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HomeMy WebLinkAbout0155 BRALEY JENKINS ROAD - Health 155 Braley Jeinklns Roa-d Centerville P A = 172 206 uu UPC 12534 No.211553�L_OR �{„ COMMONWEALTH OF lvll-1SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r , PARCEL, �p i TITLE 5 C W.._..`3 .. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ' 02WA Owner's Nam Owner's Address: A_rA Q,1-;>'70 Date of Inspection: a a c)Y. Name of Inspect please print l/ � 't m Company Nae Q Mailing Address: D Telephone:Number: 9 F' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the r)formation-repnied below is true, accurate and complete as of the time of the.inspection. The inspection was performed based 4 R*,niy r" training and experience in the proper function and maintenance of on site sewage disposal systems I am a ID-EP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste Passes Conditionally Passes Needs Fu ther Evaluation by the'Local Approving Authority ails Inspector's Signature: /� Date: // `6 j 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 ofthe 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 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address! 511 Owner. Date of Inspection Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D. A. S stem Passes: I have not found an information which indicates that`ari" of the failure criteria descfibed`in 310 CMR Y Y 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to 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 deternined"please explain, The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration.or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance. indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with.. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 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 r Page 3 of 1'1 OFFICIAL'INSPECTION FORM - NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: ( Owne 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 prolectpublic health,safety or the environriient. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(i)(b) that the system is not functioning in a mannerwhich.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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100.feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for 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: t Page 4 of I 1 1 1. OFFICIAL INSPECTION r _FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �( Owner: {� , Date of Inspection: c�J�100C D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or / clogged SAS or cesspool Static liquid level in the distribution.box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6 below invert or available volume is less than '/z day flow V Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ V Any portion of the SAS, cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface _ Jwater supply. Any portion of a cesspool or privy is within a Zone 1 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. [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. JV 1� are triggered.A copy of the analysis must be attached.to this form.] 1� (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 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 I1 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 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B` CI3ECKLIS`T Property Address: Owner: Date of Inspection: a S OC.C� Check if the following have been done. You must indicate"yes"or"no"as to each of the followinlo: Yes o , Pumping.information was provided by the owner, occupant,or.Board of Health Izzwere.any of the system components pumped out in the previous two weeks? Has.the system received normal flows in the previous two week period ? Have large.volumes of water been introduced to the system recently or as part of this inspection? Were as built-plans of the system obtained and examined?(If they were not available note as N/A) "/ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of breakout? i� Were all system components,excluding the SAS, located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? :Was.the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes o Existing information.For example, a plan.at t►te Board of Health. 44- Determined in the field(if any of the failure criteria related to Part C.is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION-FORM--NOT OR VOLUNTARY:ASSESSME'NTS SUBSURFACE SE WAGE-DISPOSAL SYSTEM INSPECTION_FORM PART C SYSTEM INFORMATION Property Address: _�ae-n w 30-& Owner: Date of Inspection: ' PLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):�� . Number of bedrooms(actual): �. DESIGN flow based on 310.C1vIR 15.203 (fof example: 11.0 gpd x#of bedrooms):_3 Number of current residents: Does residence.have.a garbage grinder(yes or no): Q Is laundry on a separate sewage system (y or no):_U.[if yes separate inspection required] Laundry system inspected( or no):IVO Seasonal use: (yes or no., ... Water meter readings, ifav ilable(last2 years usage(g -pd)); 03 �31QDO QZ—V�/ Sump pump(yes or no):/O - _ r l Last date of occupancy; /L i 0/ COMMERCIAL/INDUSTRIAOU 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(ye nr no�� _ If yes,volume pumped: gallons--How was quantity pumped determined? Reason Tor pumping; TYPE SYSTEM ptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) Itmovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) - _Tight tank _Attach a copy'of the DEP.approval —Otlier:(describe): proximate a e�anllll/nnni�oneuys,-date installed 'f known)a . source of inforrnatiorr: /tf Were sewage odors detected when arriving at the site(yes or no) 6 Y ! Page 7 of 1 1 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: .A. Owner. � Date of Inspection: z9�, ,�, � 7 BUILDING SEWER(locate on site plan)/16 Depth below grade Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line Comments(on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) J/ Depth below grade:'POLL Material of construction' oncrete_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: r (o ' tC57 Sludge depth:: Distance from top of sludge to bottom of outlet tee or baffle: ;�Z Scum thickness: Distance from top of scum to top of outlet tee or baffle: 2 Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: , Comments(on pumping recommen ations, i let and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of le kage, et ): - Ptehz 1- GREASE TRAP/"locate on site plan) L 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.): 7 Page 8 of 11 OFFICIAL.INSPECTIONFORM NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM!INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � ?0-oeyl) Owner. Date of Inspection: ,a 7` TIGHT or HOLDING TAN I/f/ tank must be pumped at time of inspection)(locate on site plan). Depth below grade: Material of construction: concrete metal fiberglass_polyethyle.ne, ottier(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: tf present must be. opened)(locate on site plan) Depth of liquid level above outlet Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of ka&e into or out of box,g� PUMP CHAMBE (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.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: CpZ�Gt' Owner. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: z TYP leaching pits,number_ leaching chambers,number. leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil; condition of vegetation, ), n Cr �- CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 a 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 Owner Date of Inspection: . SKETCH OF SEWAGE.DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the.building. 1 C q(0 (, 't � t O &Y 10 Page I 1 of 71 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: A Owner: Date of Inspection: CP5-CDODV SITE EXAM Slope Surface water Check cellar Shallow wells- Estimated depth to groundwater /LI feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: hecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Al k ^ 11 Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: j;�� ��� L" �/� ��/Z�`' �Lx- Lot No. Owner: (;t re e g/g�ew. Address: / Contractor: /�aT � l95 Address:�� �' Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. ............................................................................... .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Appropriate index well................ �"........................••.....••••• OWaterdevel range zone ...................................................... G STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to D/J y��/ water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A),.current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .......................................................................................... 2 STEP 5 Estimate depth to high water by subtracting the water- level adjustment.(STEP 4.) from measured depth to water /G levelat site (STEP 1) ............................................................................................................. !/ Figure 13.—Reproducible computation form. I i 15 -` . •,�:: '` `; .,,- -_ .. . ��. . . :. • � .�. .. i.f F j' .. F � • � .� .'� �# i � i . .� 1\- } O • �� . � .. � � � . f '� 3 • � � �. •�: . ; � s . i. �: . � P ��� �;. i E. 't; . ,a? �j }. ,j I• ' � � ;� }s s� �•.__ter.; S .3 u . ; z �_ ir � �.; - � � �.i f � Ef , •i�`s jt �- �� � � ; �. � _ � � '� . � . - � _`� .� b . � .� :��► . . } No...... ? F .............. ... THE COMMONWEALTH OF MASSACHUSETTS / /• BOAR® OF HEALTH Appliration for llispnittl Works Tonstrnrtinn Vanfit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: H SC, Iss Location-Address oor ............................................ - ►Wa ---- .. {.�1.D.X.__ � ... Address.... � 1 f Installer` ��C� Address d Type of Building T��-� j Size Lot....3.� � �Sq. feet 73 Dwelling—No. of Bedrooms............. .•..................... Attic,— Garbage Grinder '4 Other—Type of Building No. of ersons_....... ..______. Showers — eteria tz, YP g - - -- - ----• P �---•--- �-�-- Q' Other fixtures W Design Flow........................... ..............._ga..., l.l.ons........ p.er I person�e d�. T otal daily flow..------------------------ _ ? -----------___..gallons: WSeptic Tank—Liquid'capacity)!. lons Length___-......A.. Width... _..AO. ._ Diameter............... Depth_67.... x Disposal Trench—No..................... Width_-___...r.................... Total Length................. Total leaching area.............. _..,�...S . ft. Seepage Pit No..........I---------- Diameter----- _ _.... Depth below inlet... Total leaching area... _` .-. sq. ft. Z Other Distribution box ( �� Dosing0�_ Percolation Test Results Performed b ..... � -r_. .. __1.4 ___________________ Date_.�_ _ ... . Test Pit No. ..... per inch Depth of Test Pit----- ... Depth to ground water--_r. ._.._ G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-------................. �+ ---------- -- ... ..._.... O Description of Soil �7 t `�` < ' - .......�- " �• - -- x0-W ------------------------ --��� `� ---------------------------------------•--•-------......-•----------••------•------•-------------------•------------------•--•---•--------••---..._...---••-----•--•--•--•......._.....--••••......----- V Nature of irs or Alter —Answer when applicable............................................................................................... Agreement: The undersigned agreesto install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?" 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 f 1 lth. Signed._X. - - - - ----------•--•-.......-----------.---- ST_.... - r Da e ApplicationApproved By......................................................... --------•---••-• ••-••---------- -•------- - ------ D e Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- --------------------------•------------............,..----------------.....------------------•-------------•--•----•--•---•-------•-------•--•---•...----------------------------------•--•---•--•--•••--- Permit No.---.�'v.....� 2------------------- Issued...........................................Dat<------ Date r No................-....... Fss.......................... _ THE COMMONWEALTH OF MASSACHUSETTS "Cf 4— BOARD OF HEALTH Cf �J vv1V .............. .........................O F.........................................------------------............................... Appliration for Disposal Works Towdrnrtion ramit Application is hereby made for a Permit to Construct (�') or Repair ( ) an Individual Sewage Disposal System at: ............... .- ... .._.................... ...................••... -._..._..o. t .. Location-Address� �r s �e✓ .............................................................I< Address ......................................------•----•-•..................--:_..._ _ •--........... ------.....---------------.....--......--------------..................____._....__.......•'•••-•. ,&%,,d (, °� Address 3 a 3- 8 Type of Building � _Size Lot...._J....------------------Sq. feet U Dwelling—No. of Bedrooms...................:........................Expansion.Attic-("`) Garbage Grinder ()� pa, Other—Type of Building _� _C ` ..... No. of persons_______ _________________ Showers '(�) — Cafeteria P4Other fixtures ------------------------•--------------.....----------.•••••----•---------•--•------------------••-••-•••- W Design Flow.................•........__ �___`�-�__�gallons per person per day. Total�ily flow_.._.......•.._______..________.............gallongs. .� W Septic Tank—Liquid capacity/.... -----gallons Length....;_C°... Width.......... ......_t.©._ Diameter................ Depth`'........... x Disposal Trench—No..................... Width.....,........... Total Length....... .• Total leaching area............. . ft. Seepage Pit No..........1.......... Diameter.................... Depth below inlet................_... Total leaching area..................sq. ft. Z Other Distribution box ( Dosing tank-,'--) //1/'� Percolation Test Results Performed by..................................................;- -....._.. Date....._........_.._._..._......... _..__ . a < Z r L� / Z.,.... _ Test Pit No. I......=__.....minutes per inch Depth of Test Pit.................... Depth to ground water..._-.------------------ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .................................................................. . ....................... r ................. O Description of Soil 'S 1,. - f - - 1 P ------------=�----------------- UW •-----------------------•--•-------•--••----•------------•--------------------------.....••••-•••----••••••••----------------....•-••-••-••------•••••••--•••••••••-•••••••............---•-•......•- Nature of Re rs or Alter I —Answer when applicable.............................................................................................. Agreement: 01^ , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. .. -.........................•----••---•---..._....-- .........-•- ..... - Application Approved B ----- ---------------- D e Application Disapproved for the following reasons:.............................................................................................................. --••-•••---•--•--••••-•-••---••••-••......••••••••-•••••---.....••••••••••-•-•••-•--•-•••••••••-•--•--••••••--•-•--•--••••--••••-•--•••••••••--•••••••••-••••-••••-•-••-•---•--•----••••••••••••----•--- Date PermitNo..... ...--....-(••L-••••-•-----....... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .0,•�....OF..... - "2// 's r ...................................•••................ (IrrfifirFatr of TompliFatta THIS IS TO CE ividual age Disposal System constructed ( L or Repaired ( ) •..................... ............... Installei �— ,j / ✓/ r at....... �� .CA I el` L 1 - r' ` = '-�S " has been installed in accordance with the provisions of TITI �S 9 �hhee`State Sanitary Condo� drKibed in the application for Disposal Works Construction Permit No......................................... dated_...___-'.1...6 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..........................)_(7 % �i. ...... Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r �✓✓i�/ _Z:— i2a✓_Si rev 9 �- � No......................... FEE........................ "pF Wiposal Workii Tontra ion �v Y-\ Permission is hereby granted.......... ........................... .................................................. -------- ......... _-•- to Construct�(�or Repa ( ,an Individual Sewage Dis oral Sys d at No.•---- = y J g P Y L �. ---------------------------•-------...--...----------•-•----------........--------------------•------------•-------------------------------------..-- ...... ....... Street �.4— el a-- �'as shown on the application for Disposal Works Construction Permit No...................�?1 Dyat�ed_._.�==j-_....;......1........ ........ •••--------------------------- 0 4- 1..�c�_.... r� Boafd bf Health — DATE..----- ! ........... 1 l FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r' A- 4J TOWN OF BARNSTABLE LOCATION „nC SEWAGE # /� a0 VILLAGE Ge�� erv�\\ e. ASSESSOR'S MAP & L INSTALLER'S NAME & PHONE NO.Y,-,Y C\<, e• '��\- �c\`�� SEPTIC TANK CAPACITY 00 O c, cs, . LEACHING FACILITYAtype) �'�� (size) pO NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE PERMIT ISSUED: jj DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No /� ok' �3 aCk 3 C/ I u'- lt:t.. � I 4 ma's M1,Y y J t.- yp ' F3v S s 00- � y owtar. TANK t ON :r> moo S OL'+1. h{ 5 _ IL E !\ A IN F 4r r a�w • DR JN t ALA. TO 8 : is O R °-A SC JAL E: P R 0 P&"• S C -- l._ rG SPOT tLEVAT1ON .,., LZ- Sc- C, WATER SERV . w �0C AT 10 N