HomeMy WebLinkAbout0118 BAY LANE - Health 118 Bay Lane (Centerville)
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No. H� 1630R
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TOWN OF BARNSTABLE
BOARD OF HEALTH
'-7 ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION
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Date , _ I O Time: In Out
Owner I "o Tenant C
Address % O y-O L' , Address ( (
Complianc Remarks or
Regulation# Yes O Recommendations
2. Kitchen Facilities
3. Bathroom Facilities
4. Water Supply `
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5. Hot Water Facilities
6. Heating Facilities
7. Lighting and Electrical Facilities
8. Ventilation
9. Installation and Maintenance of Facilities Approved: -
won r%O'Na r
10. Curtailment of Service
11. Space and Use
12. Exits
13. Installation and Maintenance of Structural
Elements
14. Insects and Rodents
15. Garbage and Rubbish Storage and Disposal
16. Sewage Disposal
17.Temporary Housing !v
18. Driveway Width l2
19. Number of Tenants Observed
PART II
37: Placarding of Condemned Dwelling;
Removal of Occupants; Demolition
Number of Bedrooms Number of Vehicles Allowed (max)
Number of Persons Allowed (max) J �---
Person(s) Interviewed Inspector
If Public Building such as Store or Hotel/Motel specify here
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Commonwealth Of Massachusetts
Executive Office Of Environmental Affairs
Department Of Environmental Protection
TITLE 5
Official Inspection Form -Not For Voluntary Assessments
Subsurface Sewage Disposal System Form
Part A
Certification
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
Name of Inspector(please print)Sean M.Jones#SI4522 414 Z�a
Company Name: S.M.Jones Title V Septic Inspection
Mailing Address: 74 Beldan Ln.
Centerville Ma.02632
Telephone Number: 774-2484850
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
Fails
Inspectors Signature Date: 1 1 ► o �a�
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:
****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.
Page 1
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
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 which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B.System Conditionally Passes:N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or
Repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please
Explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
Unsound,exhibits substantial infiltration or exfiltration or the 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 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
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(S).The system will
Pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION CONTINUED
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
C.Further Evaluation is required by the Board of Health:N/A
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 310CMR 15.303(1)(b)that the
System functioning in a manner that protects the public health,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 supplyor tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
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.
X 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 '/a 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 cesspool or privy is within Zone 1 of a public well.
X Any portion of cesspool or privy is within 50 feet of a private water supply well.
X Any portion of 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 pp,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
X (Yes/No)The system fails.I have determined that one or more of the above 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:N/A
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:
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
If you 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
CM15.304.The system owner should contact the appropriate regional office of the Department.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
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 system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Were as built plans of the system obtained and examined?(If 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 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 tee,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.
_X_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of
distance
Is unacceptable)[310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203(for example): 110 gpd x#of bedrooms): 330 gpd
Number of current residents:-
0-Does residence have a garbage grinder(yes or no)-.—no
Is laundry on a separate sewage system(yes or no): no_[if yes separate report required]
Laundry system inspected(yes or no): n/a
Seasonal use:(yes or no) no_
Water meter readings,if available(last 2 years usage(gpd): 2006= 16.4 gpd---2007=35.6 gpd
Sump pump(yes or no):—no
Last date of occupancy/use: 2007
COMMERCIAL/INDUSTRIAL:N/A
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 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 this quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X_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 the system owner)
Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: 1987
Were sewerage odors detected when arriving at the site(yes or no): No
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
BUILDING SEWER(locate on site plan)
Depth below grade: 1`
Materials of construction: cast iron_X_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
Joints were in good condition,no size of leakage.
SEPTIC TANK:_X_(locate on site plan)
Depth below grade:_6"_
Material of construction: concrete metal fiberglass_polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 8`6"X5`6"X4`10"= 1000 Gallons
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 3.5`
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:Opened covers and took measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
Tank does not need to be cleaned at this time but should be done every 2 years to maintain the systems useful
lifespan.Water level was at bottom of outlet invert.Tank structurally sound and not leaking.
GREASE TRAP: N/A (locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene
other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
TIGHT or HOLDING TANK: N/A (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_X_(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.):
D-box is functioning as intended.Water level was at bottom of outlet invert.No solids caryover.
PUMP CHAMBER: N/A (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.):
II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
SOIL ABSORPTION SYSTEM(SAS)_X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits.Number:
X Leaching chambers,number:_3 flowdiffusers
Leaching galleries,number:
Leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternitave system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
S.A.S.was located but not excavated,soil was dry and vegetation was normal.No sign of past hydraulic
overloading.
CESSPOOLS: N/A (cesspools 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: N/A (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.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water-1 1`+/- feet
Please indicate(check)methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable Groundwater Contour map.Map shows
water elevation approx. 11'.bottom of S.A.S.is approx.6'below grade.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 118 Bay Ln.Centerville Ma.02632
Owners Name: Estate of Kathleen Shean
Owners Address:
Date of Inspection: 11/8/2008
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or
Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building
a
C7 1
front
CD 2
b C TANX
A-1=29'
B-1=21''
A-2-W
B-2=1 T
0-BOX
B-3=27'
a C-3_3
3 4 SAS.
B4=31'
G4=2T
oaTe;_511LQt____
PROPERTY AO0RES5;_ 1t$,—Uaj,T,az,=-- ,---_---
---S.arLtsrsyille----------
Q?§3�-----------
On the above data, I Inapooted the aeptlo ,syat#r7 at the aboyo address.
Thls syslem consls►s of the following,
1 . 1 -1000 gallon .septic tank.
2. 1 -Distribution box.
3 . 3-Flow diffussors. 28 'X 12 '
883ed on my Inepeotlon, I oertlfy the following oondlilonat
4 . This is a title five septic system. ( 78 Code )
5 . The septic system is in proper working order f ` y1
at the present time. f�(j U
6. Pumped the septic tank at time of inspection.
Heavy scum & solids layers were present.
SIGNATURE;,,/ _, JG
Company; Joe •.ph_P . N•comb.r_& Son , rnc ,
AddreS9 ; Box 66---
__Cencerr111e L Na ,_02632-0066
Phone :--- 508_775_7738_______
THIS CERTIFICATION 00es NOT CONSTITVTE A OVARANTY OR WARRANTY
C
P. MACOMBER & SON, INC.
T+nk�•C+�+pool�•l�+chll+ld+
Pvmp+d L In+t+llod
Town S#wf� Connootlon�
66 ontorYr7, MA 2632.0066
�a.
.\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 1 1 8 Bay Lane
(`cnt-crvi 1 1 p
Owner's Name: KathlPPn K- npdr_
Owner's Address1 Q3 Pierce Road
Watcrfc)wn Mn 07477
Date of Inspection: 5/1 /n
Name of Inspector: (please print) Jospeh P. Macomber Jr.
Company Name: J P macomber & Son Inc
Mailing Address: Box 66
rent-Pryi 1 1 A Ma 47632
Telephone Number:5nA 77r,_33u
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 Se tion 15.340 of Title 5(310 CMR 15.000). The system:
Passes
— Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shal bmit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,OW
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
c y Paee 2 of 1 I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:118 Bay Lane
Centerville
Owner: Kathleen Kennedy
Date of Inspection: 5/1 /01
Inspection Summary: Cbeck A,B,C,D or E/ALWAYS complete all of Sectlon D
�A System Passes ty
z
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
None
B. System Conditionally Passes:
W� 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.
D The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structwally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
A/L9 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, sealed 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
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
_ broken pipe(s)are replaced
obstruction is removed <"
ND explain:
2
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 1 8 Bay Lane
Centerville
Owner: Kathleen Kennedy
Date of Inspection: 5/1 /01
C. Further Evaluation is Required by the Board of Health:
_&o 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 supple.
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+vell•'. Method used to determine distance Zla�
"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 firom 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 anached to this form.
3. Other:
3
r: Y �✓ t
Page 4 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 1 8 bay Lane
Centerville
Owner: Kathleen Kennedy
Date of Inspection: 5/1 /01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No�'
�ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
ischarge 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
�esspool .,F2pw+ i0tf bus r
gj ''A iquid depth ineesspeel is less than 6"below invert or available volume is less than day flow
�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
/of times pumped
�y 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
ater supply.
�y portion of a cesspool or privy is within a Zone 1 of a public well.
�y portion of a cesspool or privy is within 50 feet of a private water supply well.
y portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
(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 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 ;elt-he
system is within 400 feet of a surface drinking water supply
th 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
"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
c =Page 5 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 1 1 8 Bay Lane
CentPrvillP
Owner: Ka hl P -n Kennedy
Date of Inspection: ;.11 .1 n 1
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant, or Board of Health
Were any of the system components pumped out in the previous two weeks^
y/as the system received normal flows in the previous two week period ?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined? (if they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
_ Was the site inspected for signs of break out?
Were all system components, uding the SAS, located on site ?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
Existing information. For example, 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 1 I f1 J
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 8 Bay Lane
rpntarvi 1 1 P
Owner. Kathj aQn Sennerjjr
Date of Inspection: 5,11 f 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN now based on 310 CMFi t 5.203 (for example: 110 gpd x p of bedrooms):
Number of current residents: _
Does residence have a garbage grinder(yes or no):Adi
Is laundry on a separate sewage system•(yes or no):it (if yes separate inspection required)
Laundry system inspected(y s r no):
Seasonal use: (yes or no): qqQ-y3,00Qy G.PD I/�•�S/
Water meter readings, if available (last 2 years usage(gpd)): 006 Qj2pi? 51/.$1)
Sump pump(yes or no): ;����`�
Last date of occupancy: �
COMM ERCLAL NDUSTRIAL
Type of establisbment: l9
Design now(based on 310 CNfR 15.203): gpd
Bans of design now(seats/persons/sgft,etc.):
Grease crap present(yes or no):40
Industrial waste holding tank present (yes or no): �11�
'\on•sinitary waste discharged to the Title 5 system (yes or no):
'A ater meter readings, if available:
Last date of occupancy/use: V/21
OTHER (describe): ,61//r
GENERAL INFORMATION _
Pumping Records r�
Soxce of information:
was system pumped as pan of the inspection(yes or no):
es. %olume pumped:,,�/ gallo How wa ant ry pu ped determined? !�
Reason for pumping: Ti� 1�k ^/,yJ/Jsti�s°
TY OF SYSTEM
Septic tank, distribution box, soil absorption system
/'Lo Sungle cesspool
Overflow cesspool
Pn,,y
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
ohtatned from system owner)
Tight tank YAnach a copy of the DEP approval
*Q Other(describe):
._.A.gprQsym ae of al c one1 date i stall e (if d s u.►c„Y;_r' fo anon:
were sewage odors detected when arriving at the site (yes or no):
6
Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 8 Bay Lane
Centerville
Owner: Kathleen Kennedy
Date of Inspection: 5/1 /01
Bl_'ILDINC SEWER (locate on site plan)
Depth below grade: �
Materials of construction:.!/cast iron f/40 PVC AOother explain): ,dif
Distance fiom private water supply well or suction line: /b
Comments (on condition ofjoints, venting, evidence of leakage, etc.):
Joints appear tight-No evidencp of leakage-System is-vented
Idod� cuJy through the house vent.
SEPTIC TANK: z0ocate on site plan)
Depth below grade:
Material of construction: oncreteA0 metalA9 fiberglass�J�olyethylene
NDother(explain) _
tan! is metal list age: _ Is age confirmed by a Certificate of Compliance (yes or no):f±(attach a copy of
ccn�f�cate)
Dimensions: r�d I 4)M��
Sludge depth:
Distance from top of sludge to bonom of outlet tee or baffle:
Scm thickness: 0
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bon o of outlet ee or baf
.Hoµ µere 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.):
t Pump the se tic tank err 9-3 ye arc Inlet & outlet tees
'are in olace.The tank is s r c s allY sound and shows
no evidence of leakage.
GREASE TRAP/} (locate on site plan)
Depth below grade:2/9
Material of construction: J�conerete.e-,1 metaIA14 fiberglass y polyethylene��other
(e\plain): AM
Dimensions of
—
Scum thickness: 4�1_
Distance from top of scum to top of outlet tee or baffle: .11)14
Distance born bosom of scum to bonom of outlet tee or baffle: X'IX
Date of last pumping: if)4
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grtrase trap i g nnt, =regent
7
Page 8 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 8 Bay Lane
rpnteryi 1 1 e
Owner: Rath1 aan kr-nnarly
Date of Inspection: 5 f 1 f ni
TIGHT or HOLDING TANK(tank must be pumped at time of inspect ion)(locate on site plan)
Depth below grade: 4h4
Material of construction: concrete metal 41.4 fiberglass AeA PolyethyleneV,±_other(explain):
Dimensions: .64
Capacity: gallons
Design Flow: _�i gallons/day
Alarm present(yes or no): 4)iQ
Alarm level: _04 Alarm in working order(yes or no):
Date of last pumping: ,tlA
Comments (condition of alarm and float switches, etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX: -2(ifpresent must be opened)(locate on site plan)
Depth of liquid level above outlet invert: .4 °
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.):
Distribution box has one lateral.No evidence of solids carry over.
No evidence of leakage into or out of the box
PUMP CHAMBER4,bjY,(locate on site plan)
Pumps in working order(yes or no): Ay
Alarms in working order(yes or no):
Comments (note condition of pump chamber,condition of pumps and appurtenances,etc,):
Pump chamber is not present.
8
r
�- Page 9 of I I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 1 8 bay Lane
Centpryjlle
Owner: KathlPPn Kannedy
Date of inspection: ,/1 /o 1
SOIL ABSORPTION SYSTEM (S:�S): Zlocate on site plan,excavation not required)
If SAS not located explain why:
Located
Type
of leaching pits, number:
leaching chambers, number.
A,�a leaching galleries,number:
V leaching trenches,number, lew-h: 0
dI1L leaching fields, number,dimer,:,ions:
�Q overflow cesspool, number:
AJQ innovative/alternative system. ape/name of technology: Title Five ( 78 Code )
Comments(note condition of soil. s . ors of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
Loamy sand to medium _fine sand.No signs of hydraulic failure
or--ponding- Soils are .dry.Vegetation is normal.
CESSPOOLSC&&(cesspool rr.W: '. pumped as part of inspection)(locate on site plan)
Number and configuration: Q
Depth-top of liquid to inlet invent
Depth of solids layer: _
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow or no):
Comments(note condition of soil. is of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present.
PRIVYA64(locate on site plan)
Materials of construction:
Dimensions: AM
Depth of solids:
Comments(note condition of soi! .:s :)f hydraulic failure, level of ponding,condition of vegetation,etc.):
Privy is not Present.
9
K• y Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properr Address: 1 1 8 Bav Lane
Centerville
Owner: Kathleen Kennedy
Date of Inspection: 5/1 101
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
-Estimated depth to ground water 10 feet
Plea/se indicate (check)all methods used to determine the high ground water elevation:
1/ ta' d from system design plans on record If checked,date of design plan reviewed: 1
served site a untn rope observation hole within ISO feet of SAS)
hecked with local Boar o Health-explain:
Checked with local excavators, installers. (anach documentation)
— Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used water contours Map.
Gahrety & Miller Model
1 2/1 6/94
11
I
. nrn.+ -n.♦�r'+r' .wry•�n�T�.-....i.-wn.rrw�rw�ww....R♦v rww�.w�n fir+-+-r.n.- .-
TOWN OF BOARD OF HEALTH
-^^ -. ._SUIiSUftFACR 9EHA(;P, f'I f'U,SAL�9Y�5TFM INSPECTION PURR -' PART D •- CERTIFICATION � -
-TYPt OR PRINT CI.rAILY-
PROPERTY INSPECTED
STREET ADDRESS 118 Ray T.nnn renteruillc
ASSESSORS HAP , DLOCK AND PARCEL #
OWNER' s NAHE Kathleen TtPi1�, nt-dy
i
PART D - CERTIFICATION
NAHE OF INSPECTOR _ Joseph P. Macomber Jr,
COHPANY NAME Joseph P. Macomber s,"Son, Inc.
COMPANY ADDRESS B 6 _ — Centerville MA. 02632-0066
tre e TOvn or City hate C P
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX
CERTIFICATION STATEHENT
I certify that I have personally inspected the sewage disposal system at
Drlecoinmendat* lons
his address and that the information reported is true , accurate , and
omplete as of the time of �Inspection , The inspection was performed and any
regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems ,
Chec one
r ?
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
heallll or the environment as defined in 310 CHR 16 . 303 , Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
Lhis form .
System FAILED
The in. which I have con acted has found that the system fails to
protect the E)tlblic health and the environment in accordance with Title
5 , 110 CHR 15 , 303 , and as specif.lcally noted on PART C - FAILURE
CRITERIA of this Inspection f rm .
Inspector Signature - Date
atn-Tre
copy of this rt.ification must be provided to the OWNER, the BUYER
applicable ) and the I30ARD OF HEALTH.
e If the inspection FAILED, thv owner or operator shall upgrade ' the system '
within one year or the date of the inspection , unless allowed or required
otherwise as provided in 3.10 CIIR 16 . 306
partd . doc
I � ;
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 1 8 Bay Lane
Centerville
Owner:Kathleen Kennedy
Date of Inspection: 5/1 /01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
q�eoy }o p eoq
...... ..... ... ......... .. ......paieo
.............
....................... .
CC-
10
TOWN OF BARNSTABLE o 33
LOCATION / G SEWAGE # g I " 331
VILLAGE a,v% ASSESSOR'S MAP LOT[AP" 3
INSTALLER'S NAME & PHONE NO. i4 C o�y10s'�,P ^ SaN 7)$= 333T
SEPTIC TANK CAPACITY lee d
LEACHING FACILITY:(type) (Size)
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �/
i
`rk
1�
~V
ASSESSORS MAP NO:-
PAROEL N0: �
Fps.... ....2Q a.QQ
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
------......T.own.................O F..............Rar n a.t.a.b.le...-----•---------------•--•--..........---
Appliratiun for Biupuual Workg Cnunutrurtiun rrmft
Application is hereby made for a Permit to Construct ( ) or Repair (x ) an Individual Sewage Disposal
System at:
- •118 Hay-...Lane.. eeaterylue........................ ....................................................
Location-Address or Lot No.
Kennerl�r-......................-------------------------------------------------- ---------------_-------------------------.....-_-_----_--_---------------------------..-----------
n�_�, y, Owner Address
----•J.,,Fi.Ama mi:�Q,x............................ ...............................
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms_-__-__-_. .....Expansion Attic ( ) Garbage Grinder ( )3 —a Other—Type of Building __________________________ No. of persons............................ Showers ( ) Cafeteria ( )
a'' Other fixtures ............................... ..
W Design Flow............................................gallons per person per day. Total daily flow_...........................................gallons.
1:4 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth__..-__-___-__-.
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 ( )
aPercolation Test Results Performed by.......................................................................... Date.....................-----•---------•-
Test Pit No. 1________________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........................
••---------•----------------------------------•-•----•-----•--.....-•---------......------------•---.........................................................
0 Description of Soil............S ajad---&-G.mv.al....--•---------•----•--•-•------------------------------------------------------------------------•----•-----------..
x
U -----------.............................................................................................................................................................................................
W
-------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable.-____11.10J:1D___t.aul,--------11!tr ___ e011e..
------------------------------------------------------------------------------------------------------------•--------...----...--------------------------------------------------......----•••...._..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i?Ti;"
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issue ybyhe b rd of I
Sign � .......................
--54/20/87--........
Date
Application Approved By............... . ---- -•--•-----------------------------------
Date
Application Disapproved for the following reasons-----------------------------•------------------------------------------------------------------•-------•--••---
---------------------•--------------------------------••------------------....---._..........------•--•-----...._....----•--------•--••----------------------•--••---•-----------•••--------------------
Date
Permit No.....1 -.33.9....----•-•--------------- Issued.......................................................
Date
No.. ._ . .'�.. Fim............ .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-�...................OF.................. '.......:...: --------..........................................
Appliratiou for Dispau al Work,6 Tonstrnr#ioaa .eruti#
Application is hereby made for a Permit to Construct ( ).or Repair ( ) an Individual Sewage Disposal
System at:
.. -----...._•..----•-......••----••........................::.: - .... -- - .....
Location-Address or Lot No.
Owner Address
r
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.......... .................... .Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures --------------------------------------- -
w Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Gd Septic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth................
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 ( )
aPercolation Test Results Performed by...........................................................-------------- Date........................................
Test Pit No. .1................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........................
•--••--•----••-•----• •---...-•------•-•------•-------------•--....-----------------•--••._.._...-----•---•-••-•-••••---•-•------....._......................
DDescription of Soil-------------.- - _......--•-_==r.............--------------•-•-----•-----...---------------------------------------------------------------------------...------._..
x
w
U Nature of Repairs or Alterations—Answer when applicable..__ _-..:::...:.......i.___ T__-__-_I....__ ....... ____:.......................
---------•-•------------------------------•---...•------•-----------------------•--•.........-----...---.....----------------------------------------•-•-----------------------------------------•-----.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T= 72 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.
Signed ........... :.':........:....r/..............................
................................
Date
Application Approved By.............. ...� =="= === -----------------------
Date
Application Disapproved for the following reasons----------------------------•-----------•---------------------------------------•--------------------------•----
-----------------------------•--•••-------------------------•---•----------------...........--------•--•.--------•.......-••----------------------------•••---------•------------------------••--...._._
Date
PermitNo.---- ...�3_.1...-••••-•-•--•-•-•----•-_. Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ..........................::.............OF.................... L.........L.............................................
%TF. rrtif irtttr of TompliFana
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (- )
1? ? `?.7 [.F v [: f.'-�;----
F E Installer
at.------. `- --- - ----
has been installed in accordance with the provisions of fiT i i of The State Sanitary Code as described in the
._F�application for Disposal Works Construction Permit NO :__�.3... ........... dated-----------_....................................
TIME ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------••-----•-.---� ... xf............................ Inspector---•---1 -- ---- ..........................
7G. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
„> + -
33 r
. ,.. ��. OF..
No 7 4� C
FEE. ....._�..s.�:.,.
Disposal Works Tonitrion pamit
Permission is hereby granted.................................. --•--------------------•----------------------..........-----------------•.....
to Construct (. ) oral Repair ,(` )� an Individual Sewage Disposal System
at i�TO... i 1 tir Y.
. . ..... ..... ................ ............................... ....------...........................................................................
Street 5�
as shown on the application for Disposal Works Construction Permit:_No'/ _ 33 .9 __ Dated.........................................
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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