---------1...................................l--------------------•---------•--.........................................................
0 of Soil......._. _�._.______. T t _ _
..
x '.e ium e ow san
wTU-'---------I2-r------fried: whi te... water at---12•
--- --------------------------------•-------------•-----_..._......----•--••---•--------•---••----•---•-•----•--•--•-----------------••------•------•---•-------------•--......•----------•••••----_....
V 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 TAITILL 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.
Pres.
Signed ................ �.
Date
ApplicationApproved By.................................................................................................
. /! 7- Date'/
Application Disapproved forjhe following 7-
.......-•--•--•---•-----•--...--•---------------••-•---------------------....•••--------•--.....•-••--•••---.............._..---•----------------------------------------•----••-••------•-----•••--•---
Date
PermitNo......................................................... IssuedL.......................................................
Date
THE COMMONWEALTH 'OF MASSACHUSETTS
BOARD OF HEALTH
T own...................o F......Barns t abl e
.. . .... ......
Trrtifiratr of Tuntplittnrr
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ) or_Repaired
by ( )
Steve Lebel
.............•-•--•..._••-- -•--------•-•-----.........------•••-•--•-•----.._.......---•-•-...--•--...----•----...._......
L ot .. Black Uak Road, 1�1 Install Marstons Mills , F-4A
has been installed in accordance with the provisions of TITLE- � of"The State Sanitary Code.as_described in the
application for Disposal Works Construction Permit No......................................... dated------..........................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCT O SATISFACTORY.
DATE...-------••---••-•-•-----_.4..1. g ................................ Inspector................. ' `
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
...........................................O F............---..................._..................................................
No.---.......•-•........... FEE........................
Dispouttl Workii Ton,strudion Vprrmit
Steve Lebel
Permission is hereby granted -- ----•----- -----------
Disposal System
at No........°t _z) - Black Oak 1%oad Iarstons Milli ,-i+;A
--n -
Street
as shown on the application f Disposal Works Construction Permit No..................... Dated..........................................
Board of Health
DATE....... .......................................
�r FORM 1255 A. M. SULKIN• INC.. BOSTON
1
\,\ M• \
N OF M{ss' ROB ' \
BR JCE
10 A E ELDRE'
o. MORSE
U L �- li,�
No.10951 O STF�`
/sTE . 6
cFSSlONAL F-a� _ _ _ G 1 , --
131
a P
O I Z F.
44\
AL ?�rL
L i �V°v C+
PrI
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v
LET
40
LEGEND
EXISTING SPOT ELEVATION Ox0 CERTIFIED PLOT PLAN
9XISTING CONTOUR --- 0 -- - _
P6AD:LSP4ED SPOT ELEVATION Lv* 9 ,�c. f! c c U �, Al ri c>.
F.4013HEO CONTOUR 0
NVtt: The location of any existing underground sewerage, - 1N
wells, or other utilities shown on this plan is approx-
imate only as determined from records and/or verbal �, ��� g�• �� , � ��
information. T�e contractor is responsible for the
verification o the existing locations in the field. SCALE- � '= 301 DATE 7 2-7/1f�
t,r DREDGE ENGINEERING Co- 'NoCLIENT.F I .CERTIFY THAT THE PROPOSED
MISTERS REGISTERED JOB NO. 3 z-S 6 BUILDING SHOWN ON THIS PLAN
CIVIL LAND 1DR.BY1 - " CONFORMS TO THE ZONING LAWS
E NO�EER RVOF BARNSTABL� MAS9,.r
712 MAIN STREET CH. By, R /3: � • .�, ,�1: ;: / ...,, ,. -- -
HYAIJNIS, MARS. SHEET.LOF DATE ' REG LAND SURVEYOR
NOTE /F ElTiYEM 7-,qe-5FP.T/C TAN/C OR
LE,tCHIivo P/T ARE "MORE' THAN /2"BELoJV
IO FT. M/�/ GRAOE,A 24'O/AM ETER CONCR.�TE COVER
SWALL BE BROUGHT TO GRA DAE.�i9N EXTRA
GONCRCTE 90PVC PIPE JyEAYy CAST/ROIY COVER Sf/-441— 8-6 VSEO
�L 6 Z_o- COVERS M/���TtT /F/" OR/V-=WAY
2 fq�o MAN. C4/VCR�TE •
A�? _ GRACE CO✓ER CLEAN .SANG
Xt
D VID LEYEL
4=•: SCNEDUL64O `�+ 4' _' %8ER%B
PKo a o -
/o9/N.o/TCN `Od O GAL. • 1 e • • a •.•o • e e•9b yyAS/IFO S729NE
%4'PEAR vT. SEPTIC TANK D I sT, • O e 1 • • e • • • e e a
B�� O e 1 � e s O 1! � .e0 •
�
3 4
/ a: .���o • • IEI=FECTlr� ` � � � •- � /2
• ° • • DEPTt/,• e 1 o e WASNED STO�t/E
- -. o • • e e. e e e• 1 e v •
lFrB'xz�•�r 47 � s• e • i • o • • •• •
_o r "7 PREI,AST SEEPAGE
1
CA p,q c i T 8 G.1 L���4y ►a, • • s . e o • o • • o pop P/7 OR �V/V.Nf/t teL EYA7"/OX S o e o o • • e. e e • • • o o
IM7
/NYE!{T AT BL//LD/NCs. S`� ° FT r 6 D1AJ4'!.
/A/LET SEPTIC TANK 58.�FT, _ F7 O/A1�9: C�5 F 7PlBlJLA770N�
dttTLET SEP7tC TANK. _ 513,3 FT..•
IAILET'OISTR/�91/Y ON BOX FI. SECT/GN 4F Y GROuNo tc�TER TABS E
Otl77.ETDIS7"R/,Bl/TtON�X S7 FT. � r- •
INLET i rAcwIIv1"r A-j-r .--5'7 o.97 SEWAME A01. . L.SY�ST�A! -rA j,AT10N ,
$CAI-E �4~ _ /=O•• dIMEI4LftOM. A
DESIGN CRI'rER/�4 D/PtrEIVSlQN _ =F'T. %
NUM6Efc OF BEDROOMS. 3 DIMENSION G_ FT. AIN.
G.4HOAG.EDr,SPosAL ulfltr Na SOIL. LOG S011 TESY' -
rD7rA4 ESTIMATED FLO*S! 3 3 -GAt./DAY SOIL TEST A/ SO/L T.-ST. 2
MUM8ER OAF 40ACMI NG P/rs / � Aer L S 7 6 0, o1 E OF SOIL TEST
S z s L EAGJ�ll NG PER PIT LSD SY� FT. r RESULTS PV17 E SSE® 46Y lT f3 E c/i4-`o a/
60TTOM Lrv4C.A,//NG PER PIT 7 SQ RT ti 0 A-7.111 AL PERCOLATION RATE#/ LDS MtI1SIINGH . .-
TOTAL LEACH/!YG AREA Z& � SQ. F7. � �'v/3 50/L PffA TIN RATE�2 TZ�M/N�IIVCi1
REs_ERVE LFr4CNlN6 AREA 2 6 6 SQ. FT. `
Of
/ate/vtij L o 7- 9 ,a tit ck O At-/< t-A.•.
o� ROBERT G.r ��P ��' /Ll/A-R S O./EIS /Y/!LL S I,
g BRUCE - a o? A
o ELDRE m4,
ORSE
O , .
17No.1095
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