HomeMy WebLinkAbout0167 ANSEL HOWLAND ROAD - Health 167 Ansel Howland Road
Centerville . P
A = 171 236
Oftndieffte
alas%
1521/3 ORA 1070 P2
III
'I
_ --- -a
u - ' COMMONWEALTH OF MAS
` SACHUSETTg
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEpAJtTMENT OF ENVIRONMENTAL PROTECTION—
R7 L- I.,_ L 1 '
FEB 0 12005
TOVvi,4: 'BLE
TITLE 5 HE,�LTH`r-r1-
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM
PART A
// AIK,fl—
� ,�r�/ CERTEnCATIONProperty Address: l10 v /-/0 c✓%H �v�AP ��7
eh rv, r'ARCEL --ro,-
Owner's Name: 3a LC1 -`2 3
Owner.'sAddress: a✓ /1d
8r`,• Od 6,7�
Date of Inspection: Iatb
Name of Lin f'
Com pector.(p�yspriaU !r"�i^
pay Name: O — TEG
Maift Address: 0 '
Telephone Numbe Oat 0-.L -
CERTMCATION STATEMENT
I certify that I have personally,inspected the sewage di
sposal SYStem below is true,accurate and complete as of the time of the at this address and that the information reported
�nspectioa The mW
training and experience in the proper fimction and tnspection was performed based on
approved system inspector pursuant to maintenance of on site sewage disposal systems.I am a D P 15.340 of Title 3(310 CMR ig 000I, The system;
Passes
Conditionally Passes
ee�Further Evaluation by the Local Approving Authority
Inspector's Signature:Jj_a&j�,.
Date:
The system inspector shall submit a copy of this in
DEP)within 30 spectiOn report to the Approving Authority(Board of Health or
gpd days of completing this inspection.If the system is a shared system or has a design flow of 10,W
DERor greater,�e infector and the system owner shall submit the report to the appropriate Sinai should be seta to the system owner and copies Sent to the buyegplicaregional
and offs'a of the
authority.
pprovipg
Notes and Comments
**"'This report only describes conditions at the time of ins
pection
time.This iuillc on doh not addret'how the vystem wi11 and under the conditions of use at that
conditions of use. 11e Orm in the future under the'!?me or different
Page 2 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: l i0 ! n Sel W d
owner. J eG v f„i ' ,
Date of Inspection: 0
Inspection Summary: Check AAC,D or E 1 complete all of Section b?
A. Sy P„ ;
1 have not found any information which indicates that any of the failure criteria described
15.303 oc in 310 CMR 15.304 exist Any f�m criteria not evaluated are indicated below. in 310 tIIt
Comments:
VS :Qt
Conditloo,Uy Passes:
more system components as described in the"Conditional pass"section need to be replaced or
repaired,The systen% upon completion of the re&c•,ement or repair,as approved by the Bound of Health will pass,
Answer yes,no or not determined(Y,N,ND)in the
explain, for the following statements,If"not determined"please
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 exfilbution or tank failure is
existing tank is replaced with a complying septic tank as approved b theta System will pass inspection if the
A metal septic tank will pass inspection if it is y ��of Eiealth.
indicating that the tank is less than 20 years old is ales not leaking if a Certificate Compliance
ND explain;
Observation of sewage backup or break out or high static water level in
ft obstructed Pipe(s)or due to a broken,settled or uneven distribution box.System will pass box due to broken or
approval of Board of Health); inspection if(with
broken Pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND extplaim
The system required pumping more than 4 times a year due to
Pa ins tiott if(with a Y be0n obstructed pipe(s). The system will
1'� pproval Of the Board of Eiealtb);
broken pipe(s)are replaced
obstruction is removed
Ng cVlaiir
��. 0(�
„ page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION(corrtinu,ed)
Psroperty Address: �1► e �OG✓�C�v�� 2,j
ovvnew SeGiv ✓' d 63�--
Date hopectioa: a o
C,. F Evaluation is Required by the Beard of Health:
/Y y�
Conditions edg which require further evaluation by the Board of Health in order to determine if the system
is failing-to protect Palth,safety-or the environment.
t. System will pass unless Hoard of Health determines in accordance with 310 Chit 13�303(1
system h sw-fuoctiaoing in n-man�w�will prntect pubic "witit 31 ty M the esvi)(br'eMt b at the
— Cesspool or privy is within 50 feet of a surhm water
— Cesspool Or privvy is within 50 feet of a bordering vegetated wetLwd or a salt marsh
2, System Win fail unlc,”the Board of Health(and Public Water SUPPlicr,if
system is functioning in a manner that Protects the Public health,safety and environment.roes that the
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 t 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 private water supply wells*.method used to determine distance feet but 50 feet or more from a
"This system passes if the well water
bacteria and volatile organic co analysis
'Aerformed at a DEP c,orlified laboratory,for coliform
icates that the well is free frown Pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
failure criteria are triggered.A copy of the analysis must be attached this f�'provided that no other
3, 9ther,
L
Pam 4ofil
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A ,
CERTIFICATION(continued)
PX'operty Address: /t/ use/ ,�J�OG✓/ti h R
owner.
Date of InspecAft. /oL o1 d
D. System Failure Criteria applkable to td11y1tema:
You nui#indicate"yes"or-W to each of the following for all inspections:
Yes No
�of sewage into facility or system component due to overloaded or c
_-�or or �8 of effluent to the surface of the logged SAS or
cMqMd mound or suftA waters due to an overlga"Or
S c liquid level in the distribution box above outlet invert dine to an overloaded or clogged SAS or
usspool
/tea deAti" cen RMI is I=than 6"below invert or available volume is lea than y
-1LG/ more than 4 times in the last year NOT due to clogged or abstructedpe(s).Number
of
• of the SAS, or privy is below high ground water el
Porttoa of cesspool or privy is within 100 feet of a � '
water PlY surface water supply or tributary to a surface
portion of a cesspool or privy is within a Zone L of a public welL
And'Porfm of a cesspool or]navy is within 50 feet of a private water supply well.
— Any portion of a cesspool or privy is less than 100 feet but
sec than 50 feet from a private water
supply well with ao acceptable water
duality analysis. [Tbls system passes if the well water analysis.
Performed at a DEP certified laboratory,for Conform bacteria and volatile organic compounds
anIndicates that the well is free from pollution from that facility and the presence of ammonia
arte tden and nitrate nitrogen is equal to or less than S Dom,provided that no other failure criteria
e triggered.A copy of the analysis must be attached to this form,}
(YesNo)The system faft I have determined that one or 15.303,theref more of the above failure criteria exist as
l4IIt ore the system fails.
described in 3 30 C The system owner should contact the Hoard of
determine what will be necessary to correct the failure.
Health to d
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,00o
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)
I
es no
system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface dri.nkng water supply
system is located in a nitrogen sensitive area(Interim Wellhead protection Area-IWPA)or a
o li of a public water supply well mapped
If you have answ "
s to any question in Section E the system is considered a significant threat, or answered
"ycs"in Section D above the large system bas failed.The owner or operator of any large Sy*m considered a
significant threat under Section E or failed under Section D shall
15.304,Th_e system owner should contact the a upgrade the system in accordance with 310 CMR
appropriate regional office of the DepartmenS,
F"pSof11
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: /� �pW�G�, ��
Owner.
v, h v►'
Date of Inspection: �liG
Check if the 11011
0wing have been done.You most indicate es"or"no"as to each of the following:
Yes No�
7 information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out is the previous two weeks
Zthe system rax'ved normal flows.is the previous two week period
tie large 014=0 of water-been isdmdwzd to the system recently or as part afais'
mspeCtiOn
Were asbuilt plans of.the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the-site inspected for signs of break out
._ Were all system components,.excluding the SAS,located on site
Were the septic tank manholes material of constrouncovered,
of the es or tees, s,-d °�°�'and the for of the tank inspected for the condition
on,dimensions,depth of liquid,depth of sludge and depth of scum
as the&dlky
maintenartcevaf 'uh sewage o (and posal*v Occupantss diffaent from owner)provided with information on the proper
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes 10
mfonnatiOlm For example,a plan at the Board of Health.
:i/-:�,
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)P 10 CMR 15.302(3)(b)J
�r
• page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY' ESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
// SYSTEM FORMATION
PIMP"Address: (o ��
v� �v1• t
V WW. 2c�v
Date of Inspection; t=a;FtL0VCOND
]RASMaNn" MONS
Niunber of bedrooms(d�gn):.� Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 1 l0 gpd x#of bedrooms _
Nzamber of current residents: �p ):
Does residence have a garbage Frinder(yes or no):
Is on a separate sewage system(yes or no):- ea
(yes or no):�v [ y separate inspection required]
water maw �no)..�A
if available(last 2 years usage(gp0y
SUMP PUMP(yes or no):
last date of occupancy: 0,,1e0
T Pew IIS'I'RiAL
establishment
Design flow(based on 310 CMR I5.203):
Basis of design flow(seats/persons/sgftetc.):
Grease trap Present.(yes or no):_
waste W&A8.1ank present(yes or no):_
waste diwharged to the.rifle 5 system(yes or no):Wader meter readings.if available:
East date of occupancyh=:
OTHER(describe):
Pumping fiords• GENERAL 1N RMATIONI
Source of informatim-
Was system puzziped as part of the
Yin,volunx pumped:Reason
no
If __gallons—Howas quantity pumped
Reason for leg
__gallons
SYSTEM
tack,distribution box,soil absorption system
_OvicrIlow cesspool
Shared system(yes or no)(if Yes,attach previous inativspection records,if any)
obtai hmovativsystemow rtechnology. Attach a copy of the current operation and maintenance contract(to be
—Tight tak _Attach a copy of the DEp approval
-_.Oar(describe):
0 age of all components date installed(if known)
AH �� ; � Btu )at>�source of info 'on*
�y
Were sewage odors detected when arriving at the site(yes or no):
�j U
• paDe7at�I
• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(conthafto
ddrew
ProPertyA �t0 /`I'/v / W tq'n �d
Date of kspeWoa 3 G
BUILDING SEWER(locate on site plan)
Depth below grade: �/ r
11
Materials of construction: iron Distance from private water supply well or suction line:other(explain):
Comma*(on condition of joints venting evidence of l�l�
SEPTIC TAW- (logte o site
per)
Depth below grade: Ile
Material.of concrete—metal-- —:.Poly�ylene
If tank is ne W fret age:_ Is age confirmed
certificate). by a Certificate of Compliance(yes or no):_(ate a copy of
Slu4p depth:Distance fmm �x
Scumic�s: ��to bottom of outlet tee or baffle:
Distance fiorn top'(scum to top of outlet tee or bale: A/
Distance from bottom of scam to Oftw, f outlet or ba81 �
How were dimensionsdetermined: c1e
Comments(on pumping reoomme �
fated to outlet im9 �inlet and et or ba81e condition, uctural �,,liquid levels
ih �N & lON, Cy A�
�� 1,
GREASE Tip: a"on site plan)
Depth below grade:_
Material of construction:_concrete
(e��): —metal— �--JXlyeth'lene_other
Dimensions:
Scum thiclmess:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or ba e
Date of last pumping
Comments(on pumpin da Wet outlet tee or baffle condition,�Wqo limed levels
as related to outlet inve )
I •
pa.Ae 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
• . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ �y SYSTEM INFORMATION(continued)
Prop"Address: 1p / 1'*.��
Ze 3-
Owner: �ur.rw-
Date of Inspection P a b
TIGHT or HOLDING TANK: /L(tank must be punped at time of inspection)(locate on site plan)
Depth below grde
Material of constriction concrete metal fiberglass_polyethylene otlur(explain):
Disncesions:
Capacity: zallons
Design Flow: galloWday
Alarm present(yea or no):
Alarm level:- Alarm in working order(yes or no):
Date of last pining:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX if present must be o ocate on site
penedxl plan)
Depth of liquid level above outlet invert j�210Z.4?o,�-
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaks into or out of box,etc.):
oX Syr/ � .job%✓1 � L�.��
PUMP CHAMBER; (Iocate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pimp chamber,condition of pumps and appurtenances,etc.):
Page 9 of I l
OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSE SMENT3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F
PART C FORM
SYSTEM WFORMATION(continues
tj
Date at Insp ow
SOII.ABSORPTION SYSTEM(SAS):—
Haste on site plan euavaiion mot rglnired).
if SAS not located=Pwn why:
Type
1eachi►g lam►number:
l � mber:
eM nu
l m uber:
leaching uvncw�a,number,length; a✓' -/.�ohc
8 fleldk
Comments mWVaovafia e/Caspoo1'm,mbte: Tywname of
n technology.�) (note condition of soil,signs of hydrawc failure evel of ponding,dam
.S�p L G H�/ p soil,condition of vegetation
�C4
CESSPOOLS:&1(C=spW1 must be pumped as
Part of inspection)(locae on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer.
D1ztensions of cesspool:
Materials of conon
Dndcation of gmundwatet inflow(yes or no):
Comments(note condition of soil,signs of hydraWic fail ur+e,level of ponding,condition of vegetation,etc.):
PXMY-&/'Oocate on site Plan)
)
Materials of constzlx*z:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level ofpo"ding,conditio
n of vege(ation,etc):
page 10 of 11
• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO
N FORM
PART C
SYSTEM INFORMATION(continued)
PtepertyAddresx
iy✓i_—T_ ff
Owner. V�
Date of inspection: a o f
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal System inchxbng ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building,
(
Li
ou
A.3- a3 '
25
��- 6ot '
i
, pgge 11 a�f 11
OFFICIAL INSPECTION FORM T NOT FOR VOLUNTARY ASSESSMENTS
. ., SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contimred)
Owner: Grvt✓
Date of Impecdon: / d
SIT&EXAM
Siope
surface water
check caller
Shallow wells
Estimated depth to ground water feet
Please mclicate(chock)all methods used to determine the high Vound water elevaticn:
from system design plans on record-If checked,die of design plan reviewed:
site(abutting property/observation hole within 150 feet of SAS)
Chocked with local Board of Heahh-explain: ✓1,IQl
C'hwlwd with local excavators,installers-(Mach documentation)
Accessed USGS database-ezplain:
��F You mnsdyibe how you established the high ground w/pter oboe: /
atd•S ,'A I o,
7
v
sOwdS� .
z o►,e G 3-0
O �
t
No. Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pplication for �DiopooY *pgtem Cungtruction Permit
Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System 1:1 Individual Components
Lo ation Address or Lot No. Owner's Name,Address and Tel.No.
167 Ansel Howland. Rd. Centerville Donald. Rogers
Assessor's Map e A y 4 2 8-7 6 51
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Repairs or Alterations(Answer when applicable) new leach system, D-box and
3tnnPD2nkPd maximi 7.Pr�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issuSo by this o of Health.
Signed d . v Date �`�$
Application Approved by Date C7
Application Disapproved for the following reasons
Permit No. Date Issued aG `
--- —
No. 919 V t Fee $50
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
�^ PUBLIC HEALTH DIVISION - TOWN OF BAR NSTABLEMASSACHUSETTS
Z(pprication for Oisspaar *potem Construction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System El Individual Components
�o ation Address or Lot No. Owner's Name,Address and Tel.No.
7 Ansel Howland. Rd.. , Centerville Donald. Rogers
• Assessor's Map e _ 0 428-7651
1
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089, Centerville
.Wye
Type of Building:
4 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Y
Design Flow gallons per day. Calculated daily flow gallons.
Plan"Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
,a
new leach system, D-box and
Nature of Repairs or Alterations(Answer When applicable) y
3 stonepaeked maximi`pr4
f Date last inspected:
Agreement:
\ The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in8accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cat&I of Compliance has been'issued by this o of Health. Q
i ) Signed k I Date 7--7 6
_� Application A proved.by P°' Date
Application Disapproved for the following reasons
r
4 Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Rogers BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY that the Qn-site Sewage Disposal Systegi Constructed( )Repaired (X ) Upgraded( )
Abandoned( )by Wm. 'R. Robinson Septic Service
at 167 Ansel Howland. Rd. , Centerville has beenconstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. E ��' dated- c � ••1�
Installer Wm. E. Robinson Sr. Designer / N
The issuance of this eerrnlit h 11 /ot besonstrued as a guarantee that the_sy ' Ai willA
nct onas desig e oDate c/� L ��� Inspector '�/ r 1 � �7
j
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Rogers lwigogar 6potem (Eon$truction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at 167 And.el Howland Rd.. , Centerville
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of thisvj rmit. �d
Date: Approved by
V6/99 .
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I Will iam E . Robinson,SAereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 167 Ansel Howland Rd Gentervi 11 meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associat with the dwelling.
/The
i classified as CLASS I and the percolation rate is less than or equalto S minutes per inche no wetlands within 100 feet of the proposed septicsysteme no private wells within 150 feet of the proposed septic system
no increase in flow and/or change in use proposed
re no variances requested or needed.
om of the proposed leaching facility will not be located less than five feet above the
m adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(1.1) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the MAX. High G.W. Adjustment
DIFFERENCE BET%'EEN A and B v
SIGNED : t DATE:
[Sketch proposed plan of system on back].
q:health folder:cen
.. �.,��
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t, TOWN OF BA.R14STABLE
LOCATION i��D A A-��^d SEWAGE #
vT—LAGF ASSESSOR'S MAP &LOT r
INSTALLER'S NAME&PHONE NO. 141 , 846 trysm -5tZ -73 S,T77:6
SEPTIC TANK CAPACITY I DQC
LEACHING FACILITY: (type) (size) ''
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: !2- 30-'Icl __COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ` Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�e
(1
. �
,. '..
t �-1
�� 1 ' �� �
'�
TOWN OF BARNSTABLE
LOCATION J(c l !ao$e-1 !ra rv.d SEWAGE #
VILLAGE_C0/14 ASSESSOR'S MAP & LOTM TO
INSTALLER'S NAME&PHONE NO. J.AJ 17_ 17 7'-
SEPTIC TANK CAPACITY CC)
LEACHING FACILITY: (type) 3 CA (size)
NO.OF BEDROOMS
BUILDER OR OWNER^. e,(a S
PERMITDATE: �- 3C'3�`�c) COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
tj
�J
LOCATION I�. SEWAGE PERMIT NO.
9.3
VILLAGE
I N S T A LLER'S NAME & j ADDRESS
S Ui DER OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
House
jilt, a�
—,_ CO'.NI'MONWEALTH OF MASSACHUSETTS
_ C EXECUTIVE OFFICE OF EIN'VIRO METAL AFF_-kIRS
-`' ` DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WI\TER STREET. BOSTON ALA 02108 (61') 292a50u
TRUDY COaE
Secreta-v
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
P'°pertyAdd'ess167 Ansel Howland. Rd. Nameefowner Donald Rogers
en i l ei 1vIA Adams of owner same
Date of Inspecti
Name of Inspector:(PI a Print)Wm.. E . Robinson Sr.
1 am a DEP approved systerq inspector to Section 15.340 of Title 5(310 CMR 15.000)
�,p a„yNarne: Wm. E . Robinson Septic Service
MaaingAddress: PO Box 0 9. Centerville ,_MA
Telephone Number: �7 5_ 7 (�
,:-gWRCATION STATEMENT
I,cj'r'pfy that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
Anil tbmplete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
mathtdnance of on-site sew#ge disposal systems. The system:
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
4 Inspector's Signature: ��LJ i Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
REc��V�O
-� g 1999
SEP
TOWN OF BMNSTAM
® HEALTH DEPT.
Sd,
revised 9/2/98 Pagel of11
A
Z.! ter.^fed on Rer-;,d P—,
, • r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
" 'CERTIFICATION(continued)
IropertyAddress: 167 Ansel Howland Rd. , Centerville
awn"` Donald. Rogers
Date of hrspecoon:
INSPECTION SUMMARY. Check B, C, of D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYS CONDITIONALLY PASSES:
ne or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon
mpletion of the replacement or repair,as approved by the Board of Health,will pass.
Indicate ye , no, or not determined(Y, N, or ND). 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 inspector with a copy of a Certificate of
TCompliance lattached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health): r
broken pipe(s) are replaced
obstruction is removed
f'
1
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
p.1rAddress:167 Ansel Howland Rd. , Centerville
Owner: Donald, Rogers
Date of Inspection:
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 the
public health.safety and the environment.
11 ,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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
1
1
I
2) YSTEM 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is 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 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
OTHER
revised 9/2/98 Page 3of11
Owner: Donald. Rogers
Date of Inspection: $►�3/^tr 4:9
D. SYSTEM FAILS:
You mu indicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d termination-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.
S
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
_ tt Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
1 Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high,groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LA GE SYSTEM FAILS:
You mus indicate either "Yes" or "No" to each of the following:
The following criteria apply to large 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 safety 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 o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Prop"Address: 167 Ansel Howland Rd. , Centerville
Owner: Donald. Rogers
Date of lnspection: ..3�-c�47
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye/ No
�C 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.
y _ As built plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components,excluding the Soil Absorption System,have been located on the site.
_ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. .
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
v - _ The facility owner(and occupants,if different from owner)were provided with information on the proper.maintenanre f
SubSurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
rroperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: W g.p.d./bedroom.
Number of bedrooms(design):— Number of bedrooms(actual)3—
Total DESIGN,flow 9d6
Number of current residents:
Garbage grinder(yes or no):_p
Laundry(separate system) (yes or no)410: If.yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):/L a
199$ 57,000 gal.
Water meter readings,if available (last two year's usage(gpd):
Sump Pump(yes or no): d 1997 58,000 gal.
Last date of occupancy: 3l—g C/
COMMERCIAL/INDUSTRIAL:
Type of est lishment:
Design flow: gpd ( Based on 15.2031
Basis of des, flow
Grease trap ii esent: (yes or no)_
Industrial Wa to Holding Tank present: (yes or no)_
Non-sanitary ags
ste discharged to the Title 5 system:(yes or no)_
Water meter,readin ,if available:
Last date o occupancy:
OTHER: Describe)
Last dat f occupancy:
GENERAL INFORMATION
PUMPING RECORDS and ource of information:
tid
System p mped as part of inspection: (yes or no)ZC'3
If yes, volume pumped: 1d'o"'��gallons /
Reason for pumping: /tom; ,p,� p, �C C�1,�,6 t� )1 `
TYPE OF SYSTEM
_ t,,/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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components. date installed fif known)and source of information:
Sewage odors detected when arriving at the site: (yes or no)�L/U
revised 9/2/95 Page 6(if II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
167 Ansel Howland Rd. , Centerville
Owner: ?Mnald Rogers
Date of hupection: f_cl 7
BU DING SEWER:
(Loca on site plan)
Depth elow grade:_
Materi I of construction:_cast iron_40 PVC_other(explain)
Dista ce from private water supply well or suction line
Diam ter
Co ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader //
Material of construction:t ncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: lL
Scum thickness: o , t
Distance from top of scum to top of outlet tee or baffle: ' 1 I
Distance from bottom of scum to bottom f outlet teg or baffle: A/
How dimensions were determined:
'omments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)• ,rU 0—IJ Ca 7-0 ^-1C
GR E TRAP:
(locate n site plan)
Depth b low grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimens' ns:
Scum t ickness:
Distan a from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date last pumping:
Co ents:
(re mmendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evid nce of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
bropertyAddress: 167 Ansel Howland. Rd.. , Centerville
Owner. Donald. Rogers
Date of Inspection:
TIG R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate site plan)
Depth bei w grade:_
Material o construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dimension
Capacity: gallons
Design flo gallons/day
Alarm pre ent
Alarm lev I: Alarm in working order: Yes_ No_
Date of p evious pumping:
Comme s:
(conditi of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:V
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, ev'den of sods carryover, evidence of leakage into or out of box, etc.) -
PUMP C AMBER:_
(locate o site plan)
Pumps i working order:(Yes or No)
Alarms working order(Yes or No)
Comm nts:
(note ondition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontinued)
'rope►ty Add►ess: 167 Ansel Howland Rd. , Centerville
Owner: Donald Rog
rs.
Date of Inspection: 8=3/--
S
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits;number:_
leaching chambers,number:
leaching galleries, number:_
leaching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs f hydra)ulic failure,level of ponying d arnp soil, condition of vegetation, etc.) LVIC., �
6
CES OOLS:_
(locate n site plan)
Number d configuration:
Depth-top f liquid to inlet invert:
Depth of s lids layer:
)epth of sc m layer:
Dimensions f cesspool:
Materials of onstruction:
Indication of roundwater:
infl Icesspool must be pumped as pan of inspection)
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on ite plan)
Materials f construction: Dimensions:
Depth solids:
Comme s:
(note co dition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
revised 9/2,/yC Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontirrued)
�►openy Address:
Ansel Howland. Rd.. , Centerville
,wner: Donald Rogers
Jate of Inspection: g
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Lt!
YLp h�
Lr�
g
t
ti
revised 9/2/96 Page 10of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ropertyAddress: 167 Ansel Howland Rd. , Centerville
Owner: Donald. Rogers
Date of bapection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS. Date website visited
Observation Wells checked
Groundwater depth: Shallow. Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
,I x
Estimated Depth to Groundwater /� Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
/Determined from local conditions
V Checked with local Board of health
Checked FEMA Maps
_Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
ail �vC
revised 9/2/98 Page 11of11
Fps..... .Noll...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QV HEJ�IL H
7
—........................................
.....OF........ .....
Appliration for Dispasal Workii Tomitrurtion thrutit
Application is hereby made for a Permit to Construct )Repair an Individual Sewage Disposal
Sys1�
a/ -�--
-174
.. ....................... .......------------------- -----------------
No.
5,-
-y'Location. —re 0 1
......................... ......
-----------
---- -- ------------------------------- --
40,,,Yn�� Address
............ .................
............. -- ------- ..............................................................
Installer Address
Type-of Building Size .......Sq. feet
U oms....... .r—W...:......................Expansion Attic ( )
Dwelling—No. of Bedrooms._____ Garbage Grinder A�
Other—Type of Building ........................... No. of persons............................ Showers Cafeteria
Otherfixtures ....................................................I...............................................................................................
Design Flow............4 1-�,7—.C——-------------gallons per person per day. Total daily flow...............?.�_.�..............gallons.
04 Septic Tank—Liquid capacity.,#\ gallons Length................ Width.............._. Diameter..._........_... Depth....._..........
Disposal Trench—No. .................... Width............._..._.. Total Length......._............ Total leaching area....................sq. f t.
Seepage Pit No... Diameter.................... Depth below inlet................_._. Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........;................................................................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.__.__.............. Depth to ground water........_..._.......___.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_____......._.._.._...
..............7..............................................................................................................................................
0 Description of Soil.........................................................................................................................................................................
U ........................................................................................................................................................................................................
....................................................................................................... ............................................................................................
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'T':IZ- 5 of the State Sanitary Code—The undersigne 'further agrees not to place the system i
operation until a Certificate of Compliance has been issued by the board of health.
nmil_tom...........
--------------------------------------------- ....... ---------
D;
r
Application Approved By.......... ..... ........................................................................ .....
Application Disapproved fort Zffolwingg reasons:.........................................................................
--------------------------------------------------------------------------------------------------------------------------------------------------
Permit No......................................................... Issued-...........
No..r�.: :.:: FEs......
.� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ ". ------------..OF..........................------.......-----......._.............._......._......._-----•.
, VVftraftou for Dispwial Workii Tomitrurtiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_----...._...................................................................... ......-----------•--•-----........-•------------•--••.............---•--------------.....-•.--•••-
Location-Address or Lot No.
.....--•..............»....----.........---------...---.......---••-............................. ..........--......................................................................................
Owner Address
W
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
.-,
Other—, Type of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures --------•--------------------------•------------------••••-•••••-••--•••......••-•-............--•--••..............................................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_.------------------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.........................................
j Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ••••-•-•-•••-•••-•-•----•••-••-••••-•-••-•-•-••••-•••••-•-...•-•.........-•-•••................•............................-•-..........---------••---......
0 Description of Soil.......................................................................•---.....---------------------------------•-------...-----------------------...................••
V .....••••••••-••••-••--••••••••••••••••••-•••-••-•-----•••-•-•-•-•...............••-••••••--•---••---••••••••••....---•-.....•--•--•••----•-•-•-•-••-•••---•••--••-••••-•-•-•----••-----•-•••----•-•.-•--
W ••••-•-------------•.....•-----------------•--•-•--••---••••--------•-----•-------•----••--•-••--•-•---•-----........•------•-••--••••••----•••••-••••••••••••••-•••••-••••......-••••••.....-•----.....
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT 1.;,_. 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.
Signe ...........z..........................................•-•-••-------------.........-- ................................
" Date,
ApplicationApproved By.......•..... -----------------------------•-••-•-•--•--•-••-•----
.l< 't
Application Disapproved for t f oll ing reasons-------------------------------------------------------------------------I• •-••-•-----•----•-.
..--•-..._.......••••--••••-••••....-•••-••••-•••----•••-••.....--•••••••-----•-•-•..._..-••-•••--•••••...-•----•-•-••--•••••••••----•----••-•--•••--•-•••••••••-••--•••••••••-••----••----•-•-••......._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trrfifiratr ,af Tuntplianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed Repaired ( )
b .......... f �............ ----...... ..... ........ ------................---•--......-•-------....A........-•---....------------------.....
/'l nstaller
al /. ..
has een installed in accordance with thvlio s`off i LE 5 of The State Sanitary Codes de ribed in the
application for Disposal Works Construction Permit No- �. _ _�.................... dated_..
. ...........................
THE ISSIJ NC OF THIS CERTIFICATE SH�CLNOT COIdSTRII S Ac7�► �6 THAT THE
SYSTEM W IF CTIOId SATISFACTORY.
DATE..... ..�Z ..................................................... Inspector..... .. ---------------------•---------------•---.._......__.........._.•--••
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` o.... ,�..�.. ...... .... FEE........................
�t��rr��t� nrk� �nn��rnr#inn rani# '
Permission is hereby granted• ..................................
to Construct ) or Repair ) an vidua , 'e�age. sposal System
at N -- jj J
�l�J�-mil Street
as shown on the application or Di posal Works Construction Permit No..................... Dat '_ . `. : ...............
ar —fyHeal h
DATE... -• ....................................................
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