Loading...
HomeMy WebLinkAbout1288 BUMPS RIVER ROAD - Health 1288 BUMPS RIVER RD., CENTERVILLE A= 188 046.003 r d r i l e 534 No 2 1_ 5 OR h48TING8. MN .r.asc,.�6:-�.. .� :a...,�.a�a.;.,,.�,.�tlnm....._.:...........�..w...�,,,..-�::...v,.�....�....�.� ..._,. .., .::.__... ._.._:...,,._ -.r.�..�-..�.:.�_...,:.__..._.. - -- - — — �— -._�...,W_d.... -._.................:���._....,�.�....�..�._.. _...,._.u.,..,.. �_ .... _.�.,..�._�.c_..e�c..e,ena...... Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is P required for Centerville MA 02632 A rll 14, 2009 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. Genergi Information forms on the I � computer, use 1. Inspector: only the tab key to move your David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name r� 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification 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 insp?ction. e inspection was performed based on my training and experience in the proper function and maintenance bf on-:�site sewage disposal systems. I am a DEP approved system inspector pursuant t -Section 15.340uof Title 5 (310 CMR 15.000). The system: - -= ® Passes ❑ Conditionally Passes ❑ F ❑ Needs Further Evaluation by the Local Approving Authority ® ;° l co r_ April 14, 2009 Inspector's Signature Date The system inspector shall submit'a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. ****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. G I� (Sins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 3 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14, 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is Centerville MA 02632 Aril 14 2009 required for p every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N FIND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® 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 1/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. 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 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 1288 Bumps River Road M Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14 2009 every page. City/Town State Zip Code Date of Inspection C. Checklist 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? ❑ ® 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 break out? ® ❑ 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): n/a Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a -no plan t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): 79 gpd Detail: 2007-2008 Sump pump? ❑ Yes ® No Last date of occupancy: undeterminedDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: N Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age unknown—system is assumed to have been installed at time of dwelling's construction in 1984 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3-- feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 1.5feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10.5 ft x 6 ft x 5 ft(1500 gallon) Sludge depth: 4 in t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30 in Scum thickness none Distance from top of scum to top of outlet tee or baffle 10 in Distance from bottom of scum to bottom of outlet tee or baffle 14 in How were dimensions determined? Previous inspection report Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last um in p p 9 Date t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is p required for Centerville MA 02632 April 14, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. No effluent contact staining was observed above the normal operating level of the distribution box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is Centerville MA 02632 Aril 14 2009 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down loudly into the leach pit. 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 ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14, 2009 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately IR Q 12 w w 31 %2�� PIT i�1�toX i t5ins-09/08 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9c� 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is required for Centerville MA 02632 April 14, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 13 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Previous inspection report dated 12/5/98 ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Previous inspection report dated 12/5/98 shows bottom of SAS to be 3.0 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1288 Bumps River Road Property Address George and Ruth Genlot Owner Owner's Name information is Centerville MA 02632 Aril 14 2009 required for p every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 y` =: COM-MO.N- EALTH OF I1-1ASSACHtiSETTS EhECL'TIVE OFFICE OF E\XIRO\A4E\TAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON 1LA 02108 (617) 292.550w TRUDY CORE Secretary ARGEO PAUL CELLLCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , fy f_ tM6 PART A ��r_� d CERTIFICATION ,u\,�,pte,�,y� Property Address: IZ C�� �vtKr Name of Owner C��' w\NsJNd �u- Address of Owner: (0 Date of Inspection: �z1S\ci% O�CZt-\i l\l_Q_ Name of Inspector: (Please Print) Ht I C (/VO I am a DEP approved system inspector pursuant to Section 15.340 of Trde 5(310 CMR 15.000) Company Name: A4-1 ct u fr C �I11 v i'L u �1L(� . Mailing Address: - t✓ - /V/9- C)2-64 Telephone Number: L G., 9�a 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature:. Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 16,000 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 9 j0 10 n r. 8 199p ►.. N ti A �, revised 9/2/98 Page I of 11 n is 1'r:r.trd on Reqwkd Faper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A _ CERTIFICATION (corrtirwed) "roperty Address: Jwnef: Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or 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 X— 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. Indicate yes, 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 Compliance (attached) 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 pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed n J � r ! revised 9/2/98 Page 2of11 . Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A — CERTIFICATION Icontirwed) Property Address: Owner: 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. 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 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. S 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 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 I 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). 3) OTHER revised 9/2/98 Page 3of11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIC ATION ( corrtirwed) — Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: `You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static 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. _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ Any portion of the 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. LARGE SYSTEM FAILS: 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: 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 owner 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 — Property Address: Owner: Qj�_1i Date of Inspection: V Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes Pumping information was provided by the owner, occupant, or Board of Health. x _ None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow f� rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. 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. X _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. K _ 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)) - _ The facility owner (and occupants,if different from owner) were provided with information on the properinaint.enanr.8-of SubSurface Disposal Systems. revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION — 'roperty Address: Owner: Cc,%A�W-G. Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: g•p•d./bedroom. Number of bedrooms (design): Number of bedrooms (actual): vS Total DESIGN flow S V Number of current residents: Garbage grinder (yes or no): t-164 Laundry(separate system) (yes or no): f%j: If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): N Water meter readings, if available (last two year's usage (gpd): f--� Sump Pump(yes or no): Last date of occupancy: "&0M �4— � c\� COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_LJU If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) 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 (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6(of 11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'roperty Address: \i. ; Owner: Date of Inspection: \,4, \ BUILDING SEWER: U C (Locate on site plan) Y� Depth below grade: Material of construction:_cast iron_A40 PVC_other (explain) Distance from private water supply well or suction line Liss tuu -�. Diameter It- Comments: (condition of joints, venting, evident of leakage,etc.) 3 �; —CC�TT4; \fit yi i� 1 QJ re SEPTIC TANK:TANK:%Atj (locate on site pl n) Depth below grade: Material of construction: ,concrete_metal_Fiberglass _Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No) Dimensions: ��JCJD Gam` 5 Sludge depth: All Distance from top of sludge to bottom of outlet tee or baffle:_ Scum thickness:_ `! Distance from top of scum to top of outlet tee or baffler `1 Distance from bottom of scum to bottom of outlet tee or baffle: Imo\ How dimensions were determined: Mta-4� 'omments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level i relation to out t invert structural integrity, evidence of leakage,etc.) t JJOLie OJk,a C. GREASE TRAP:_•p,ZJ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Iage7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) — Iroperty Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK:_It&) (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order:Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: S (locate on site plan) Depth of liquid level above outlet invert: (:CkY VA 0,� Comments: (note if level and distribution is a al, evidence of solids carryover, e,>� O ` vi ence of leakage into out of box, etc.) IG l Cif ti PUMP CHAMBER:_LL-0 (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.) revised 9/2/98 Page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: ��-�� ✓��S Q�UZtL_. Owner: QO(�T—� Date of Inspection: kzj S SOIL ABSORPTION SYSTEM (SAS): V1.,S (locate on site plan, if possible; excav tion 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, igns of hydraulic failure, level of ponding, Aamp soil con ' ion of vegetation, etc.) ut" ti n l/ CESSPOOLS: (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: )epth of scum layer:. Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_010 (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.) revised 9/2/98 Page 9ofII I- _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: (vis�r, Jwner: Lyx,ilv,L. Date of Inspection: 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) r � yO � 3 361 revised 9/2/98 Page 10ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) roperty Address: Owner: CC:�C�"�� Date of Inspection: NRCS Report name O Soil Type_ - Typical depth to groundwater USGS Date website visited �U Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Lp Surface water- {.KG4- Check Cellar 't>" Shallow wells F'jN- i Estimated Depth to Groundwater �3 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 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) revised 9/2/98 Page 11of11 —TOWN OF BARNSTABLE 1 g7 V" �I ^^ `` i:Gt.:O' N � P� �� G�Qo 1L� SEWAGE.# ,VILLAGE C�Yy���Qa11 \\� ASSESSOR'S MAP & LOT k1% o 00 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 600 �w4� LEACHING FACII,ITY: (type) (size) V300!2�Wr NO.OF BEDROOMS BUILDER OR OWNER PERMITI)ATE: k1 r1 c'l a COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ± 13l Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ►J 0\ Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by -�_C,\C.�7 r 11.V6 ,a 3 y � AZ, 3 $Z Yi A`�• N 5 '53�- Jo' 11 iLlo- C AON '"'�# �a�� WAGE PE itMIT NO. I IV ( VILIAGE 1 _ � INST-A LLER'S NAME i, ADDRESS R UILDER 0 OWNER DA T E PIRMIT I S S U E D f� DAT E COMPLIANCE ISSUED J W, No.. ..... . :1- --fir ............................ 0 THE COMMONWEALTH OF MASS -CHUSETTS BOARD OF HEALTH ezv^'.. O F..... ...•vsy: +.B to Appliration for Disposal Works Tunstrnrtinn rrmit' Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: __. ...................... -_.... ........ ----...-•--•-------. ------------------••---•......----------- ocation_Address or Lot No. Av. a :«ram ?� �o // Owner Address ------------------------------------------ -----.....----•-...............------...........------•--...........-- Installer Address Type of Building Size ...Sq. feet V Dwelling—No. of Bedrooms.- g ...................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type of Building ........... No. of persons....3.................. Showers ( ) — Cafeteria ( ) dOther fixtures -----------••-• •---••-•---••--•-•--•••-•---•--•--•-..-•-•---•---•--------•••----------------••••-•-••--•--•-•-•-....-•--•-•---------•-.....------••. W Design Flow.._.......9_K Zt� ................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. ZOther Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.__ eC .....�7�'..A r?`'............................. Date......./'a...................... W 14 Test Pit No. 1.....P.......minutes per inch Depth of Test Pit------ Depth to ground water-._- ®_-_'___-___. (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------•--....--•--•-•---•--------•---.........--••-----....................................................................... O Description of Soil....0--rz-,�2 Z0��...._syw.sai V ..................... ............................... !?.-•-- « ------------------•----...-•---•---------------•--......-••-•-.... W ---•-------------------------------------------------------------------•-----------------------•------------------------------------------------------------------------------------------------..----- V Nature of Repairs or Alterations—Answer when applicable------------------------------................................................................. -•----••----•-••••....----•--••-.....---•••-•••--•••---•.._..•---••-•-•-•---••-•-•....................••••••-••-•-••--• •---•---•-•-•................................. ................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha n issued by the boar of health. y d- ...... ---•-- ------- -----------•...-----•--- Application Approved -_......_. to�� --------------------------------•-------------------....••••-•--- Date Application Disapproved r t f ollowing reasons----------------------------------------------------------------------------------------•--••-••-•------......---. .........-•--------•...............................................^--•--•---•--•---........-•----.......-•-----•-•-----•-•---._.....-----.__-•-•-__......----•--•--••--------...-•-Dat......--------- Permit No.:-�_... "^ q.a---•---•----------_. Issued------w Date 1 THE COMMONWEALTH OF MASSACHUSETTS r.� BOARD OF HEALTH �Gcv- ........................OF... �',J.,.�_—' .�-FC ApplirFation for Dhipvii al Works Tatuitrnr#iun Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: ......16.;, _F f��� �` ems'/t e C>" _---------- --------------•-------- ----...........-- -•----•-----..........•-----......----•-•-•---••-•--•--------------------•---•-••---- Location-Address er fJc�i (/i t c'y et s Cr, /ry 7' �G %sue = ao.✓�C . ............. •- Owner Address --------- ----------------------- © - //r.. Installer Address UType of Building Size.Lot"' :__ G..%°----Sq. feet Dwelling No. of Bedrooms..ff"'7.`_y�-----_ _� g— ______________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Buildings?ff. -r�............. No. of persons...�............._..._.. Showers ( ) — Cafeteria ( ) Otherfixtures .._.. ------------•---•----------------------------------------------------------------------------------- W Design Flow.......:.R Z./CG..................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 b �r -! ---_a ' .y_x- ..............'... Date....-_................................. a y..' ----------- � Test Pit No. 1---:zQ........minutes per inch Depth of Test Pit._... v'___..�.__ Depth to ground water................... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -•--•-•...-----•--------•---••••••••-•-•.......-•••--••--•--•--•--•..........--•••------••--•-•.............................................................. D Description of Soil.... _......_. ' -- ----------- -•---- ------------------------------------------------------------•----------- W x --------------------------------------------------------------------............................... -•••-••----••••..._..----------•-••----••------•--•••-••-••-----•••.....--••-••-•-••............•-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... -------------------------------•--•-----------------------------...------.....---------....----------•-••---------------------------...------------------------------------------..............---••-•• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 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 boarsLof health. Si ed........... -'r - ........................... -- . D Application Approved ,F ate_/f j Date Application Disapproved r e following reasons--------------------------------------------------------•------------------------------------------------------ ...................................................... -•----•-•••--•----••---•••----•----•--------•••--•-••--•••-----•-.....---•••----•••-••••••--••-••-••----------•-••---•--•-•-••-••--•--••......--- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......... Tn#if iratr of f ompliana —T..H IS , CERTIFY, That the Individual Sewage Disposal System constructed ( ) o'"" r Repaired ( ) by-.x ti.'r _ ...... - --------------•--•-------- f � /,��nstaller at. ........ ------•--.- .�_.�. 1 has been installed in accordance witk the provisions of TI T bFt 5 o e State Sanitary Code as described in the application for Disposal Works Construction Permit No... -_•.._--.•............... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. pp ��yy DATE..... - .... ...... Inspector----- • •------•--••-•• --------------•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Vc �, .t NOR................. ..... FEE........................ i n trkii T�ani#r ian lerani# Permissiont eriy granted... :: ------------------------------------------------------------•-------------.....--------•-------........-----.. ._.. to �on�struct- . l epair�( ) an}Individual Sewage Disposal System at ...r_._..... Street as shown on the application for Disposal Works Construction_P_er- ' ' o..................... Dated.......................................... ........ .............................................................. J Board of Health . PATE_............................................................................... FORM 1255 A. M. SULKIN, INC., BOSTON t' i qL 'C%A T ION A G E PE RMIT NO. VILLAGE G�tirr��v 1 ti�� �gINSTA LLER'S NAME i ADDRESS �R U I L D E R OR OWNER L (l,4L t?6 C2hJ r/i-1-1,J DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� -� '�`'�- a� .. � � 29 3 '�� 3l �� �3 I - II II 41 IT t 71 it 10 A I ..� t/ L✓ '�� {` / / \ S.T. ✓ Is it � � �14_'`/ �i (/ . -./ l �`-' f'( - ..�-•- -_-w.� ;. I II AVV 7o �w lot- z Cam` "/,��' -T�d4T� ,7"�-rl,� f�,f''1�.�`-?'�"�i..��. .l'.n�rT�:>E�t/��;/.�i�• �,,�.>,,f'�'�� �"f��%�v`,�,����,���'' ������;15 l�'i`T.�` .���rs% �.� ,�X�Nr_.sU,�'✓Er .5'' L n t � t A. ��rtsf I ._�iP/��.�y,��.� �`/""/',�' �'.���✓c`r'`""� S.�L..�^!ri'f�/tit/,_,`�`'if- ''>��C,.� .,[� ..�.�•�1:� g�ej�`�w