HomeMy WebLinkAbout0116 SANDY VALLEY ROAD - Health LL
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RECEIVED —
TROY WILLIAMS JUL 3 0 2001
TOWN OF BARNSTABLE
SEPTIC INSPECTIONS HEALTH DEPT.
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive ✓
South Dennis,�A 02660
COMMONWEALTH OF MASSACHUSETTS
i U9EXECUTIVE, OFFICE, OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTF,M FORM
PART A
CERTIFICATION
Proper(N Address: 116 Sandy Valley Road
Marstons Mills,MA
Owner's Name: Ann McLean
Owner's Addres,: 68 Temple Street, Apt. 201
Whitman,MA 02382
Date of Inspection: July 25,2001 Q
Name of Inspector: O Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
Telephone Number: South Dennis,MA 02660
(508)385-1300
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. 1 am a DEP
appro,ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sysienv
v� Passes
Conditionall,- Passes
Needs Further [:valuation by the Local Approving Authority
Fails
Inspector's Signature: �^,a,,, Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. phis inspection does not address how the system will perform in the future under the saute or different
conditions of use.
Title S Inspection Form 6/15/2000 pace 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 116 Sandy Valley Road
Marstons Mills,MA
Owner: Ann McLean
Date of Inspection: July 25,2001
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
J/ I have not found any information which indicates that anv 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 replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Boar 0of Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the for the following statement f"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(w her metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is i minent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by a Board of Health.
•A metal septic tank will pass inspection if it is structurally sound, t leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out o igh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or u en distribution box. System will pass inspection if(with
approval of Board of Health):
broke ipe(s)are replaced
obs ction is removed
tribution box is leveled or replaced
ND explain:
The system requir pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(wit pproval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of Inspection: July 25,2001
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303 )(b)that the
system is not functioning in a manner which will protect public health,safety and the ebvironment:
Cesspool or privy is within 50 feet of a surface water Y
_ 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 Wat Supplier,if any)determines that the
system is functioning in a manner that protects the public he ,safety and environment:
_ The system has a septic tank and soil absorption s tem (SAS)and the SAS is within 100 feet of a
surface �%ater supply or tributary to a surface water pply.
The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and S and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tan, nd SAS and the SAS is less than 100 feet but 50 feet or more frottl a
private water supply wel,
". thod used to determine distance
"This system passes if a well water analysis,performed at a DEP certified laboratory, for coliform
bacteri>and latile ganic compounds indicates that the well is free from pollution from that facility and
the pre onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failurea 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)
116 Sandy Valley Road
Property Address: Marston Mills,MA
Ann McLean
Owner: July 25,2001
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/,day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Aag Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
NJl) Any portion of a cesspool or privy is within a Zone I of a public well.
,�iv Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. IThis 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.]
Ali> (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a desig ow 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 ove)
yes no
the system is within 400 feet of a surface drinking w r supply
the system is within 200 feet of a tributary to urface drinking water supply
the system is located in a nitrogen sens' ' e area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply we
If you have answered"yes"to any ques ' n in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large s tem has failed.The owner or operator of any large system considered a
significant threat under Section r failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner sh d 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: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of Inspection: July 25,2001
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yet, No
f ..;:-,ping information was provided by the owner. occupant, or Board of I Lahti,
Were any of the system components pumped out in the previous two weeks'
y Has the system received normal flows in the previous two week period?
V 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)
vl _ Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS, located on site'?
_ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems ?
The size and location of the Soil Absorption System (SAS)on.the site has been determined based on:
Yes no
Existing information. For example,h 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 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of inspection: July 25, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): a
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): .2.2.u
Number of current residents: O
Does residence have a garbage grinder(yes or no):
Is laundn on a separate sewage system (ties or no): ao [if yes separate inspection required]
Laundry system inspected(yes or no):w1A
Seasonal use: (yes or no): Na
Water meter readings,if available(last 2 yearslusage(gpd)): 60= p 4 c,(/,, 23,duo�CL/c,ems.
Sump pump(yes or no): No
Last date of occupancy: AA c.. t. 01
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no
Non-sanitary waste discharged to the Title 5 syste yes or no): _
Water meter readings, if available: _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Af6 ,•,ram',K# ;..fr, c-i�-s New:j P 1t.
Was system pumped as pan df the inspection(yes or no): ivu
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TYE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):.
Approximate age of all components. date installed(if known)and source of information:
T S 6
Were sewage odors detected when arriving at the site(yes or no): ,o
6
Page 7 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of Inspection: July 25, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: - cast iron _/40 PVC mother(explain): f:y k J6x r✓
Distanr:' fron. pri%ate water supply well or suction line: /r/I
Comments(on QQcondition of joints, venting, evidence of leakage,etc.):
r 1, +k �"i.� Ire t1� C. U-1� w�l- �/h.� �f'�•1..c G �nS�-c -?7 uh.
SEPTIC TANK: ✓ (locate on site plan)
i
Depth below grade: r
Material of construction: concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of
certificate)
Dimensions: S
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: 2 �&
Scum thickness: ivow�
Distance from top of scum to top of outlet tee or baffle: Ato s 4��+•
Distance from bottom of scum to bottom of outlet tee or baffle: &o
How were dimensions determined: Poem .
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
G.J"J c.a h c r` � �t� ✓. „� .�L"� (...itr4 S✓.-�.�
r L. tn/V� �' •^� o r�.c✓r /Ju G✓. V x h `.c (S .� �tc. k q�i_ .Q�-- —- i
o�Iq'�►,.�q` c✓etrS '�a ti.�. ''�C�r. h w r.S P1 u i a
T v►+t/ /
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass po ethylene_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 r baffle:
Date of last pumping:
Comments(on pumping recommendations,inl and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leaka ,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of Inspection: July 25,2001
TIGHT or HOLDING TANK: (tank must be pumped at time of' pection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fibergla _polyethylene other(explain):
9
Dimensions:
Capacity: ga/ordyes
Design Floe: ga
Alarm present(yes or no):
Alarm level: Alarm in woDate of last pumping:Comments(condition of alarm and
100,
DISTRIBUTION BOX: ✓ (if present must be o ened (locate on site plan)
P ) P )
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carrygver, any evidence of
leakage into or out of box, etc.):
L
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,con/pumpsappurtenances,etc.):
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: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of Inspection: July 25,2001
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain wh)
Type
pits, number: — 3 (K C. L f
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.): I
w u h L�
.J. L C�- Cr h / , Lam+c, s c�v G L. if
'. b �.c /f Yy ,h•� � '1 h.c. ca /o
2✓1�tN L� ,,e/7 (n�.� �.� '*o 4-1�'
D.-�- ,c ^T7iN-�' 0 1� r h S/W•c —JJ 0 /ofnspeclion)(I
CESSPOOLS: (cesspool must be pumped as on site plan)
Number and configuration:Depth—top of liquid to inlet invert:
Depth of solids layer.-
Depth of scum laN er:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or n/hyulic
m Coments(note condition of soil,signs of 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 hydraul/- ure, vel of ponding,condition of vegetation,etc.):
9
1
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
116 Sandy Valley Road
Property Address: Marston Mills,MA
Ann McLean
Owner: July 25,2001
Date of Inspection:
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 ells within 100 feet. Locate where public water supply enters the building.
wu fig,. i •..� T
r I
n•- �
F = 1S ' GE - S6 ,
� F � zy � ar spy
10
Page 11 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 116 Sandy Valley Road
Marston Mills,MA
Owner: Ann McLean
Date of Inspection: July 25, 2001
SITE EXAM
Slope ✓
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water 12'4 feet Adjusted high ground water elevation — feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: S 0- .Z 5-3 ' Ln„_ .d S/. S d 'a�►;
You must describe howyou established the high ground water elevation:/ e i
/'/�..n� ��..i4�_�v�t J •.S � Se. �v t..J b.. -TZ ✓ti_.. � /.c a.-+�1, +S
w��,o--�-ar- /e..✓.._.t a.'�" �t
`'O. L�" '� / C 6,A-1, / �' �cc_f w t') o cA ry
dti �tigyp-c.L-�Oh
11
LOCATION SEWAGE PERMIT NO.
VILLAGE
IN �k,E It IS NAME A ADDRESS
/c Sa r
R U I L D E R OR OWNER �—
r
DATE PERMIT ISSUED ;
DATE C0MPLIA,NCE ISSUED
r �
' 1
4
t�
30
' u
F � ,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Toim Ba....rnstabl. . . . ..e
...........................................:..0 F....... ..... ......... ..
Appliration for M-4paiittl Workri Tonotrurtinn Frrutit
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot ,"22, Sandy Valley Rd. , Marstons Mills I,iA
.............•-•--• --.........-•----........--••--------•--•--........-•-----•-.........---•-• --•--•------•-••-...---•-•••----......--------.........---•._.._..........---.........•-------•...
Capricorn- Red.�t` y 'Vftst 765 Falmouth Ro° B N°tiyannis
........--•...............................................••---•-----•--•----••••-•----•-••....... ......--••-••--•-••------••....._..---•------•----•••--••--•..._..•---•---....•--•................
W
Steve L e b el Owner Address
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Buildin ranch No. of persons............................ Showers
w YP g ----------------•-•--•-----• P ) — Cafeteria ( )
a' Other fixtures ............................ .
Design Flow.......55...............................gallons per person er day. Tot 1 daily flow.......)O............................
gallons.
W000 §'�'�-- ' 10"
WSeptic Tank—Liquid capacit ........:..gallons Lengt __.... Widt ......... .... Diameter__._........_._. Depth...............
Disposal Trend —No. .................... Wid i................... Total Length .......... Total leaching area------- . ........sq. ft.
' 6 2ss
x Seepage Pit NaL..._................. Diameter.................... Depth below inlet............_....._ Total leaching area....;...______._..sq. ft.
ing 11-2 g 5
Other Distribution box ( ) Dosin ta�c
Z Percolation Test Results Performed b Y-.�ldredg�e Enineer -81
----------•.................. ------e ... ........._.__ Date........................................
5
2.0 12' one encounte -
`�a Test Pit No. 1..rr. ....._.minutes per inch Depth of Test Pit:.. ............... Depth to ground water._._. .....___._...._.. e
Test Pit No. l._A..........minutes per inch Depth of Test Pii1IA............. Depth to ground water!y�k_......._..__..
G: •-------•-------------------------------------•--................---.....................................-•-•-----•--••--------._..........•----•---.........
O Description of Soil........O.f.__..'_..?'.r loam & topp o it
----------------------------- ........ ----•--••-----------
x Iviedium yellow_sand
ib - I2 med. wlzi a sand races o ravel no water a 12
W •-••-------•---------------•---••-----••----•-••--•••--------......•• ----•-. -•-...-----••--•-•-•-•-•••---•----•--•-•---------••--•------•---- .......-•----•-••--•--...._..............•---•-.....
VNature 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 s en issued by he board ealth.
e $.. -... . Pre s........9l�l..3....
Application Approved BY -----�� 3.
r, Date
Application Disapproved for t f ollo ng reasons-------------•-••-•------••----............---.............-•----------------.....---•.........................
.
......................................-----•----...--------•-------------....._...--•--....-----.......-•-••-•---•--•--•-•---•-•----•---------------•••-•...---...----•--------------------------••---.
Date
PermitNo......................................................... Issued.......................................................
Date
•..I��l '✓ z FEs...../ ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T oivn Barnstable
.... ...................OF .......................................................
Appliration for Biiipo,iaal Vorkg Tomitrurtion motif
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at: Marstons Mills DID
Lott, Sandy alley Rd. ,
------...--• ..... . .. ............... •--..._..__...........__---_.. .._._.._.._...•-
Capric rn .�'- 'ty&d� Ust 765 Falmouth R�`dd °Hyannis
•"--"•-•--•-"--______..d::A.....-•••......... ......................................••-•---_. ............................................. -_.....•-----•------- ••-------•----------
..
W Steve Lebel Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedroo ranch...................................Expansion Attic ( ) Garbage Grinder ( )
p4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ..............................................
W Design Flow......... 5..•---------------� 000_gallons per persgji�p�e day. Total•wily flow.........
_......................._gnl,Qns.
WSeptic Tank—Liquid capacity____________gallons LengthZt_55_.__bb_.___.__._ Width................ Diameter.......____.____ Depth__.__.___.__..
x Disposal Trench—No_ ____________________ Widt _V__________________ Total Length......_ y......... Total leaching area..... .......No
ft.
Z Other Distribution box ( ) Dos in a k
�t r&dAe Engineering 11-25-81
Percolation Test Res lts Performed b Date..._ ____ _ _ _ _ _____________.
a Y ,- ------------ -
.0 pone encounte�-
,� Test Pit No. 1.__.//._._.______mmutes per inch Depth of Test Pit_____ ______________ Depth to ground Ovate .__.-y�............... e
Ci, Test Pit No. 2Nf_A..____._minutes per inch Depth of Test Pit ........... Depth to ground water._`��` ______________
------------- ---------••-_-___—
O Description of Soil-•-•--•-•-��---------� r ::loam & topsoll
x - ye ow san
------•---•••--•------------•-
w ........................................fay..-•_•--12-,-----med 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 has been issued by the board of Health.
C
Si ed - Pres. 9 22�8
Application Approved B
ate
Application Disapproved for t f ollo ng reasons_______________________•-___.._.__._..___..._._.__._.............................................................
.....................................................--•___..._..________..._•-•---____.....____--•___•---•_______________________-•-••-___•-•_...-•--•---___________---•-••--_._._____....___...__--•-
Date
PermitNo....................................................... Issued--"-----"-"-"•--"-""""-"__.....__•---••-•-••-•••••••••.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
`I'o wn Barnstable
i ..........................................OF..........I..........................................................................
C9rdif iratr of Tontpliatta
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed (X ) or Repaired ( )
Steve Lebel
by ........................ ---------------_-_----------------------------------------____________•------•-------------------------
------------------
•........
._..
Lot :r�22, Sandy Malley Rd., InstalleN-a.rstons Mills , T:'iA
at.. .."--•-- "-"•-"-"-..._...--"--"""-""•-•-"...."-"-"-""" ""-"-"--•-•-•-............ ___••-•-•-•........................................ .. ........
has been installed in accordance with the provisions of TITLE of The State Sanitary Code des • ed in the
application for Disposal Works Construction Permit NO.__S!}_'" /______________ dated__/!?._Y��_ __.__.__........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................~ ..____-••-----____........... Inspector........
________________________.................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r` _ Barnstable
N�3 15 Z
..........................OF................_....__...._....._.........._......___.......__......_............... AA
...._.. FEE.�V...............
`r �i��o�ttl ork� �on��nrtion rrmtt
Steve Lebel
Permission is hereby granted..............................................................................................................................................
to Construct R air d'vi Sewa Di osal S stem
T - 2` 'an�y � a�1�ne . , gNiars�tonsY Mills , i�lA
atNo. -- -------- ---•••• ....
Street
as shown on the application for Disposal Works Construction Permit No..___._ _. l _Dat ...
/l_ '�
..............
.................... r` -
SBoar or Health
DATE ..... -"----"-"•--. """"•--•""-"--•• ,� ......
FORM 1255 A. M. SULKIN, INC., BOSTON
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EX/STfHf 70pvGRA PH �, J�A OFM
rAom PLAnI )
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Dec.,, IY76 B y
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No.10951 Q
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LEGEND Fss��NAk-
EXISTING SPOT ELEVATION Oj% r-, CERTIFIED PLOT PLAN
EXISTING CONTOUR --- 0 --- � ~J`� MR,s�c
• „ a GAILTI fE Pr -��oy ��� lcy <o.FINISHED SPOT ELEVATION ROBE 0z
FINISHED CONTOUR 0 �BRUCRET 57-L,)AIS MLLS
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o ELDn^c0 I N
APPROVED BOARD OF HEALTH /
DATE AGENT :. ;;.,;, ,.;::-: SCALE, "_ 30 ' DATES /o// 31D3
' LDREDGE ENGINEERING Co. INd>
17rzA/✓c-o
CLIE,NT� • I CERTIFY THAT THE t'F70POSED
EGISTERE REGISTEiRED JOB p�O, � rs6 BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
ENGINEER SURVE R DR.BY1 OF BARNS TABLE, MASS.
712 MAIN STREET. CH. BY Er �%N_
HYANNIS, MASS. Z /ECGZL�_
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