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HomeMy WebLinkAbout0102 SANDY VALLEY ROAD - Health ��102 Sandy Valley Road Marstons-Mills A 101 • -085 r , 1 DATE:_ ;. /A1__ PROPERTY ADDRESS: 102• -Sandy,-V,- yjgy. Mass. 02648 ----------------- On the above date, I In3peoled the ceptlo •sy3tOTh at the above address. ThI3 3y3lem conslsls of the following, 1 . 1 -1060 gallon septic tank. 1 -600 gallon precast leaching pit. t ' X12 'X4 ' Based on my Inspectlon, I certlfy the following oonditlona; 3 . This is a title five septic system. ( 38 Code 4 . The septic system is in proper working order at the present. time. r 5. Pumped the septic tank at time of inspection. 6 . The waste water is 32" below the invert 0 �� pipe of the leaching pit. $IGNATURE;„/ --•�-=J %f� Name „ �.P . YJS9MtLL..,Uj__........ Company: Jo, .yh_P _ H&cowb9!:.& Son , rnc , Address :- Box_ 6 6--------__...._ -_Cent: srY111e L Ha_-02632-0066 Phone: 508_775=7338_______ THIS CIATIFICATION 001!3 NOT CONSTIYVYC A OVARANTY OR WARRANTY • CP'00. P. MACOMBER & SON, INC, ichl ""Pvmpod 4 In+tillyd Town 3twor Conneclow 66 C+ntorYllli, HA 02632.0066 776-3330 776,6412 .\ COMMONWEALTH OF MASSACHUSETTS t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 102 Sandy Ua 1 1 ray Rid Marstans Mills Owner's Name:Arl enra i lson Owner's Address: rbame Date of Inspectlon: 5/1 /01 Name of Inspector: (please print) T�ospnh P M cnin. er Jr. Company.Name:J.P ' MacomhPr i son Inc. Mailing Address: Box 66 t^r�ntarvill.o mass Telephone Number: 508-7 75—3 3--I 8 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true; accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on'site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _ Conditionally Passes _ Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: `d The system inspector shall bmit 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. Notes and Comments )'""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. Title 5 Inspection Form 6/15/2000 page 1 I Page 2 of I I , OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date or inspection: 4 f 27/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D rA. y�Fasses- Ale 1 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: septic system is in proper working order at the present time. B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. V,0 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 structwally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ydf t Observation of sewage backup or break out or high static water level in the istribution box ue to broken or obstructed pipe(s)or due to a broken, settled or uneve distribution box ystem will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced _obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4/2 7/01 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 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: X_Q 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 I of a public water supply. /LJQ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. Id The system has a septic tank and SAS and the SAS is less than 100 feet feet or more from a private water supple well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 I Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4 27 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no" to each of the following for all inspections: Yes No ckup 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 �_A)06/t? Static liquid level in th distribution box bove outlet invert due to an overloaded or clogged SAS or cesspool ,squid depth in4asspeeFis less than 6"below invert or available volume is less than ''A day flow !/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number — �of times pumped I ty 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 zwater supply. Any portion of a cesspool or privy is within a Zone I of a public well. _ � y portion of a cesspool or privy is within 50 feet of a private water supply well. ny 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma -1/0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board o� 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no th system is within 400 feet of a surface drinking water supply system is within 200 feet of a tributary to a surface drinking water supply _ Y �' g _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I WPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 I Page 5 of I 1 ' OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4/2 7/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes ypurnping information was provided by the owner,occupant,or Board of Health _ 2 Were any of the system components pumped out in the previous two weeks / ^ 1/ _ 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 e~Iuding the SAS located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the b ffles 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 _ P maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no _ / Existing information. For example, a plan at the Board of Health. !/— Determined in the field(if any of the failure criteria related to Pan C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 102 Sandy Valley Road Marst ons Mills Owner: Ar•1 anp Wi 1 cnn Date of Inspection: 4/2 7/fl1 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):—2— Number of bedrooms(actual): �DESIG.' now based on 310 CMR 15.203 (for example: 110 gpd x q of bedrooms). ,�1 Id ';A&Ile/11� Number o(current residents: sC Does residence have a garbage grinder(yes or no). t/d Is laundry on a separate sewage system ( es or no):4' (if yes separate inspection required)Laun dry system utspected(yes or no): Seasonal use: )or no(yes : &JI Y Water meter readings, if available (last 2 years usage (gpd)): Sump pump(yes or no): D Last date of occu anc : —Q P Y COMM ERCIALUMUSTRIAL Type of establishment: �¢ Design now(based on 310 CMR 15.203): 4-),4 gpd Bans of design now(seatsrpersons/sgh,etc.): A0 Grease trap present(yes or no): Indusmal waste holding tank present (yes or no): Non sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OT H E R (describe): ,{J� CENERAL INFORMATION Pumping Records So`.rce of information: A), s 7' ulA % as system pumped as pan of the inspection (yes or no): es. %olume pumped. / gallons •• How w s ua ttry pumped determined?�Pi "*41 Reason for pumping: _>i`e.�11y �ct�.� ,� TYV OF SYSTEM Septic tank, dise4titilen box, soil absorption system r Single cesspool Overflow cesspool Privy ,Uj° Shared system (yes or no)(if yes, attach previous inspection records, if any) 4& Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be ootatned bom system owner) Tight tank ,I&Anach a copy of the DEP approval lj�h Other(describe): 4/16 Appr .ximasaee of all components,date installed (if known)and source of information: were sewage odors detected when arriving at the site (yes°or no):1-b 6 i Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propene Address: 102 Sandy Valley Road MArctnnc Millc Owner: Arl ane Wi 1 enn Date of Inspection: 4/27101 BUILDING SEWER (locate on site plan) �f d • Depth beloµ grade: ----L-- s Materials of construction: cast iron �0 PVC ✓other/ (explain):kiLw r �lJG, Distance born private water supply well or suction line: /d50-" Comments (on condition orjoints, venting, evidence of leakage, etc.): ,joints apDear ticrht.No evidence of leakacfe.System is 160 �S vented through the house vent. SEPTIC TANK: locate on site plan) Depth below grade: � Material of construction: ✓concrete, metal.t/d fiberglass✓y12Polyethylene UD other(explain) ,(Jig !i tan, is metal list age: Is age confirmed by a Certificate of Compliance (yes or no):,tA(attach a copy of cenificate) Dimensions ��� -yi.' ���tA�d� (���/�✓J Sludee depth: Distance from top of sludge to bosom of outlet tee or baffle Scum thickness: �Q— D!stance born top of scum to top of outlet tee or baffle: D.sLance from bonom of scum to bonom of outlet to or affle: C� Hoµ Here dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels as.related-to,outict'nYen, evidence�of leakage,etc.): —Pump' the septic tank every 2-3 years. Inlet & outlet tees are in place.The tank is structurally sound and shows no evidence '�o��f"�"" leakage. GREASE TRA1449x .(locate on site plan) Depth below grade:dL Material of constructionA{aconerete,(metal4LtfiberglasWepolyethylene4_other ;explain) XIA Dimensions: Z4 Scum thickness: Distance from top of scum to top of outlet tee or baffle:_AIA Distance from bosom of scum to bonom of outlet tee or baffle: 4)h _ Date of last pumping: t `L Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): C;rPaSP trap i S not nracPnt- 7 r Page 8 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM • PART C SYSTEM INFORMATION(continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arl ana Wi 1 snn Date of Inspection: 4.427.101 TIGHT or HO .DING TANW,�,t (tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: V4 Material of consaruction: concrete metal &&Lfiberglass ,IZ Polyethylene A&other(explain): .11�! Dimensions: A14 Capacity: gallons Desien Flow: AM gallons/day Alarm present(yes or no): _,VX Alarm level: A1,4 Alarm in working order(yes or no): Ali Date of last pumping: Am Comments(condition of alarm and float switches, etc.): Tight or holding tanks are not present. DISTRIBUTION l30Y4 c. (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:—& 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.): i)isi-rihntinn hnx is not prasant_ PUMP CHAMBEW&je(locate on site plan) Pumps in working order(yes or no): A)4 Alarms in working order(yes or no): .d1A Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pumas ehamhPr is not nrr�sant c L 8 f • Page 9 of I I • OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 Sandy. .Valley Road Marstons Mills Owner: Arlene Wilson Date of inspection: 4/27/01 SOIL ABSORPTION SYSTEM (S.�S): locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: _ leaching galleries,number: P leaching trenches,number, leaching fields, number, dimer,:,ions: overflow cesspool, number:d ,,,,�� A Dinnovative/altemative systen: ype name of technology:71ye— Comments(note condition of soil, s:: :is of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to medium fine sand.No signs of hydraulic failure or ponding_._.Soi.ls are dry.Veaetation is normal CESSPOOLSt�(cesspool rrus: Pumped as part of inspection)(ldcate on site plan) Number and configuration: 0- Depth-top of liquid to inlet inveru: Depth of solids layer: Depth of scum laver: �,tt Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(.\-::, or no): Comments(note condition of soil. :.. :is of hydraulic failure, level of ponding,condition of vegetation, etc.): Ces5pools are not nresent- PRIVY rl,(locate on site plan) Materials of construction: 1_4J4 Dimensions: Depth of solids: Comments(note condition of soi;. _ ) hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present. _. 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 2 Sandy Valle Road Marstons Mills Owner:Arlene Wilson Date of Inspection: 4/2 7/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 1 U 2 $anc1, alit Kol , �ar3�aV�5 V�l��� 10 • Page I I of I I ' r • OFFICIAL. INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propem Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of inspection:._4/27/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system desi lans on record •.If checked,date of design plan reviewed: serve siteuaing properry bservation hole within 150 feet of SAS) _ hecked with local Board of Health-explain: Checked with local excavators, installers. (attach domnentation) _ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used water table contours mar, Gahrety & Miller Model 12/16/94 II •. • ; s TOWN OF Barnstable BOARD OF HEALTH SUNSUNFACR SEWAOF, DIS MS AL SYSTEM JH8PKC7I0N FORM -' PART D •- CERTIFICATION -•ten�►...•, -•.u -..�.+v.,n.a/wn�w��+rn•.w++�,�.��•.•��..w-��wvw�.wwwww� nw w-.r..--�. _. 1 -TYPE CIA PAINT CLEA10- PROPERTY INSPECTED STREET ADDRESS 102 Sandy Valley Road Marstnn� Mi11G ASSESSORS HAP , DLOCK AND PARCEL I OWNER ' s NAHE Arlene Wilson i PART D - CE1irIFICATI0N NAHE OF INSPECTOR Joseph P. Macomber Jr, ` COHPANY NAME Joseph P. Macomber &'''Son, Inc. COMPANY ADDRESS Bow Centerville MA. 02632-0066 trevi Tovn or City scat. cTP COMPANY TELEPHONC ( 508 ) 775 - 3338 FAX ( ) - CCRTIFICATION STATEHCNT I certify that I have personally inspected the sewage disposa`1 system nt this nddress and that the information reported is true , accurate , and omplete as of the time of .. inspection . The inspection was performed and any recommendatlons regarding upgrade , maintenance , and repair are consistent With my training and experience in the- proper function and maintenance of on- site sewage disposal systems . Check ne ; 4 v ' System PASSED The inspection ;rhich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CHR 16 . 303 . Any failure criteria not evaluated are as stated in the -FAILURE CRITERIA section of Lhis form , System FAILED* The inspection which I have con hcted has found that the system fails to protect the E)tiblic health and the environment in accordance with Title 5 , 310 CHR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector 8ignatuzr ':�Aj -M,Z6' /. Data ..... no copy of thi rtification must be provided to the OWNER, the BUYER Dh.re applloable ) and the AOARD OY HEALT,I . ";`perator shall u� pgrade ' the syetem If the Inspection FAILED , thb owner or o within one ,year of tl)e date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 . partd , doc • DAT2:_�I^ /.A.1____ PROPERTY ADDRESS; 1n� _%ajUj,y -V-ajjajA„ •-Mass 02648 ------------------------ On the above date, I Inspected the septic ,systO'M at the aboye address. This system conslsts of the following; 1 . 1 -1000 gallon septic tank. 1 -600 gallon precast leaching pit. 'P''X12 'X4 ' Based on my Inspection, I cortlfy the following oondltlonu 3. This is a title five septic system. ( 78 Code ) 4 . The septic system is in proper working order at the present. time. 5. Pumped the septic tank at time of inspection. 6. The waste water is 32" below the invert pipe of the leaching pit. SIGNATURE:,� Company: Jo�•ph_P : H•comber_& Son , Inc , Address : Box 66----_— —————— ------- _-Cent erYilleL Na ,_02632-0066 Phone, 508-775_))28-__ THIS CERTIFICATION OOES NOT CONSTITVTE A OVARANTY OR WARRANTY • C P, MAC0MBER & SON, INC,+nki-Cesipoolt•lea<chflelds Pumped 4, Initl;lledTown Sewer Conneotlone 66 CenlerYllle, MA 02632.0060 775-3336 77$.6412 ,per .\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 102 Sandy VA 1 1 Pv Road M i , j s Owner's Name:Arl inns jAi i g$P Owner's Address: Date of Inspection: „5/1 /01 Name of Inspector: (please print) jo-gp-ph P macomher Jr. Company Name:J P MacomhPr R cnn Inc. Mailing Address: Box 66 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection..The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature?bmit Date: The system inspector shall 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 authoriry. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I f Paee 2 of 1 I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of inspection: 4/27/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. ystem 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: Septic system is in proper working or er a present time. B. System Conditionally Passes: 1410 One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined" please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: ,oftf/e Observation of sewage backup or break out or hi static water level in the istribution box ue to broken or obstructed pipe(s)or due to a broken, settled or uneve distribution box ystem will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: .418 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 obstruction is removed ,,c" ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: _ 4/2 7/01 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: JI/C�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 any) determines that the system is functioning in a manner that protects the public health,safety and environment: /l © 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 I 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. 420 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 supple well•'. Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4/2 7/01 D. System Failure Criteria applicable to all systems: You must indicate'-yes"or"no"to each of the following for all inspections: Yes No ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool J Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool psp1/Q Static liquid level in th distribution box bove outlet invert due to an overloaded or clogged SAS or esspool _ &%equired iquid depth in.Gesspes is less than 6"below invert or available volume is less than 'h day flow pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s), Number — �of times pumped f 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. _ v portion of a cesspool or privy is within 50 feet of a private water supply well. 3�ty 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma ,JID (Yes/No)The system tails. 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes !/? t system is within 400 feet of a surface drinking water supply _ 7system 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. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4/27/01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes N � 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,~luding the SAS, located on site ? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the b ffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?P 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: Yes no Existing information. For example, a plan at the Board of Health. � — Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)) 5 Page g 6ofll OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 102 Sandy Valley Road Marstanc Mi11c Owner: Arl ana Wi 1 con Date of Inspection: 4117Im FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):Jp_ Number of bedrooms (actual): DESIGN now based on 310 CMR 15.203 (for example: 110 gpd x q of bedrooms): X/d -;31jtelle� Number of current residents: 1_ Does residence have a garbage grinder(yes or no): i.0 Is laundry (on a separate sewage system es or no):Zd- (if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use: (yes or no): Water meter readings, if available (last 2 years usage(gpd)): /. �� = '�y �'� Sump pump(yes or no): .' e Last date of occupancy: : —0 COMM ERCIALMfDUSTRIAL Type of establishment: Design now(based on 310 CMR 15.203): A)A gpd Basis of design flow(seats/persons/sgft,etc.): A0 Grease trap present(yes or no): &0' Industrial waste holding tank present (yes or no): .Non•sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: ', Last date of occupancy/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: / 7- Was system pumped as pan of'the inspection (yes or no): I!'\cs. volume pumped: /&V gallons •• How w s uanurry pumped determined?/�llr'•tl G / Reason for pumping: h/eAV'y Jcy ��a , TYV OF SYSTEM Septic tank, disw4wien bait-soil absorption system tpr Single cesspool Overflow cesspool ,( Privy IJO Shared system(yes or no)(if yes, attach previous inspection records, if any) 4& Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank s,A) Anach a copy of the DEP approval /l h Other(describe): Ale Appr_o.ximat.C..a2e of all components,date installed (if known)and source of information: w'erc sewage odors detected when arriving at the site (yes or no): 6 r Page 7 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propene Address: 102 Sandy Valley Road Marctnng Mille Owner: Arl ant- jaj I Qnn Date of Inspection: 4 f 27.40-1 BUILDING SEWER (locate on site plan) rl Depth below grade: & A Materials of construction:4y1cast iron LDt O PVC Pother(explain):4 av r �l/� IX' Distance from private water supply well or suction line: r14'�O— Comments(on condition ofjoints, venting, evidence of leakage, etc.): Joints a ear ti ht.No evidence of leaka e.S stem is me �/� / vented through the house vent. SEPTIC TANK: (locate on site plan) r/ Depth below grade: Material of construction: ✓concrete ometalfldfiberglasWIpolyethylene Q)other(explain) k5_ 1 i tank is metal list age: Is age confirmed'byyra Certificate of Compliance (yes or no):.&A(attach a copy of cenificate) Dimensions: s-y ,W, Sludee depth: y ' Distance from fop of sludge to bottom of outlet tee or bafilep(, Scum thickness: Distance fiom top of scum to top of outlet tee or baffle: Distance from bosom of scum to bosom of outlet teS or baffle: Hoµ were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition. structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumpathe septic tank every 2-3 years.Inlet & outlet tees are in place.The tank is structurally sound and shows no evidence�� ��""""of leakage. GREASE TRAr (locate on site plan) Depth below grade: Material of construction-Akconcreter,# meta l,PSAflberglas l?lolyethylenerh other (e\plain): WA Dimensions: A14 Scum thickness: Distance from top of scum to top of outlet tee or baffle: AIA Distance from bottom of scum to bonom of outlet tee or baffle: Vh Date of last pumping: *t),4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Crease trap is not prPgPnt 7 Page 8 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 102 Sandy Valley Road Marst-ons Mills Owner: Arl ana Wi 1 con Date of Inspection: a f 27.4Q] TIGHT or HOLDING TANW,�c (tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: 4A9 Material of construction:d1h concrete metal 4fiberglass dg Polyethylene Aother(explain): Dimensions: A14 Capacity: gallons Design Flow: AM gallons/day Alarm present(yes or no): V,4 Alarm level: v,4 Alarm in working order(yes or no):.1 Date of last pumping: .414 Comments (condition of alarm and float switches,etc.): Tight or holding tanks are not present. DISTRIBUTION BOXt&v, (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): Distrihnt-ion hox is not nracant PUMP CHAMBEILLalk-(locate on site plan) Pumps in working order(yes or no): xM Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Plimp nhnmhPr i c not =scant 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 02 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4/27/01 SOIL ABSORPTION SYSTEM (S:6): locate on site plan,excavation not required) If SAS not located explain why: Ct 6 , Typeleaching pits,number: leaching chambers, number: _ aleaching galleries, number: A leaching trenches,number, len: .h: leaching fields,number,dimen:,ions: overflow cesspool, number:6 _ AjDirtnovative/altemative systen, 'vpe/name of technology: Comments(note condition of soil. s:. ns of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.): Loamy sand to medium fine sand.No signs of hydraulic _failure or ponding.Soils are dry.Veaetation is normal. CESSPOOL y(cesspool rr.us', pumped as part of inspect ion)(locate on site plan) Number and configuration: Q Depth—top of liquid to inlet inven: ' Depth of solids layer: AN Depth of scum laver. Dimensions of cesspool: Materials of construction: j� Indication of groundwater inflow(y::, or no): Comments(note condition of soil, _.., :�s of hydraulic failure, level of ponding,condition of vegetation,etc.): Cesspools are not pent_ PRIVY4iJ�(locate on site plan) Materials of construction: Dimensions: j Depth of solids: AW Comments(note condition of soi; : , .:s Of hydraulic failure, level of ponding, condition of vegetation,etc.): Privy is not present. _. 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 102 Sandy V_ a_ 11-ey Road Marstons Mills Owner:Arlene Wilson Date of Inspection: 4/27/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. po� � / 10 Page l l of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem-Address: 102 Sandy Valley Road Marstons Mills Owner: Arlene Wilson Date of Inspection: 4/27/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: Obtained from system design tans on record - If checked, date of design plan reviewed: serve site a utting proper�t bservation hole within 150 feet of SAS) _ hecked 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: Used water table contours map. Gahrety & Miller Model 12/16/94 11 r +•r'wan.-wry-�*-twrwr•rn.+rrwA'w.+w#n,wwAlw/.wwnTR�v►A'�1.�11nn TwT-.-Tew-' . .- 'TOWN OF Barnstable DOARD OF HEALTH 9U1)SURFACF 9FWACP DISPO,4AL ,SYSTEM INSPECTION FORM -' PART D •- CERTIFICATION -TYPE OR PAINT CI.CAALY- PI?OPERT Y INSPECTED STREET ADDRESS _ 102 Sandy Valley Road Marstnnc Mi115 ASSESSORS HAP , DLOCK AND PARCEL I OWNER' s NAME Arlene Wilson PANT D - CERTIFICATION NAME OF INSPECTOR _ Joseph P. Macomber Jr, COMPANY NAME Joseph P. Macomber &,'Son, Inc. COMPANY ADDRESS Box 66 Centerville MA. 02632-0066 SCr•It Tovn or City >ftat• I P COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( j - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage d1sposs`1 system at this address and that the information reported is true , accurate , and omplete as of the time of .inspectionI The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne : � Sy y I . stem PASSED The inspection «hich I have conducted has not found any information which Indicates that the system fails to adequately protect public health or, the environment as defined in 310 CHR 16 . 303 , Any failure criteria not evalunted are as stated in the FAILURE CRITERIA section of this Corm , System FAILED* The inspection which I have con acted has found that the system fails to protect the j)ciblic health and the environment in accordance with Title 5 , 310 CHR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signatur AEG ZDate atn s copy of thi rtification must be provided to the OWNER, the BUYER h-r- applioable ) and th• DOARD OY HEAL'I'll. • If the inspection FAILED, thb owner or operator shall upgrade ' the eyetem within one ,year or the date of the inspection , unless allowed or required otherwise as provided in 3.10 CHR 16 . 306 . partd . doc W ti b - SbjY 3J71 TEE COMMONWE.A LT]EI OF MASSA.CHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE TT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Departiment's qualifications as required and is hereby authorized to use the title CERTLFI ED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the i General Laws_ Issued by The Department of Environmental Protection_ I )uoc a. 1995 I Acung Director of the ion of Watcr Pollution Cooturol r t; CO'MOMVEALTH OF Mgg3ACHUgETTS CX . EXECUTIVE OFFICE OF Ertvl ) - DEPA,IgT�ENT OF EVI NiO1�h; Frt �FAIRS MENTAL T PROT N CTIO TR 2 I P4 42: 3 I� 3/,�,-T- iVI 16 OFFICIAL.INSPECTION FORM TITLE S NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM PART A CERTIFICATION Prop"Address: So►h d 4wnEy's Name; G 04 rIn (,t/i DoZ -g Owacr's Addn mss Date at Name of Iospector. lease pr(nt)Company Nam: !/i 0— G n8 Addrets: o �P /at TelephoaeNumbert tiger A�Gu,1 CERTil CATION STATEMENT I certify that I have pe��'inspected the sewagecomplete disposal system at this address and Ong and experience a rw the as of the time of the inspection.The. that the i am>ation approved system i PWer f niction and sewn 'Ott was performed based o"moo inspector pursua:Z� maintenance of on site sewage disposal Sy�m&j 13.340 of Title S j310CMR iSOMq; �e �a DEPasses system Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: The system inspector shall submit a Date: DEP)within 30 cop'of this inspection report to the A qIfOving gpd or greater s of completing this inspection,if the system is a shag ,n sty Ei3oard of Health or DlP.The original should be��thand e owner shall submit the ��flow of 14,(N� authority. system owner and copies Sent to the buyers abl te regional a d the a of the Notes and Comments plxovtng ****'Mis re port only describes conditions at the time of time,Thi1 inypgCtion doe.,not address how s the h y v inspection and under the conditions of use at that conditions of use, e•y tem will perrorm in the future under the same qr different I i I Pate 2 Of 11 . OFFICIAL IlVSPECTION FORM NOT FOR V +' SUBSURFACE SEWAGE VOLUNTARY AS E DISPOSAL N FORM ME POSAL NTS SYSTEM INSPECTION FQRM PART A CERTIFICATION(C°n ) ftvWdyAddn! s: Date of InsPectioe: Lispectlon Summary: Check A,H,C4 or E complete all of Section D A. Sy Passes: —_ 1 lave not found any information which in 15.303 Orin 310 C11r1R 15.304 exist ,failumcateS that any of the failure criteria d bed in 310 CMR criteria not evaluated are mated below. Comments; ConditlonaUy passes: Br Syste �otmorerepaired The system components as described in the"Conditional �' upon completion of the "section need to be repb or ent or repair,as approved by the Board of Health will pass. Answer Yes,no or not determined MNexplain. ,ND)in the — for the following statements.if"not determined. please The septic tank is metal and over 20 years old'or the unsound,exhibits substantial infaltration or exfil Septic tank(whether metal or not)is structure existing tank is replaced with tratioe or tank failure is �' *A metal septic tank will a� � septic tank as approved 1 system will paw�spection if the indicating that the tank is lest rectron if rt ly sound,not leakm Board of Health.indi than 20 years old is available. g and if a CertW=te OfCoMpliaMe ND explain; O?semation.of sewage b 1ckup Or break out or hi obstr t Pipe(s) or due to a broken,settled or uneven is static water level in the clstributiOn box approval of Board of Health); disnibudon box System C dll due to broken or pass inspection if(with N0�n IWPe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain; The system required pumping more than 4 Pass inspection if(with approval of the Board of Health):times, year due to broken or obstructed prle(s)• Tle system will broken pipe(s)are replaced obstruction is removed ND e..vlain: j I . P%sBe 3 of 11 yi ' OFFICIAL INSPECTION FORM NOT F " SUBSURFACE SEWAGE D OR VOLUNTARY ISPQSAL SYSTEM INSPE T ASSESSMENTS E U�TS PART A CERTINCATION(cow Property Address.- la Sir,, AQ- C'l Owner: t v Date of IBspecEbat 3 _ C. Further rwaluati.is Required by the Boyd of Health: Conditions exist which require fUther is arhn��o Pict WA s�yor the evaluation the Hoard of Health in order to determine if the syste L System will pass unless Board of Health determines system is sit Au"Q trig in aver which wil In accordance with 310 C11�[R U303 1 h,�satetg and the.eat)rote )that the — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated w0daad or a salt marsh Z. System will fail unle"the Board Of Health system is functioning in a manner that (and Pbj'c Water Supplier,it any)determines that the Protects the public head,s��,9nd environment; The system has a septic tank and soil absorption s"�water supply or tributary to a mace water sum (SAS)and the SAS is within 100 feet of a —- The system has a septic tank and SAS and the SAS is within a Zone t Of a public water supply, — The system has a Septic tank and SAS and the m le SAS is within SO feet of a private water supply well. _. The system a septic tank�SAS�the SAS is less am gate water supply well** ,mod used to dete mm distant 100 feet but 50 feet or more from a **This s'skm Arises if the well water bacteria and volatile orpznic comp ems'Aerfoled at a DEP Wrtif od laboratory, for lif the fence of ammonia nitrogen indicates that the well isfm from pollution fromo Ann failure criteria an;tri g and nitrate nitrogen is equal to or less ���'� A Copy of the analysis must be attached to this fnoppM provi�that no other 3, other 3 1Me 4 of l l K • OFFICIAL INSPECTION FORM_ SUBSURFACE SEWAGE DISPOT FOR OSAL SYSTEM INSPECTION ASSESSMENTS PART A ECTION FORM CERTIFICATION(continued Pt r ty Address: ,O cj VJ Date of bspectioa; _ a D. System Failure Cri#eria appllcahle to all ay1teml; You must indicate`Yes"or"no"to each of the following for all Yes No i uom Di of sewage inSO fkwty or s'�'component due to over o r gpd US�cesspoolnd�8 of eDiuent to the surface of the gro d or or loaded clogged SAS or cesspool surface waters due to overlo an aded or Static liquid level don box above outlet invert due to an overloaded or clogged SAS or in theRequired dcon cesW1 is less than 6"below invert or available vo1 l ping more than 4 times in the last ume is l e d�,flow /6f trim piped_ Y�r NOT due to clogged Piers).Number ,AW t�oa of - �poctioa of cess L oOr�is below high Wound water elevation, /w sup* privy is within too feet of a surface water supply or tributary to a surface cesspool or privy is within portion of a n a Zone L of a public we1L _ �,Iyportion of a or lmvyY is within 50 feet of a private water su Supply well with l or privy is lees than 100 feet but greater Sp well.m a performed w a no We water quality analysis private water red laboratory,for coliform b systemPasses if the well water analysis, 81 indicates that the well is free from and volatile o �> ee and nitrate nitrogen Pollution from that facility and the rggak compounds h»gen is equal to or leas than S Presence of ammonia are triggered.A co of the analysis must he• pp., provrded that no other failure criteria py y attached to this form.] lye descrNO)The syskm�I have determined that o described in 310 CUR 15.303,therefore the ne or more of the above failure criteria exist as Health to determine what will be n system fails.The system owner should co �Y to correct the failure, n Board of E. Large Systems: To be considered a large system the system must serve a[acility with a design flow of 1 gpd- 9,0"gpd to 15,000 You must indicate either`Yes„or'-no"to each of the following; (The following criteria apply to large systems in addition to the criteria above Y s ad ) system is within 400 feet of a surface drinlang water supply the systcr_n is within 2()n fit of a tributary to a surface drinlring water supply system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-I�ypA or a . ll of a public water supply well ) mapped If you have answered"yes" to any question in Section E the"Yes"in Section D above the far system is considered a significant significant threat system! faor failed underiled,The owner or operator of a_ la great,or answered 15104,The System Owne�hou d contact the Section D n3' rge system considered a shall upgrade the system in accordance with 310 CMR 1pp"P6,1te regional office of the Department, s page 5 of 11 . ' OFFICIAL,II�TSBECTION FORM—NOT FOR VOLUNTARY SiTBS FAQ SEWAGE DISPOSAL SYSTEM INSPECTION PART B FORM CHEECKUST Property Aaaiug AS A— Owner: (�(l,Xf.l t °�/�j.5r Date of Inspection: Check if the f011owinp.have been done.You most indi cate es7 ory no..as to each of the followin Yes/No !/ /PumPmg information was P rowded by the owner,owupant or Board of Health Were any of the system ComponentsPumped out in the Previous two weeks the"M remived.normal flows.m the boas two wear period —/— Have l�'vo�nes cif water.be�mooed to the �L Were as-bum Plans ��or as part°f�1°�on Plans'If the system obtained and examined?(1f 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 component%excluding the SAS,located on site Were the septic tank des o of the baffles or tees,rnater�ial of construction,dimensions, d� 0!of of tunic mcp��for the c � Was9��depth of sludge and depth�� of�sewage& owner fand WPMW fmm owner)Provided with information on the proper The she and location of the Soil Absorption System(SAS)on the site has been Yys�no coned based on: Existing information.For example,a plan at the Board of HWtL —_ Determined in the field(if ro of the failure criteria related to part Cis at issue aPP� mation of ' is fable)010 CMR 15.302 3 dista= Page 6 of 11 OFRML INSPECTION FORM_NOT FOR UBSURgA�SEWAGE DISPOSAL VOLUNTARY SYSTEM INSPECTION FASSESORM MWTS PART C RM SYSTEM INFORMATION Psroperty Address; �(� ,LV. L,oIleQ Omer. Date of Inspectio; a c p FLOW CONDITIONS lf=lb r of bedrooms(design): .Z N N �DIESIGN ffory ba.9od on 310 Char5.203( ����(��)� "Z Does r�denoe�twve a� ��: 1 k 0 gpd x#�of bedrooms): Is laundry on a sep�wage syste or no): mspectCc �(yes or no):?103"00)'" fifyel �spactiion p p Ss►'f a usage(Yes no):� Gast 2 years use (may Last date of occupancy: w�- COMI UXCU L/ODUSTRIAL TYPe of establish Desig°gow ftsed on 310 C- I S.203).Basis of designGrca fl (seatyp���etc.): �P l�sent:ow(yes or no):tmk — Non-sanit I wad�gharged to� C.(yes of no) the Niue s Wade (yes°F )r"Ida1eadin if availa6ie: sY�em °p lash °f 0° y/ase: OTEER(describe): PumpLig DeCords. GENERAL,INFORMpTTON Source c7fwo.=fm.Was system Pumped _ If Yes, �P Pe& art P of the inspecti n(yes or no):� me e o• - ,6d son fw�g -�Itons-How was quawty pumped determined? Tz�fuw*distribution x,soil Single cesspool box, On System Overflow cesspool _privy Shared system(yes or no)(if Yes,aawh previous. U�ternative rtechnolem, ogy,gitach a�,0the OATcnt 0records,if station and —Tight tank Attach a copy of the DEP apprn al contract(to be — Other(describe): Approxiinalte age of all con p°nct%date installed(if known e of info Lion: Were sewage odors dctectcd when arriving at the site(yes or no): � U I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL,SYSTEIII INSPECTION FORM S SYSTEM Il�p T C INFORMATION(coximu Property Addrgs: /O.L -Sand led Owner: 6V V Date OfInspectoa o - .Z?- BURDMG U_WER(taste on site plan) Depth belowgra&. / , Materials of constructz iron _top _�pVC (explain): Distance from private water supply wen or suction COS(oncondition�jointa�venting. of 1eakag,�etc.): SEPTIC TAAIIL_�(1 site plan) Depth below grade. /oil Material of consftuc"a _other(explain1) concrete--' -- ._polyethylene if teak is mew list age:_ Is age conSrnied by a Certifiate of Compliance o ceAwcate). c r, (Yes no):_.(attach moons• � a copy of Sludgedepft , Dtenoe at. Scum to bottom of outlet tee or baffle: top of scum to top of outlet tee or bale: bottom of scam to rta/moutlet tee How wen dimensions d ce ba81e: !/ Comments(On Pumpng nacotiime e, e Cie f c C� as fated to outlet inv of met sad ou et tee or ba8]e condition, .,� ,„ C� y�gge,etc.): &ity,liquid levels � Q q r GR ''7'ItAP:[L'.(l�ocate on site plan) Depth below grade: Material of construction; — CO°�� (explain): — _metal rgLW--JVIYethylene_off Dimensions: Scum tluclmesj;Distance ftm Distance from'Gi of'SCUM to top of outlet te or e baffle: bottom of scum to bottom of outlet tee or t1e= Date of last pumping Comamnts(on pumping recommeridap° as related to outlet im, o ma inlet and outlet tee or baffle condition, uctural lute err,evidence f leakage,etc.): l�tY, liquid levels )ell f� � I i Pages of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION(continued) Prq"Addy w c, LA 41e �Io� Owne,: 1A1, lsOh / Date of Inspection: of- as . 06 TIGHT or HOLDING TANK:Z(tank must be Pumped at time of inspection)(locate on site plan) Depth below grade: Makriai of construction concrete metal fiberglass_.polyethylene o Dions: )� Capacity: ,�„L D�ignFtow: ��,� At==l (yea or no): Alarm level:. Alarm in working order(yes or nop Date of be pnmpang: Comments(condition of alarm and float switches,etc.): DfSTKIBUTION BOIL: (if present must be opened)(locate on site Pam) Depth of liquid level above outlet invert: l�ift or(note boof x is distributionto outlets equal,any evidence of solids carryover,any evidence of PUMP CRAMMER.- (locate on site plan) A=ps m working order(yes or no): Alarms in working order(yes or no): Comments(note condition of Pump chamber,condition of pumps and appurtenances,ctc.): i 1?aga 9 of 11 r{ OFFICIAL,INSPECTION FORM_ SUBSURFACE SEWAGE fl NOT FOR VOLU111TARY t DISPOSAL SYSTEM INSPE Y ASSESSMENTS PART C ON FORM Ad SYSTEM INFORMATION(Con PmPerO /o� ` Date of Inspion: / SOIL ABSORPnON SYSTEM(SAS): — pocate on site 1 Pan,excavation not required) i If SAS not low Baia why; Ml j lealchm gain mbevr " leaching =1 'nmmber, ovona: ►ealt�,e sours(note confto'()f'iilms.� of technology; s ,hydraulic failuue,level ofpon p soil,condition of vegeo4 spa,M s- eE&SPOOLS:-d'f(Cesspool must be lmnped aspen of ins eWocate Number and cowl=tion: pon� on site plan) Depth-top of l' to iN Depth of solidsbye, et invert: Depth of scmn layer Di ons of cesspool: Materials of counlction: Indcation of groundwater inthow Comments(note (Yes or no):— mlitioa of soil,sigrs of hYcfraulic fail ure,level ofpon&�condition of vegetating etc.): PR"'�L Oocate on site plan) MaterWs of construcpoa Dilnensions: Depth of solids: Comments(note --,-condition of soil,signs of hydraulic failure,level of pone"dition Of vegetalog etc.). i r , • Paso 10 of 11 ' OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS PART C FOR SYSTEM INFORMATION(continued) Property Address: Owner: Date of In gMmon;:7704 at?- 0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewagediVosW system including ties to at least two benchmarks.Locate all wells within 100 feet.Locate where public water mppty en builthe ding or Y -?v " n _ LN- v� f Pose 11 of 11 r a OFFICIAL INSPECTION FORM T NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(c�ontimrod) property Accrete vti/le j /1 w• offs . �� owner. L✓dSOr p) &Ate of Impaction: dL-d7- o SIB LRAM- sicnx sine water 5G. Check cellar shallow wells `o/J t� 0 Git Estimated depth to ground water/6 G feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-H checked;date of design plan reviewed: ssite(abutting property/obsuvation hol within 150 feet of SAS) Checked with local Board of Health-ern:_�"'l•cPf Checked with local excavators,installers-(Mach documents on) 7- Accessed USGS database-explain: You must describe how you established the high ground water elevation: rOrLw W.v t � f OCc. o V 40 fo to 0 vc • _� rD .0 0 m 0 A� IC I,7 sdW a-53 zo�� a � Y i 0 C t N SEWAGE PERMIT* fig. Pbf I N S T A. l_LER'S M A M E ADDRESS 7T S UILDER QR OWNER DATE PERMIT IS.SUED DATE COMPLIANCE. ISSUED � � ;. 3 At ` l �03 ` few �� • ••. Nofl:_ Fps.... v................ :THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town4 .` ..............OF...Barnstable .::........ .... ...... ....................................................................................... ,A I lo ` tir,Blisposal Works Tonstrurfiun umi# Application-is hereby made'for-a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal `System at I,ot 123, Sandy Valley Rd. Yiarstons Mills I A. .:................. --........--•-••-•---..............--•---.........................--_... .........-------•.....---••--••------••-------------•........----.....---.....--_.......--.---- Capricorn Rbodlt)�"TTust 765 Falmouth RPfd-,d Q°•Hyannis •-...................-......................................................................... ....................._..................................----...........-----...------•---••......• W :-.' 'Steve T ebel Owner Address Installer� Address U Type,of Building 3 Size Lot.......................... .. q.S feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Buildin ranch ..__ No. of persons............................ Showers 2 C4 yP g •----•--•-- P ( ) — Cafeteria ( ) a "Other fixtures -------------------------------•----•-••------------•---------------•--------------------------------•-•-------••----......__...----•--..._......---- Design Flow........� ..........................gallons per pers ppe�r day. Tot ity flow-_--...--330........_.........._.._....gallons. 04- Septic Tank—Liquid capacity 000 gallons Lengtff.b......... Width................ Diameter________________ Depth5-............ "- Disposal Trench—No..................... Widt _ ................. Total Length Total leaching area .. ."sq. s ft' x.,, p r g Y......-•- g q• 1 6 ass•-•---- >x, Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z ' .Other Distribution box ( ) Dosin a ` cr4dAe Engineering 11-25-81 Percolation Test Results Performed by....................... Date............__........_._.__._......_... Test Pit No. 1....' ..._._minutes per inch Depth of Test Pit_. 2..___.__._. Depth to ground watepon/e...encounter— Li, Test Pit No. 2I�...... __..minutes per inch Depth of Test Pit�� ............. Depth to ground water. 1..ti..___....._. e r� l------------------.-.---.---.--------:-1 •---.--.-.............................................................................. Owx Description of Soil.......... oam' & ..topsol ......Y6 diumw ----------------------------------------- --------------------------------- 1UT.......... Z 1_ .. ned wllie..sariciJ`traces' o .. ravel/rio water a 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 TITLE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance jyccq issued by the board health._.._ Pres. ..... Application Approve ..... ............. Date Application Disapproved t following reasons:--••--••...........................•--------•---------••------------------...--•--------•....................... -•...............................•--•--•-•--•---........----.............--••----•--------....-•----•----'---•-•--•-----••-•-----...........-•--••---------•-•---•--------------••--------------•--.---•- Date PermitNo......................................................... Issued....................................................... n Date ------ -- -'= ��., .-.------- .-- .--------------- ------- - -.-.-. NoFEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable -•................... ......O F..............................-........... ApplirMtion for Di_gpv ial Workii Totuarurtion JIrrutit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at ,0t 23, Sandy valley r.d.,.r arstons Mills mL: r ........................................................................... .. ..... Ca;�ricorn l e y"da crust �' 765 Falmouth �,6e6 N°' -;err nnis •--•----•---•.•-••-----...................................••-------•......••...................... --•-•--------•--••---•--......._......----•...---•--••..---.........----................-• .. Owner W Steve Lebzl Address •---•............................................................................................• •-----.....-----•----•----..._._.....-••••.........------•-•-•---................................. Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.... ......................................Expansion Attic ( ) Garbage Grinder ( ) ranch " a Other—Type of Building ............................ No. of persons............................ Showers ( =) — Cafeteria ( ) dOther fixtures ..................................................... ---...--•----•---•----------•-......_...---•--....----------...--•-•...........•--........----- W Design Flow..........55r..............................gallons per person per day. Total daily flow-_........�_ _..,....__.__...._.__.....gallons. t�n W Septic Tank—Liquid capacity. o dggallons Length 8...6.�...._ Width � "- Diameter__----y_.._.-. Depth.5_-........-. x Disposal Trench—No. ........... Width_�................ Total Length....... 8._...--. Total leaching area.__...r__ ......sq. ft. Seepage Pit No.l.--------. -----. Diameter_-_-.b---.---.--- Depth below inlet..................... Total;leaching area....��'v_.._.sq. ft. z Other Distribution box ( y) Dosin k g� n� Etldredge( ) Engineering �' 11-25-81 a Percolation Test Results Performed by.......................................................................... !Date........................................ a 12 ~Test Pit No. 1._2// �.-.-.minutes per inch Depth of Test Pit..../ .......... Depth to ground waterriOne•.P)Ek9aunt Qr- 44 Test Pit No. Al_A.__....minutes per inch 'Depth of Test Pit.T�l-?�__.._...... Depth to ground water...a?�y............. ----------------------------------••.......--•----•---••-------...-•------.... -•----------------- --------------------------- ........... O Description of Soil........... - 21 loam & topsoil v--------• ----� ----- ------------ --------------------....-----...--------------•••---•--........._......-•-•---- x - 0 Medium vellow sand Vs ....__.....s ,.sr -i--------------------------------------- -- --------° . 12• mea. waT,e sana/braces of gravel/no water -at 12 ' W --••---------- -------------------•-•••--•------- 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 TITLE 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. 2/g3 ate^ ApplicationApprove $y-,r- '` ..................................._.......... ......................... --- '�' d a-be Date Application Disapproved f o, t ollowing reasons:. =-----......••--------------------------•--•••---------•••---------=----..........----•- ., ------•--•----••-•--•................•-•-•-----•----•----•--•------•-•••-••---- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............T 0 wn................O F........Barnstable .........................•----•-•••......... Tatifiratr of f9lautplimirr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (7 or Repaired ( ) Steve Lebel by................................................. --- ....--------.-_--......... . ..... Lot 123, Sandy galley Ptd. , InstallerMarStons Mills , : at ----•--------------•---•-•--•----------..........---------••---•----••-••---••-. -••---. ----•-••-•--------•-••-•--•---.....----•--•-----•-/. . ---_..... has been installed in accordance with the provisions of TIC , j of The//State Sanitary Code bed in the application for Disposal Works Construction Permit No.__..._-�.. ../-. Ll--__...... dated.--.��.-- .. ... - ------•••-•-....-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C STRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... __�_3.��. gS Inspector........ .... - _b C44A v THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tom . Barnstable ' O F.......................... �l •-•...........-•-..........•---•-••-•-......•••............ f No..�.....-••.......... �e FEE........................ Div,� ���tl rk �ua� r�tr##irrn rr�ti Steve Lebel Permission is hereby gra #Ea ......--. to Construct (;: , >; Rea ) 111t1iv ,1 Sewage Disposal System at No - Y;.arstons . -- -----Mills--.... Street as shown on the application for Disposal Works Construction Permit No......: Dated.......................................... r' Board of Health DATE..............•--•-•------•-------.......-------•-------••--•••••--------....... FORM 1255 A. M. SULKIN, INC., BOSTON , '� s..br` /2EPieuDvcc--� FK0M.P1 �f! f 6; 197fT 9Y t oio Lv ' .{ s�, 1 / l ��- 7, jF GENE ,„, ► %/ t 4 OF/yes O i RSE ° p No.10951'p ADp��GISTE� Fs ONAC�a� LEGEND EXISTING SPOT ELEVATION . OxO CERTIFIED PLOT PLAN EXISTING CONTOUR �--- p _--- , � �N +�y p-r 2 3 ,�1 / Y ►�.a ��.c—i ��. FINISHED SPOT .ELEVATION o ROB.RT cN , FINISHED CONTOUR . 0 — . , BRUCE EG.MD n I N APPROVED , BOARD OF HEALTH DATE AGENT ti' '° SCALES / :- 3o. DATE+ to / 3.. �DREDSE ENS/NeER/NS CQ l v 0l � �T --°»— I CERTIFY THAT THE PROPOSED EGISTERE REGISTERS Jp p, 3�. � BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINE OF BARNSTABLE, MASS. 712 MAIN STREET. C14 9Y� *AE HYANNIS, MASS. - --. '=- �_ _.'SNEET_l. OF . REG. LF,ND SURVEYOR. .. if '/ �_EaiC.y/ivG P/T..4A4 MORE rAfA: /2b9ELDty • 9�AwC oiP` SJ4.4LL. .B.F 49,e00a 7- To G,TA OE �XT?n CONCJ4i�r'L ,y�� A/TGII i r �o j4F. VY,CA S 7- R/ O oV C�iYE.-r Sf rA L� a EL'd 3A: ecvCRs , , /F/�V GR/✓E.iv.4 Y r - � p�FT 1 ? .��w. CCn�'C.ZE'TE ��• 0-Q 37 Joe PAW/T. ,Sa��r/� �/�/S//� O/ST. • r 1 a • . s ! f . WASt1F0 S7vNE Y ! ._r�,. 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SOIL TFST p D/L TF33 it �{lUMBER L1•ACAUVG PUTS Y f L i t& `54.S of QR TE 30/G :TEST �$JDE LrACN/Nft PER P/T /S/ ' � P7. _.._. � �Ets►Y___ • c,y;s' 'a rroi+.ZjG+crviwaJFR v/T RCOLATtOir �IATC joss TOTi'1L L.-ACH.IV& AREA '2 CoY SQ. fT. !yli1S/iNCJ'0 su�sv�� AF.tCoc..�?'iow R.•iTE ifk2 1` i flivcN': QESERvEL•E.temny''s 4.qeA SLY SQ. FT. � p �0 `77�57- Lv 7 - Z 3 S.G�✓t>.y V�?z /. a. per' ROBER7 GJ 02 tiG BRUCE 1 �, / 't P�'STf�/�-S /G,L-.S o ELDREDGE MORSE - p No'10951 t � c;S��`�o� '°go�Fc,srE¢���`` - ELOREDGE cNGINEF.T1i1iG CO S..i�``c FSS/ONAI�a 71Z )WADY ST_ VYANNlS. .tilq ® wo GROVN�7 �rAreP ENGouivrEr��o C'LAf"r fe.�►�rc.� C.] GROUND :yvATE�Q .�lT�eL.�� DRTE% w .- • LUCA"11ON SEWAGE M ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1402 LEACHING FACILITY: (type) �'` ! (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distanc e Between the: Maximum Adjusted Groundwater Table to the Bcttom of Leaching Facility Fcct Private Water Supply Well and Leaching Facility (If any weUs exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and ching Facility(If any wetlands exist within 300 fcc f ac ciliry) Feet ' Furnished �" �c� 2 �a�.� ��ll�. 2� Marskotns V�I;I�s a F..