HomeMy WebLinkAbout0140 SANDY VALLEY ROAD - Health 1,40. Sandy Valley Road
Marstons,Mills
A= 101 —082 \
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A
COMMONWEALTH-OF MASSACHUSETTS
F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
i•
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owners —e shame: CARBON � t
Owner's Address: SAME
Date of Inspection:2/22/07
tr7co
Name of Inspector: print Douglas A.Br wn = --
an Name: Douglas i
� D Com A.Brown S Company a e. g Septic Inspections --,
Mailing Address:P.O Box 145 ;
Centerville MA 02632 r-_3 Fn
Telephone Number: 508-420-4534
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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F Us
Inspector's Signature: Date: 2/22/07
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving,
authority.
Notes and Comments
SYSTEM APPEARS TO MEET MINIMUM PASSING REQUIRMENTS AT THIS TIME.
****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 Revised on 10/31/2000
Page 2 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection: 2/22i07
inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information winch indicates that any of the failure criteria described in 3 10 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 Pase' 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 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:
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
obstruction is removed
distribution box is leveled or replaced
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
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 140 SANDY VALLEY RD
MARS TONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection: 2/22/07
C.Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ the system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 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.
_ 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 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:
Page 4 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.PART A
E C RTIFICATION (continued)
)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection:2/22/07
D. System Failure Criteria applicable to all systems:
You must indicate"yes or no to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X 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
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for 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.]
NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 3 10 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 no
— _ the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
ys'm 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
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner: LARSON
Date of Inspection: 2/22/07
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
— X Pumping information was provided by the owner,occupant, or Board of Health
— X Were any of the system components pumped out in the previous two weeks ?
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the p system obtained and examined? f— Y d (I they were not available note as N/A)
X — Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out ?
X _ Were all system components,excluding,the SAS,located on site?
X _ 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?
_ X 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
X _ 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 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection. 2/22/07
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN How based on 3 10 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 3
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NA
Seasonal use: (yes or no): NO oG - 1 g y
Water meter readings,if available(last 2 years usage(gpd)): 0 T• J,71 GV D
Sump pump(yes or no):_
Last date of occupancy: coxxsNT
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
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:
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE 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 awner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site (yes or no)? NO
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection: 2/22/07
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_ (locate on site plan)
Depth below grade: 12"
Material of construction: X 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: IOOOGAL TANK
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
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.)-
GREASE TRAP: 1_(ocate 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(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
f
• Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection: 2/22/07
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection) (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0°
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.):
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,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection: 2/22/07
SOIL ABSORPTION SYSTEM(SAS): —(locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number:
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.):
PIT IS ABOUT HALF FULL AT THIS TIME NO STAIN LINE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
. Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection: 2/22/07
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.
ad(I
IV
�� G ti4
► Page 11 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 140 SANDY VALLEY RD
MARSTONS MILLS
Owner's Name: LARSON
Owner's Address: SAME
Date of Inspection:2/22/07
SITE EXAM
Slope:
Surface water:
Check cellar:
Shallow wells
Estimated depth to ground water 62' 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 datatase-explain:
You must describe how you established the high ground water elevation:
OFF PREVIOUS INSPECTION DATED 7/20/04 BY J.P.NACOMBER
.�!.WHlir; 11ViJYi';l:'1'1V1VJ Y
DATE -7
`I LAGE r16 1C� ASSESSOR'S MAP,& LOT )OI
Li
~INSPECTOR j I� c,o locr- a*',J
SEPTIC TANK CAPACITY 1 ��
LEACHING FACILITY: (type) L (size) 10 0"
NO. OF BEDROOMS
BUILDER OR OWNER L."yle
OWNER MAILING ADDRESS
1
cy�
/
a
--- 230
MAP
PARCEL.
LOT
DATE 7/20/04
PROPERTY ADDRESS:_140 Sandy Va.P.eey—Rd.�
02648
-------------------
On the above date, the septic system at the above address was
Inspected.
This system consists of the following:
1. 1-1000 ga Uon zept•ic tank.,
2. 1-di.6ta.igut.iori 9ox.,
3. 1-1000 ga eion ieach.ing it
Based on Inspection, I certl the following conditions:
4. 7h.iz •iz a t.i.Ue live zept•ic zyztem(78 code)
5. The zept•ic zyhtem .iz .in paopga wo zk.ing oadea at the /?aezent time.
6. 7he. wazte-'.waten -in .Peach.ing pit .iz 46"&e. ow .inve2t 12112e.
SIGNATURE: 19 ;
Name' [32uce flacai2.iztea — r
Company:_a'_P-Macomge2 _and zon—Inc.• a
Box 66
Address:___ D
----------------- m
CA ,--
m
( onfon»�1�l�ail7n_ 07677
Phone:_____(508) 775_3338-------
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR
WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-oCesspools-Leachftelds
Pumped .& Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
r
COMMONWEALTH OF MA,SSACHUSETTS
EXECUTIVE OFFICE OF ENViRONNttNTAL AFFAIRS
W
DEPARTMENT OF VNVIRID14.MENTAL PROTRCTION
�n TITLE 5
OFFICIAL INSPECTION.FORM—.N0T.-1OR.VOLUN RY SYSTEM FORM
SUBSURFACE SEWAGE DISPOSAL
PART-A
CERTIFICATION
Property Address: 140 sandy Valley Rd.
Marstons Mills A 0 $
Owner's Name: Irene Framer
Owner's Address: Sam_
Date of Inspection: '^ Q d
Name of Inspector: (please print) Bruce M.aca 1i.s_ter
Comp anyName;.�,.MacomRe�t, .SSon Z�cc.
Mailing.Add-Tess:
(C- e2vc e, ah.�z 02632
Telephone NumF�er: 5 0 8,7 7 3 3 3 8
CERTIFICATION STATEMENT
1 certify that 1 have personally inspected the sewage disposaj"gystein.at this address and that the.information reported
based on my
below is true,accurate and complete as of the time�4 the inspectif on ce sewaco disposal systems I am a DEP .
training and experience in-the proper fur ction and:paintenance o & sewage.
approved system inspector pursuant to Seetion.1�5:340.of-TItle 5(310 O1ViR 45 000). The system:
Passes
Conditiona ly Passes f`
Needs F er Evaluation.by the Local Approving,,t tfhority
Fails .
Inspector's Signatore:
The system s ins ector.shall submit a copy of this inspection repor .to the-Approving Authority-(Board of Health or
P
DEP)within 30 days of completing this inspection.If the system,is.a.shated system or has a design flow of 10,00
gpd or greater,the inspector and the system owner.shalPsulimit th6 report to the appropriate regional,offiee of the
DEP.The original should be sent to<tho 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
ss how the system will perform in the future under the some or different
time.This inspection does not addre
conditions of use.
'Page 2 of 11
OFFICIAL INSPECTION;FORM—NOT:FOR V0LUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTFM INSPECTION FORM
PARTA
CERTIFICATION (continued)
Property Address: 140 Sandy Valley Rd.
Marston Mills MA
Owner: Irene Kramer
Date of Inspection: 7/2 0/0 4
Inspection um`mary: Check A;B CD or.E/ALWA ..comp.lete-all of Section D
A. System Passes:
I have not found any information which indiCates`ihat any of the failure criteria described in 310 CMR
15.303.or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
A13 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 substantiallinfiltration or exfiltration.ortank failure is fi minent: System will pass inspection if the
existing tank is replaced with'A complying septic oak-us-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:
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):
brokett.pipe(s)are replayed.
obstruction is removed
distribution box is leveled or replaced
ND explain:
UThe system required purttping;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 l l
OFFICIAL INSPECTION FORM-NOT-VOR-VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property Address: 140 Sandy Valley Rd. '
Marstnna Mills MA
Owner:. Tr _ne Kramer
Date of inspection:7/20./n d
C. Further Evaluation-is Required by the Board of Health:
Conditions.exist whichrequire fiuthenevaluation.by.the-Boar&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 atcordance with 310.CMR 15:303.(1)(b)that the
system is not functioning in.a manner,which will.protect public health,safety and the,.enuiro.nment:
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:
� _ The system has a septic tahk 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 theSAS 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•;tnore flora 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 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:
I
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT TOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 140 Sandy Valley Rd.
Marstr)ns Mi�MA
Owner: TrPn2 Kramer.
Date of Inspection: Z,f01 n'r
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"tovach.ofthe: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
_ J Liquid depth in•cesspool is less than 6"below invert or available:volume is less than'h•.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.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply..
Any portion iof a cesspool or privy is within.a Zone I.,of a:public well..
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 SQ 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 nitrgte nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are-triggered.A copy of the analysis must be attaehed.to this forM..]
_(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 design flow of L0;000 gpd-to I5;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
Z 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(linterim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
.15.304.The system owner should contact the appropriate regional.office of the Department.
4
f
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAU SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 40 Sandy Val 1 Pv .Rd.
Mar-,t,C-)ns Millc MA
Owner: TrPnP Kramer .
Date-of Inspection: 7.19 n/ra i f•
Check if the following have been done You must indicate"yes!'or"no"as+to each,of the following:
Yes 9Pumping.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 ttote 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, excluding the SAS,located on site?
1
_�_ 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,a plan at the Board of Health.
_ J 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)J
5
Page 6 of 11
OFFI:C.1AL jNsPEGTI:UN:: 'OItM'—NOT FOR VOLUNTARY ASSESSMENT'S �
SUBSUPYACE S+`W AOE DISPOSAL SYSTEM,INSPECTIOZ4 FORM
PAR .0 .
SYSTEM INFORMATION
Property Address: 140 Sandy Valley Rd.
.Mars tons Mi s MA
Owner: Irene Kramer
Date of Inspection: 7 -2 0 4
FLOW CONDITIONS
RESIDENTIAL
�)..�.:_: = )
Number of bedrooms(deli Number of {actual : -
DESIGN flow-based on.3Io cNM 15.203(for example: l lO gp'd x#of bedrooms).' x'l 16 '—�*� Cj,?D
Number of current residents: .: 1
Does.residence have a garbage grinder(yes or no):flue
Is laundry on a separate sewage.system(yes or.no):7Q [if yes separate inspeption required]
Laundry system inspected es or no). r.. j`J.e�=v = 13Gi• �'
Seasonal use:(yes or no):&• o �j 17 E (y
Water meter readings, if yailabie(last 2 years usage(gpd)): � 3 ' yZ,J�'0 1 °
Sump pum,�??(yes or no): '
Last date o$occupancy:
COMMERC DU TRIAL
Type of estate lient: �
Design flow.( ed on 310 CMR 15.203):• 1 and
Basis.of di sig0ow(seats/persons/sgft,etc.):, ''
Grease trappresent(yes or no):_
Industrial waste holding tank present(yes or noA ,
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water-meter readings, if avail;ple: V
Last date of occupancy/use:
OTII'ER(describe):.` ,
GENERAL INFORMATION
Pumping Records f 4-50i1
Source of information: S
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:__gallons--H w was quantie. ty puum ed determined?
Reason for.p..umping: '
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system - .
M Single cesspool
t0 Overflow cesspool
1' Privy
Shared system(yes or no)(if yes,attach previous inspection records,if arty)
N Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
7% tned from system owner)
Tight tank. Attach a.copy of the DEP.app oval
Other(describe):
Approximate age of all cod ponents,date installed(if known)and source of information:
Were sewage odors detected when arriving at.the site(yes or no):
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 140 Sandy Valley Rd.
Marstons Mills MA
owner: Irene Kramer
Date of Inspection: 7/2 0/0 4
BUILDING SEWER(locate on site plan)
Depth below grade: _
Materials of construction:_cyst iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: [0 f
Comme is(on condition,of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: /°(locate on site plan)
l�
Depth below grade: D,
Material of construction: concrete_metal,_fiberglass_polyethylene
--other(explain)
If tank is-metal lis—taje.U7 Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
-- Dimensions: sfG I'm
Sludge depth: 'WbxA
Distance from top of sludge to bottom of outlet tee or baffle: _;r,e
Scum thickness: i-o.c g-
Distance from top of scum to top of outlet tee or baffle:fa\¢.a.
Distance from bottom of scum to bottom of outlet tep or baffle.-T,Z t,,f-
How were dimensions determined-.*- Qj-kDAS V s-e13 '
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): _ f
vn IC clxe t .'" C}St a _, (It kt U t�i
GREASE TRAP:I U�(locate on site plan)
Depth below grader '
Material of construction:AconcreteRA-metal fiberglass k polyethylene RAother
(explain): VIA
Dimensions:
Scum thickness: _
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom 9�scum to bottom of outlet tee or-baffle: d ,
Date of last pumping:Q
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc
Titl,- S Tnenortinn Wln 411 ei)nnn 7
P2ge 8 of 11
OFFICIAL INSPECTION FORM, NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 140 Sandy Valley Rd.
ons m1i s MA
Owner: Irene Kramer
Date of Inspection: 2 0 0 4
TIGHT or.HOLDING TANK: w (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass O _polyethylene 6� other(explain):
Dimensions:
Capacity: gallons
Design Flow: allons/day
Alarm present(yes or no�:
Alarm level:�_ Alarm in working order(yes.or no):
Date of last pumping: 11,01 _
Comments(conditio of alarm and>loat, witches,etc.): 1
, Jr -
DISTRIBUTION BOX:1 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:. I)
Comm ents(not
e if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
� •Jt.SJ �•'a •.`
t d�^ � (�4S -. I
PUMP CHAMBER:&(locate on site plan)
Pumps in working order(yes or no): rtr�
Alarms in working order(yes or no):4 '
Comments(note Eondition of pump chamber,condition of pumps and appurtenances,etc.):
• mar
8
Page 9 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
r .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 140 Sandy Valley
ars ons i s
Owner: Irone Kramer
Date of Inspection: 7 2 0 0 4
SOIL ABSORPTION SYSTEM(SAS): .(locat on site plan,excavation not required)
If SAS not located explain why:
dE' t a
Type
leaching pits,number:
ru j
leaching chambers,number:
leaching galleries,number:
1\0 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.): 11 1
ka
LF vQ4PLE 1SUVQ w^. 2," v•x4-
CESSPOOLS) V (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: —
Indication of groundwater inflow(yes.or no):
Comments(note condition o soil signs of ydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: YID (locate on site plan)
Materials of construction:
Dimensions:k
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY-ASSESSMENTS
SU$S,URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:, 4 0 S a ncl u Vv i. 12c1.
Owner: Iaene lC2ci_m_n2
Date of Inspection: 7120/o 4,v— '
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.
r
1 / \
^�T- �,
N'\
10
f
Page 11 of 11 ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 140 sandy Valley Rd.
ars ons M11 MA
Owner: Irene Kramer
Date of Inspection: 7720M4
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
-
Estimated depth to ground water 7'D 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:
IV?Observed site(abutting property/observation hog within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach document do
�Accessed USGS database-explain: Wkk.T�yilr� c 117, )T,, V 5
You must describe how you estab ' hed the high grou d water elevation:
JIL
V 6 Z rg ).—O ri c •L r Q urail 6
P:}
�,_�}.ter--rT +rn�nrr'nn„re'T�rtTf rn�rrnT•r•nvrrr++r*T.+rtn..s*nv*Te-�Tnnr►TI
'1'0NN OF Barnstable ' _ HOARD OF 11En.LT11
SU1181111FACF SFWA(;F, I)ISNSA.L SYSTEM IN8119CTION FORM - PART D^ GERTIT F1 CATION .-
I
1 rn+sr.,n•nmrlTw.rmsrrr+r+r*+�'..+-•.''•-Qmrvenrarr•'*"""'r'feA'�'r•�s
+•••Tt'1'T'• �T.IIR••••• -TiPt OR PRINT C"Xl "—
PROPERTY INSpCCTED
STREET ADDRESS 140 Sand. Vaiie R
ASSESSORS MAP , B1200K AND PARCEL #
1011082
OWNER." s NAME
PART D - CERTIFICATION
NAME OF INSPECTOR /32uce .
Ca
COMPANY NAF1E Joseph P. Macomber & 'Son Inc
COMPANY ADDRESS $�� Centerville Mass 02�632 State LIP
SCreQt To►m or QIxY
COMPANY TEUEPIiONE ( 50-8 ) 775-33.38
FAX ( 508 ) 790-1.578
CrR'rIFICAT•ION. STATEMENT
I certify that I have personally inspected
ithe
sewaaocuraosi'l system at
:this address and that the iliformation rTherpspection was performed and any
complete as of the time of ,inspection,
recolnmettdatiOtis regarding UP,, .Rden th�np�nperefunction repair
and maintenance ofon-
with my' training and experience i
site sewage disposal. systems )
Check one ;
LN AI
Systeof .PASSED
The inspection which I have conducted has
not
found
any protecformation
wh
ich indicates that th.e system falls toadequately
crater of the valuated areaasdstated in the FAILURE303 ,CRITERIAfailtire
section of
ar>. teria not evaluated
this for"' , '
�. _ System FAILED$ \• .
The inspection whichI hflve eon�Ct'eted. has found that the system fails tc
lth and the environment in accordance with Title
protect the Eoub.lic hea
5 , 310 CMR 161301 and as spec tcally noted on PART C - FAILURE
CRITERIA of this inspection for.o.,
Date�Tu�` .
Inspector Signature
P 1
one copy of thisication must beep Qvided to the OWNER, the BUYER
'( where a�plicable�) and the 13.OARD O
* It the inspection FAILED , th`e owner or operator. shall upgrado ' the ayetem
within one year oP 0)e in ot.e of thinsPection , unless elbowed or required
otherwise as provided 15 partdldo(
a CAT10 � � d SEVA E PERMIT NO.
: vlllACF !—
I N S T A LttLER'S NAME & AD0ItESS
b:5A AL
B U I L D E R OR OWN ER
Ron/
t� k
DA T E PERMIT ISSU (0� _ g
DAT E COM ►LIANCE I S 5 U E D � .
ti
�p 1
`* o.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
............................O F........................................--------------------.........._.........._..------
'Appliration fur iiVasal Work,5 Tnn,itrnrtinn Frrmit
Applicatiori is hereby made for a Permit to Construct or Repair ( ) an Individual -Sewage Disposal
System at:
ot rstons Mills I'+AL .720Sandy falle Rd, Ma
--• • ......--•-----•---•--•..................... ..........-•----....---••--•--•---•-......
tN°iAdrust on
.C.a icorn Rear..- 6 a� yaznis
...... r...----................... .................---•--•--- --------...... .........-----•------.................. •-----........-•---....--•--•---••--••---•--•-
Owner Address
W Steve Lebel
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms-_3.......................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building X'c�.Tl01l.............. No. of-persons............................ Showers (2 ) — Cafeteria ( )
a Other fixtures . _....._....._.... ---------------------------------------
---•--•-------
...................
d
W Design Flow........5.5..............................gallons per person per day. Total daily flow........33.0.__............._..........�allons.
WSeptic Tank—Liquid'capacityl000•gallons Lengtl .._6��...... Width l.1Q1�.._ Diameter________________ Deptli2...$
Disposal Trench—No..................... Width............._...... Total Length...__._._.__...__.. Total leaching area_.._.____.....___.sq. ft.
Seepage Pit Nol................... Diameter_....6�..._...... Depth below inlet_.._b�........-.. Total leaching area..2.66_...._.sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by... ldredge. Engineering 11-25-81
........ ............ Date........................................
aTest Pit No. 1-2.•.Q......minutes per inch Depth of Test Pit.. 2........... Depth to ground wateln021e-. PPgGunte -
LX4 Test Pit No. N/A........minutes per inch Depth of Test Pi9j/A............ Depth to ground water. &*........_._. e
----•-------------------------------•-----------•---........................................................................................................
O Description of Soil.......... ......-._.2•.•-••----.�..43m.-8e--tnapil------------------------••--------------
x 2' - 10' Viedium yellow sand
v --•-•-•.................. ..••--- -----
w ..10.. 12' med. white sand`traces of gravelJno water _at 12 '
M. 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 h een vssued by the boar f health.
9/�. �..._
Application Approved By.. o � .........
Date
Application Disapproved for e f owing reasons:_...__ .
• ---•-•..... ..............................•----•-------------........_. ........•-•-------
.........-•-----------------••--•-•••-••••.......•---------................-••-•••••-•-..........._...•-----•-•--.........---...........----•---------------••--•••---......----••------. ......---
Date
PermitNo......................................................... Issued................-----------••----•----•-•........--••--
Date
N4,.a-1'�5 3.. FEB....�1..62...............
s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �
Town Barnstable
................OF......................................... ----------------............
.......
,� �irtttinn fnrintt1 nrk� C�nnrnr#inn Fermi#
Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal
System at: I
20 Sandy lalle Rd. Ylarstons Sandy r �r 1;
........................L....,............................................ Mills ! ...
Loc
W Capricorn
a p r ico r n Reaft ru st 765 Falmouth Roaidt,'OHyannis
....... ..._'-__ ... Owner Aress
...........................................
acev Leb2.. ............................................•-• i
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms._..........................................Expansion Attic ( ) Garbage Grinder ( )
a —Type g X!A4 h______________ No. of persons............................ Showers (2 ) — Cafeteria ( )
Other—T e of Building _ ___
d Otl�r-Sfixtures
-----------------........................
llons er---erson-gger da Tot 1 clail flow.:..__..-.-30___•----•--•--•••-•-•-••.--•g._�••1�� •-•-
W Desi n Flow------- 1000 a 'b�� '1�'" r t5
WSeptic Tank—Liquid capacitv---_--__-_._gallons p L ng&...61......•Width................ Diameter.:............_. Deptl�-_._ lons.
x Disposal Trench—No..................... Widt i.................. Total Length._._.. .;.......... Total leaching area....-_. _._ sq. ft.
Diameter.................... Depth below inlet_.._.......... Total leaching area..�s6.._._._sq. ft.
Seepage Pit No1._._......._
z Other Distribution box ( ) Dosin tank ( )
Eldredge Engineering 11-25-81
a Percolation Test Results Performed by ---_-- --------I. - ---------------.............. Date --..... -••........
a Test Pit No. 1.2..0._.___.minutes per inc Test Test pit �_......__. Depth to ground wateFlenTe___encounte�-
Lz, Test Pit No. §A..._.._.-_minutes per inch Depth of Test Pitt Depth to ground water.-WA.............
A e.l- l A e
------------------------------------------------------------------------------------•-....-------•--.........................................................
O Description of Soil......... '._..-__2.1_________loam & to-psoil
i 2' - 10' Tviedium yellow sand
W 10' - 12' med. white sand races of rave no water at...120
-------------- -------------------------------------------------- ----------------••••--------•---••---•-••-•---------•--•-----•••--------••----•-•----•--•-•-•••-••-------•-••-•••-•---•---.--•-•-
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 TITLi� 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. 9/
t 22/83
d----------- ................= :................. .•..--• ......•--- -----
Application Approved By...... .. ... ii . .. -
-- • ..--•-• ----••.
ate
/
D
Application Disapproved for he f owing reasons:.... ---•---- --•-•••-------------••......-------•-•.-•-. --------........._
--------•-•----------------•-•---....••----_.._.....----•-•••....•------•-•---..._...-•---•-•••-----•-.......-•-•-•--•••••-•••••...------•-•----•--••---•------•-----••---------•---•••---•--••••.......
Date
PermitNo........................................................ Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .q!Nn.................0F.......Barnstable..............................................
�rrt�f�rtt�e n� f�nm��ittnr�e .
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( )
bY---•---•--------•--•-------••---------•-.------Steve Lebel --------•--
at.........Lot ,°r 20, Sandy lalley In s Install eMarstons Mills I, i:,,A
.....--•--•--•-------------------------••-- ---•-•-•-••..............----••-•-•---•--•----•--•-•--_---
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cod �a�s, -cribed in the
application for Disposal Works Construction Permit No. __�- � ............... dated�D 1.J . .._.._.._...___.___.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED UA ANTEE THAT THE
SYSTEM WIW FUN ION SATISFACTORY.
DATE... ..z ..- •..................•---------•.........._. Inspector..... ... -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
.................................OF..................................................................................
Nd=.al... ..... FEE .v....
R.5 jumtt1 Works Tnnstrnrtinn "permit
Steve Lebel
Permission is hereby granted .... ....... ............
to Construct (_ ) epair an ndividual Sewa a Disposal System .
,,o , COI; ar�dy) Talley �cd. , viarstons Mills i�,A
atNo. :..:.. ...:...... -•----•-------------.....-•----••----..............••---•-•-•--...--•----------------------•-•---------------------------------------
.
Street i `^
as shown on the application for Disposal Works Construction Permit No...__.__ �a .._��-.1__�___ ...- -= .
....................... _--------.--•.....................................................
Board of Health
DATE................................................................................
FORM 1255 A. M. SULKIN. INC.. BOSTON
r
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9°,cFSG/S.YEP��c``' �t� 7- 19 in
LEGEND s�ONAL EN
EXISTING SPOT ELEVATION X CERTIFIED PLOT PLAN
EXISTING CONTOUR --- 0 -- - �'����0���y Lb7- yo s4AIC> v�-«LY rzv .
FINISHED SPOT ELEVATION ROBERT , G ��I,gT�S7-C�/1/5
FINISHED CONTOUR 0 BRUCE ,
ELDREDG y IN
APPROVED , BOARD OF HEALTH
SS T 10AJ141 ASS*
DATE AGENT 'Y° su SCALEt
LOREDGE ENGINEERING CQ lM CLIENT R_ I CERTIFY 'THAT THE PROPOSED
LGISTERE REGISTER JOB NO. �s6 BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
E
ENGINEER SURVEY R DR.BY1 OF BARNSTAB LE, BRASS. 8
712 MAIN STREET. CH. BYt
HYANNIS, MASS. a SHEET % >-%
/ OF ATE REG. LAND sU-RVEYOR
- 20 tT_ MI/Y. ,TOTE = /f E/TNG•R :NE SEPT/C TA.�/,� O R
?=.EfC-AVI'VG. ?/T ARE MORE TH.1:•� /2"9ELOry
/O r7►. M/�/. �.4/1 OEM A ?Q 'O/AM E TER CaNCR F?-E CC vE,r �
CONC/ttTL 4'oi+C o/P� SNALL BE BQOUGNT To G,qA 0E �.:,v c�J� T? a
eL . 7/: S CCYE�t.S MIN. P1TCN h'E.4Vy Girl ST /RON G�YE.4 Sh�.4 L.:._ 3.
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