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HomeMy WebLinkAbout0125 SANDY VALLEY ROAD - Health 125 SANDY VALLEY:' A= 101 105 1� i I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road lye Property Address ,_ Ruth Lacava o` -c Owner Owner's Name information is required for every Marstons Mills Ma 02648 10-26-18 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information S* 1 y3 �f on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 Q Company Address Sandwich Ma 02563 City/Town State Zip Code ,M X (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 10-26-18 Uele:3018.t0.J(110:19:B LC'gl Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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 form should be sent to the system owner and copies sent to the buyer, if.applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 <Z , Commonwealth of Massachusetts ' �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: I ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c Commonwealth of Massachusetts { h Title 5 Official Inspection Form 15 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Tc� 125 Sandy Valley Road —v Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 r c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ a Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 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. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I; 125 Sandy Valley Road V� Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no" for each of the following for all inspections: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ ED Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑ Were all system components, excluding the SAS, located on site? El ❑ 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 ❑ El 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: ❑ El Existing information. For example, a plan at the Board of Health. 0 ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a% 125 Sandy Valley Road V Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans Number of bedrooms(design): Number of bedrooms(actual): NA DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes [E No Does residence have a water treatment unit? ❑ Yes R] No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes 0 No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***2016-46,000gallons 2017-29,000gallons*** Sump pump? ❑ Yes ❑■ No Last date of occupancy: Current Date t5insp.doc-rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts +o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 125 Sandy Valley Road V� Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 4 years ago Was system pumped as part of the inspection? ❑ Yes N No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 r Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: unknown due to lack of record Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 11511 Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c� Commonwealth of Massachusetts I� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road u Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 5" Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gallons Dimensions: 10if Sludge depth: 2811 Distance from top of sludge to bottom of outlet tee or baffle 311 Scum thickness G 11 Distance from top of scum to top of outlet tee or baffle V 1311 Distance from bottom of scum to bottom of outlet tee or baffle measured How 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.): The tank was in working order at the time of inspection. The tank is in need of pumping at this time and should be pumped every two years for maintenance. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . 125 Sandy Valley Road v Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of.Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date,of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): or, 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.): The d-box was in working order at the time of inspection. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �d ,lp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No* Alarms in working order: ❑ Yes 0 No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: IDleaching pits number: (1 ) 6'X6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts �M Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11: it Absorption S cont.So sor stem SAS p y (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in working order at time of inspection. Pit was approximately 75%full when viewed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to Inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction.- Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts �n Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 125 Sandy Valley Road u� Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: P Y Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately REAR B A Al-20' 61-26'6" A2.21'6" 132-30'6" A3.24'6" 83.36'6" A4.21' B4-46'6" 3 t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 125 Sandy Valley Road V Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope ❑■ Surface water ❑N Check cellar ❑■ Shallow wells Estimated depth to high ground water: NoGW@12'feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date El Observed site (abutting property/observation hole within 150 feet of SAS) El Checked with local Board of Health -explain: Info provided by the town ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Perk information for neighboring properties showed ground water to be greater than 12'at the same elevation as inspected property. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Offdal Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lol Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 125 Sandy Valley Road Property Address Ruth Lacava Owner Owner's Name information is Marstons Mills Ma 02648 10-26-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1, 2, 3, or checked ❑� C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 TOWN OF BARNSnT„A®BLE LOCATION AIL) " SEWAGE. # VILLAGE u"t. CT�I�S• \`�S ASSESSOR'S MAP& LOT 101 O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 0o 0 c� LEACHING FACILITY: (type) t 1 (size) 100 0S. NO.OF BEDROOMS BUILDER OR OWNER P0tMffDATE: COMPLIANCE DATE: Separation Distance Between the: p Maximum Adjusted Groundwater Table and a. 20 Feet Private Water Supply Well and.Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) NI P, Feet Edge of Wetland and Leaching Facility(If any wetlands exist �� within 300 feet of leaching facility) . Feet Furnished by q� as � t L I QDy � 3 6I Rol' kt-%'b" Q�jZ- 8016" Pr3-ay`�� 03 - 36""' >r • COMMONWEALTH OF M4SSACHt SETTS . _ EXECUTIVE OFFICE OF E?NIRONNIENTAL AFFAIRS DEPARTMENT OF E'�VIRON"NIE\TAL PROTECTI / . r^I.' ONE W1N7ER STREET.. B OSTON. NIA 02106 61 i--S_•`: !o... Vr7LLIA%f F.V67ELD S e ARGcO PALL CELLI'CCI . . -P 'AVID B Lt.GoVi=i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM C ,i ors= PART A • .;�, CERTIFICATIONI. :" •-.:. •_ -- . - ..._. �". . iZ. .5Y tj ...Q.�:. t�Csrt' e.>;si. _,� Address of Owner: . Property Addres,• @�►i 4�5. Date of Inspection (ol'7. � //��' ' (If different) - Name of InspectorN.�� -o +' E� �� 1 am a DEP ap roved system inspector pursuant to Section 13.330 of Title S (310 CMR 13.000) Company Name:A-17-oa t•,4—i r g577,i -'t-� r' c P"` Mailing Address: 'P� A.=x �3� �SNO:1� '447 . Telephone Nurnber: CERTIFICATION STaTEMF\T I cer:ifl that I have pe•sonally irspec:ed the se�a¢e disposal syster- at this address and that the iniorrratson resorted below is true. accurate and comole:e as o:the time of inspe-,on. The inspec:xn %%as pe^orrrier base--' oa my training anc experience in the proper fu :.icr and maintenance of on-s-te sewage disposa: systems. The sKtem: _ _ Conciocnaii% Passe: _ Neec_ Furthe- Evalu o- a Local Approving Authority Fa.-- Inspector's Signature: Date: Y:ie Svs.e^ Irsze_e• shall submit a capv ai this inspec,en reoc n to the Approving Authcrir�• within thin,: (30i days of c_mplesing this inspec.icn. It the svven is a share-* s\•stern,o• ha- a ce:ign now of 10.000 gx or greater, the inspe:or and the syste,. owner shall subrr:it the repo- tc the aapropnate re_oral o..ice of the De;.artmeat of Envirenmenta' Frote^ier.. The original should,b; se tc the s�ste.. o�nrr and copies t--i:to the buyer, ii applicable. and the approving authority INSPECTION SUMMARY: Check A, _E, C, or I Al SYSTEM PASSE:: . . XX 1 Have nct found any information which indicates that the system viciates any of the failure criteria a-, defined in 310 CMR 15.303. Any failure criteria not evaluated are indicate-d' below. . COMMENTS: El SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' sec:icn need to be replaced or'repaired. The system, upc completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y. N. or NDi. Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspeaar with a copy of a Certificate of Compliance (attachedi indicating that the tank was installed within twenty (20) years prior to the date of the inspection: the septic tank, H•hether or not metal, is cracked, structurally unsound, shows substantial infiltrtion cr exfiltration, or tar. failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. SUBSURFACE SEWAGE DISPOSAL SYSTEM IrvSPECTiON FORM _ . . _ I .pART A . . CERTIFICATION (continues Property Address:r 4 4 Owner: Date of Inspection: Bl SY57EM CONDITIONALLY PASSES (contin.,x.'. ._ _ -F _ '- Sewage backup or'breakout or high static water level observed in the distribution box is due to broken or obstructed pipe sllor due to a broken, sealed or uneven distribution box. The system will pass inspection if(with approval of the Oz i BoalhftHea(tht. Describe observations: broken pipes) are ieplaced �,°►� obstructien'is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipes1.:7he system will pass inspection if tw•ith approval of the Board of Health): brokers pipeisi are replace: obstructior. is imoved Cj FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: Conditions exist which reouire furthe•evaluation by the Board of.Heaith in order to determine if the system is failing to protec: the public health. saie.v and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETER.MINE5 THAT THE SYSTEM 15 NOT FUNCTiONmr. IN A MANNER WHiCH WiLL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cessoeol or pn.ti is within 50 fee:of a surface water - Cesspool or pri%'%- is within 50 fee: of a bordering vegetated wetland or a salt marsh. - 2) SYSTEM WiLL FAIL LINLE55 THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROFRiATej DETERMINES THAT THE SYSTEM 15 FUNCTiOti11G-I.N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFci f A-ND THE ENVIRONMENT: _ The svnern has a septic tank and soil absorption system (SAS, :nd the SA-5 is within 100 fee:tc a surface water supplYcr tributary to a surface water supoly. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supaiv we!I. The system has a seppc tank and sal absorption system and the SA-5is within 50 feet of a private water supply well. _ _ The system has a:septic tank and soil absorption system and the SAS is less than 100 fee: but 50 feet or more from a private water suppl. we!1, unless a we!I water analysis.for ccliform bacteria and volatile organic compounds indrcates tta the we!I is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to of less than 5 ppm. tAethod used to determine distance (approximation not vaiid). 3) _ OTHER (revised 04:25/7') T.q. 2 of l0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM - PART A - CERTIFICATION (continued) Property Address: ' Owner: Date of Inspection; ''"• D] SYSTEM FAILS: _ You must indicate either "Yes' or 'tio- as to each of the following: have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans for this determination is identified below. .The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ _ • :.,Discharge or ponding of effluent to the'surface of the ground or surface waters due to an overloaded or clogged SAS or. cesspool. Static liauid levei in the distrib.ition box above outlet invert due to an overloaded or clogged SAS or cesspool. Ltcuid depth in cesspool is less than 6- below invert or available volume is less than 1/2 day ticv. Reeu;red pumping more thar. 4 times in the last year NOT due to clogged or obstructed pipes . Number o'times pumped _. Any portion o-the Soil Absorption System, cesspool or prig)• is below the high groundwate• a+eyatior: _ Any por„on o:a cesspool or prwi* is wither. 100 feet of a sur.'ace water supply or tributan- to a surace water supply. _ Any porion of a cesspool o�,pri.ti iswith�r. a Zone 1 of a pubtic�well." Am pc":io- o:a cesspool or privy is within 50 feet of a private water supple well Anv por,,or. o a cesspool or privy is less than 100 feet but greater than 50 fee: from a private water supply well with no acceptable Ovate- quality analysis. If the well has been analyzed to be acceptable. attach cope et well water analysis for coliiorm bacteria yola:ile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 1rou must indicate ei:her 'Yes- or "tio- as to each of the following.. The foliow-ng criteria aopiv to !urge systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (large System; and the system is a significant threat to public health and safet} and the environment because one or more of the following conditions exist. Yes No . the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �....... ., PART B , ;CHECKLIST Property Aidcess: - Owner. 0 Vori(JO Date of Inspection: You must indicate either 'Yes`or'No'as to each of efollowing: Check if the following have been done: No . . _. .. •... - Pumping information was provided by the _owner,occupant, or Board of Health. , None of the system components have been pumped for at least two weeks and the system has been receiving normal _ flow rates during that period. large volumes of water have not been introduced into the system recently or as part of this inspection. As bu+l; plans have been.obtained and examined. Note if they are not available with n1A. " _ The fac:l1-.1, or d%%eR+ng was inspected fo►signs e*sewage back-up. Tne system does not receive non-sanitary or industrial waste flow. _ The site %as inspected io► signs of breakout. . All !Fite?: component:. excluding the So+l Aosorpt+on System, have been located on the site. r The septic tank manho;es %ere uncovered. opened. and the interior of the septic tank was inspected for condition of baiiies or tees. materia� o• construction, dimensions..deptn of liquid,depth of sludge. depth of scum. (J The size and locat-on o"the Soil Absorption Svstem+ on the site has been determined based on. _ The iac,llt. o,.•ne• %anc occupants. t'd+neren: trom owneri were provided with iniormation on the proper maintenance of Sub-Suriace Disposal System. Existing iniormation. Ex. Plan at B.O.H. _ C�eterrnined in the field td am of the failure criteria related to Part C is at issue, approximation of distance is unacceo:abie 115.302:3):bt! SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit PART C t SYSTEM INFORMATION Property riress: ,ZS Ut Owner: Date of Ihspection: \ FLOW CONDITIONS RESIDENTIAL: Design tlo. 0 .p.d!bedroom for S.A.S Number of bedrooms Number o?current residents Garbage g%,der (yes or noi:_k=� Laundry co-•-ected to system (yes or no!. Seasonal use tyes or no': 1`l ---- - Water meter readings, if available (last two (2,year usage tgpd): Sump Pump Ives or not Lays date or occupancy COMMERC i AL'INDL'STRIAL: Type of establishment Design fio%%-_galions da% _ Crease trap present tyes or no_ Indusma! %'taste Holding Tank present. Ives or no_ ':on-santtan %ante d�scnargec to the Tale 5 system. ayes or no %later meter readings. rf availabie Las:;ia:e o: o C6;;2-1C-. OTHER: .De!cribe Last sate o►occuoa-c-, GENERAL INFORMATION PUMPING RECORDS and source of tnformanor• J(aO w System pumpe • as par, of ins Coon: tves or no. If yes, volume pumped- ¢allons• Reason for pumping �- F SYSTEM '—�X—�e Septic tank/distribution box.'soil absorption system Singe cesspool Overflow cesspool Privy - Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: VLS Sewage odors detected when arriving at the site. (yes or not,�Z� r _ ' J : % ' i ..:fit;;�-:=!i �;ii"','f:: •.. .. ,.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C : SYSTESA INFORMATION (continued) Property Aodress: NIS SmAt Owner: fS�oNNC ' Date of Inspection: b�Z1cl - (!r J BUILDING SEWER.- (Locate on site plan( `11�1 Depth below grade. Material of construction: cast iron _40 PVC —other (explain! Distance from private water Supply well or suction li-t Diameter Comments: (condition of joints, venting, evidence cf leakage:eic.) SEPTIC TANK: (locate on site pl _..._ .... ___ Depth below grade material of construR:O^: concre:e _meta _Fiberglass _Polyethylene _othertexpla:n If tan►, is me:al, l:s: age — Is age con:"rmec o: Ce-t:f:ca-e of Compliance _(1�es`No D:menstors, l()UNq'WJ Sludge depth r3 Y Dtsiance from top o'ts!udge to bonon o' ou::e: tee o• ba-;e ti Scum thickness- Distance from top of Scum to top o'ouile: tee of ba . e t2 Distance from bottom of scum to bo-cm o;outlet t e c• ba�.e l� _ How dimensions Mere determined Comments. trecommendat:on for pumping. condition o; tniet and till t tees or baffles. depth of liquid IevVJ in relation to outlet invert, structur 1 integrity, vidence of I kage. :c.i lea v GREASE TRAP:_ (locate on site plan: Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene ­other(explain) Dimensions: Scum thickness: Distance from top of Scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: . Comments- , ... _.__._. (recommendation for pumping, condition of i:tlet and outlet tees or baffles• depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage• etc.t f.. ..A MA,11. •.:1 D•qa 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Propert% Address: L�,S Owner. Date of Inspection:�j TIGHT OR HOLDING 7A'VK:-V ".Tank must be pumped prior to,or at time, of inspections (locate on site plan, „ "Depth'below grade Material of construction.— concrete _metal •_Fiberglass =Polyethylene other(explain) ----- ----•------- - --- Dimensions: -- Capacm, gallons Desig^floes' galiona'da. Alarm level Alarrn in working order_Yes. _ No ---- -- -- Date of previous purnping - Comments (condition of inlet tee. condition o! ala•m and float switches. etc.) - - ----- —- -- - DISTRIBUTI0% BOX: S (loca:e on site pima- ,,�, Deoth of Iicuid level aoove ouue: in-,el� Comments -incto v. eve! and distrib !o is aua' evi ence of solids carn•over. idence cf I aka e r to or out of box, etc.t l l U - - PUMP CHAMBER: "- -(locate on site plan." Pumps in working order: (Yes or No' Alarms in working order fYes or No Comments:---•--• (note condition of pump chamber, condition of pumps and appurtenances,-etc.) ---- - - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-ss: SCI.Di Owner: Date of Inspection: 07A , b SOIL ABSORPTION SYSTEM (SAS): S (locate on stteplan, if possible; exca% tion not required. but may be approximated by non-intrusive methodsi ✓ If not determined to be present, explain: - TYPe lea chin---its-number.'t - ^` leaching chambers, number:_ leaching galleries, number: - ---`-- - '- - leaching trenches, number,length: leaching fields, number, dirriensio^s overflow cesspool, number Alternative system Name of Tecnnolog-,- Comments. tngte condition of soil, signs of hydraulic failure, leve: of pondin . con on vegetation, etc.► -- - - 1 - - - - eQ CE55POOL5: (locate on site plan. Numbe, and conf,gura:.cn Depth-top of liquid to inlet Inver, Depth of solids lave-- Depth of scum layer. Dimensions of cesspool Materials of construction " Indication of groundwate inflow• (cesspool must be pumper as par, of inspection Commenu: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: ..... .._.._..... ... . _____._.._..-- --...... _"(locate on site plant Materials of construction: Dimensions: Depth of solids: Comments: - (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) trev%ud 04/35/97) Page • of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM T Is-FORMATION (continued; Propert% Address: iV111- 2� Owner: Date of Impection:�f L 11 �� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) e z Nz,—;4 l�,n 30I6� 3 - ��'b" t3—30' ��� �i� ��`•��f-t�"bpi -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION (continued) Propertv A dress. �ZS( 5 �, Date of Inspeciton: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation:... Obtained from Design Plans on record Observation o'Site (Abutting property. observation hole, basement sump etc.) Determine it from local conditions Cneck with loca! Board o• nea!;r Check FE..%AA maps Chect. pumping records Check local eacavato•s ,ns;oII •c l_-se `SCS Da:z ' o - Desc}ibe in vou, o%.- v.orc, r.o•.% %c:. es:abhshed tie �iggh Ground%ate+ Elevation. (Must be completed: tl Irw_��3 ;�:S'9'. P�Q• I^. c! 10 �o O;C A T 10 SEWAGE PERMIT NO. VILLA INSTAj.IER'S NA E� ADDRESS B U I L D E R OR OWNER �f DATE PERMIT ISSUED /d - DATE COMPLIANCE ISSUED � , �� � e lI z6 y �o �G 36 y6 No Fxa o._............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tovm Barnstable ....................OF..........................................................-.......-....................... Appliratiun for Biipuiittl Workii Tunitrurtiun Orrutit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at:Lot Y 38, Sandy Niarstons Mills ) I'��Valley Rd. , .....----•----••....................................•-------.......---------•-•--•--.............. -----•----..._.....----•-•-••--------------------------•-----------•--............................ Capricorn R&RIty" IfMSt 765 Falmouth Rd�dt,N°ryannis ....---•.............._..------......................................-------•.....----•-----•-... .........••••--...._...••--•----••-•--------••--•--•---------•--------......--------...........•-- W Steve L e b el Owner Address Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedroomsranch ..Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) PqOth�rs fixtures ...-- -------•--•-•--•-•--•-•--•-••...............••.••••••----•••-•••--••-••......•-----........••. ........................................ Design Flow.............................. . gallons per pers ii �T day. Tot 1 i flow........._._.._._............. .........._ ons. w YOT, 4 WSeptic Tank—Liquid capacit�.__.......gallons Lengt'r............... Width................ Diameter................ Depth..._..._...... x Disposal Trencl —No. .................... Wid T___..._._.._....._ Total Length......_y-.-----... Total leaching area.... sq. ft. Seepage Pit No..............,_....... Diameter... ............ Depth below inlet.................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin a Date........................................ ��c�r4dde Engineering 11-25-81 _ Percolation Test Re It Performed b ................... 12 one a i No ................minutes er i ch D eth of Test Pi17/A_,___._..__. Depth to ground NIA eneountees Test Pit No. minutes per inch Depth of Test Pi ___ Depth to ground wate ...... ................. d f� Test Pit P P P g water .................. cf-,I----------ZT---------Y03R1 •& -S01�.......................................................................................... O Description of Soil......... 1a*..... Op xmediuylow""sand.............................................................................. ,.. f ...12ZC. -12# ned.. wfi1 e x •---•---------------------------•---• --•---•----••-------••-•----.....-•-•-•-----•-••••••---•--••••---•-----•---•---•-----••-----••••------••---••---------•-••••••••-•••--•-•----••---•....._......... 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 TAITILE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Complian n iss by he board ealth. igne -••• .Pre s..-- .......9/ 220 Application Approved By....... .. ...... :..•••••-•--•--•--•-•----..........._........... --..= c9 1 .................••- -----......... Date Application Disapproved f t following reasons:.......................................•--•-•---........------•-•-----.....-•---- .....•---•---•--------------•--•---••---............--•-•--••--••---------•--•-•-•---....-•---•----...--••-•-•••••--•--•-•--•-----••--••--••-•-•-••-••--...•--•---•••---••-•---••-•-----••••-•--------- Date PermitNo......................................................... Issued--•---•--••-------..._..........-----------------...... Date A - .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tovm Barnstable ....................O F................................. Appliration for Uiipniittl 10ork.5 Tomitrnrtinn rrmit Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal System at: �,ot Y38, Sandy Talley Ind., Marstons Mills IVIA .............""-------•--•---........-•-----""-"-•-•---........"•""_........_._.........---•-----• --••--........-••----••-...•••-----------•---•---•......_....-----••-•---...................---.-- Capricorn R60dalt 'd st 765 Falmouth RB t,N°Ryannis _................................ ..... ... ............_..... W Steve L e b el Owner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms-_-- ----------------.........•......._._...Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building r .............. No. of persons............................ Showers (2 ) — Cafeteria ( ) dOther fixtures -------------------""----------"-"-"---•""-"-• ....................................................... ......_.. WDesign Flow..............................................................i000 .gallons per person pie� day. Totgl d�ily�flow.._.....33..........................._gallons. WSeptic Tank—Liquid capacity..._.__...:.gallons Length'.............. Width..............__ Diameter................ Depth................ x Disposal Trench—No. .................... Widt .4------------------ Total Length_.......r......... Total leaching area . . . sq. ft. ,,> Seepage Pit No'................... Diameter.._........_..... Depth below inlet......._.......... Total leaching area,..���...........sq. ft. Z Other Distribution box ( ) Dosin a k Jclr4d�e Engineering 11-25-81 Percolation Test Results Performed by....................... Date........................................ a Test Pit No. 1.2'_0..___.minutes per inch Depth of Test Pit___.12 ....___ Depth to ground wate>nOne eriCOunter— T -- cl 44 Test Pit No. 2N.............minutes per inch Depth of Test PitI1...A_._...._._.. Depth to ground water.`'r ..............94 e .........................................................................._._...........:_................................................................... 0 Description of Soil.._......0_T.... _._?1 Y loam & to sol x 2 - 10 Tviedium.ye low sand W 1�, _ jZV inecl: wf�i e sand/traces ..oi` gravel/rio wader""at 12 -------------------------------------------------------------------------------------=--"---------"----"---------------------------""""----"-""-----""--"---------...---------.._...---•-•......--•---. V Nature of Repairs or Alterations—Answer when applicable............................................................................................... ..............••.---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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. igne ----...---""""...._.."-"""".........""""-""-"""""....................Imeat... .....9122,E Application Approved B . !%© ._.- Date Application Disapproved r e following reasons:..................................................-"""""---"•-"-"------"--"--""".........:..................... ........."•..............................••-------•---••--------.....---•-•------•--.._......----__......._ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T.oi.v.n .............0F.......Barnstable . ................................................................. Tnrtifiratr of Tomplittnrr THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed or Repaired ( ) Steve Lebel by ---•......................................................•-•--•........•-----..........__.._._._........--•-•--•--........---•--.....--•--•...... at. Lot Ot Sandy =Talley Rd. , InstalleMarstons Mills t i'.;A .................•---•-----.........-••--••------_.._.._....__.._._...._------•---•--- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod as ' cribed in the application for Disposal Works Construction Permit No.�.1 ,1� ............... dated ?.. .s,... .----....._.._...___._... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................... '........._.�.�--...---•--------...._. Inspector.........&__�••----._._._.•--•............_.----•-.........._....---•...... THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH 3 C y T.° .......................OF....Barnstable ...... .......... ......... N .._.......�..---••-... FEE/4................ Uhipml Workg Tnnitrnrtion rrmit Steve Lebel Permission is hereby granted -------""•-"•"-•.............. .... to Construct (: or Re air ) Individ al Sewag� Disposal System at No.._...::. .I._`. �._. d Jalnley i 1Vlarstons Mills , 1.;A ---•---------- -- --"-""-"".......... Street as shown /thepplic ion for Disposal �horks Construction Permit .::........... Dated'..__Z_ .....".-.... --"----------•----"-"----•-------•---------- ---------------- Board of Health DATE..-- ..................•--.------------•....... FORM 1255 A. M. SULKIN, INC., BOSTON I ,i ° C T pJ � vo D 7- 3 7 \ 3 1 ----6 6 —WA OF TGZ OTE Mq s Ex sT,,rG �ovoc,KAPAY ALB A t2E PA r,5 v D RSE ti 3 0 o p No.10951�p Q /STE� �F4. 0NAL ENv LEGEND CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION Ox0 _ak ; EXISTING CONTOUR --- 0 ---- LFY rc� FINISHED SPOT ELEVATION (�0 4: / ROBERT �j., ��� . ,.L S 7 M /%-!_ FINISHED CONTOUR O BRUCE 1, ; L.: ELDRED is IN APPROVED =.BOARD OF HEALTH �, � ;f ' S, DATE AGENT `'y'��w SCALES J"_ 30' DATE [ /D,/7/&-3 LDREDGE ENGINEERIIVG CO. IN CLIENT 1 CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. `'" `s�' BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS TO THE ZONING LAWS ENGINEER SURVEYOR DR.BY, n OF BARNSTABLE $ MASS 712 MAIN STREET CH. By " N Y A N N I S MASS. ?- —DATE- -- -- ' SHEET L OF DATE REG. LAND SUR EYOR /OTE : /F /Tf/LR '_E.�ChiiivG P/T A.tE MORE THA:•/ /2 " 3ELOw 14 I•'l. M/A/• :j,41E OEM � ?Q 'O/.l.N E TFR ['OyCR c T'E CC vS,f• ' N .S All"-4'PVC P/PL 5NALL BF B ?OUGHT TO G,gA z> ` a y `�,r ? GOCRfTL h EAVY CA ST /h'ON C YF.R. S AY,4 L 3= S e= coIKE /N_ PITCH PFQIr /O.V F'1PE U p U _ t r ..r.s�; �-- 2 LAY E.? AflAl. T+r�I .. GAL: . _ •• o a ct �i8- _-'/115 ' ids Pew j-r. S.EPT/G 77ANK D/sT. .' _.-.: - -- - • D1rPTl•I � . WASJyEDSTc�NE _ G..k-&-x Z 5- 4:7 CD • • • r • • • • • • �_ Ise • INVCXT. 4A&V.1T/Qtw.� :~��T Cfl l�i� �i-7 y S�C� 4'AG1, ,14 y • � r • • • • o ••r E�.4GE' • • . • • • • • 1 PRFG4.S T SE .?VYFJtT AT d►LVLD/NQi .. s-.oJim t FT. D/Atl. NK 5 F� � .• OyT<@T.S�l'f�'IC TANK FT. O.UOM. C�SFC TiaDIJLATJON, 1 4tlTZ�TDlJTRl� �� LIB - S�G7"laN OF_ GROUND JVtT.E*t TABLE I andiV� '7A dULATtG/Y . D.Esisir CR�TE��aDJMENSIQN Ater. 3: DJ.*1.HvS/O/y a f7:. NUMSER OF 46WDJWOMS D/I►"1E1V S/CN C d- FT:NI iN r GAAgaAG.Ep/SPOSAL awy, iy011."L SO/,� LOG i �TQTAL EST//+^INFO FLON/ •3 3 0 G.4L 1QAY SO/L TEST jO/ $O/L 7FS7-,*Z s0/1- 7496.3T NUMBER C64W L.fACX/NGr P/TS I t,4;7 SIDE 4--ACH1N6 PEAL o/T 9-6` J-(g f)r / �`ELIY,__. agTLw OF SOIL TEST .9o7-7'OM LE�ICK/NG PAR P1T �� gyp, /trr- d RESCILTS AV/TNLSSED dY /Z Ste'. (JACu0<a i 7'07AL L--ACN/NG AR,EA 2!0 �' •f'p f T ` L� �1 �Y� _. PER COL ATiOw ,lq TE, F/ _l/�`S3 ^1/A,5/I NCN ?ESE:•4VELEACNIAdAREA SP. FT. 6 s��• L' P-L.tC0IAT/oN i4'.4TE r OF Af,4ss i Lo T- 3 8 5'.4�c/D Y ) ROr3ERT '-•* y i EI.JREDGE v MORSE N r No.10951�O ^~��,,/,��`�"�`;r% �G/STE9- LJ L-L . L z 7 ELOREDGE cNG/NEF�i.iG co,/,YC. •;;.�_' •c��,�.{� FS/ONAO Nc G*T0vN0 vYi4TG.T ENCOGJNTf�eE,C, CL/ N • ': Q GM O WV 0 L�rA TE,Q A T' EL / E T: t=rq ArC v DF!'E = /v j 7%r JOd ,yob �3 -2 s SfIEET ZOf