HomeMy WebLinkAbout0076 CAMP OPECHEE ROAD - Health /76 Camp OpecheRoad
Centerville P
A = 210 150
G
Omrford. NO. 152 1/3 ORA
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TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive RECEIVED
South Dennis, MA 02660
-\ COMMONWEALTH OF MASSACHUSE'I"I'S SEP 1 3 2002
EXECLJTIVF, OFFICE OF ENVIRONMENTAL. FFAIRS_ _
TOWN 01 t Ai CN:,1 t,o��7
10 DEPARTMENT OF ENVIRONMENTAL PR TEt KJN EPT.
TITLE 5
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A IV z
CERTIFICATION -
ProperfN Address: 76 Camp Opechee Road
Centerville,MA
Owner's Name: Gemma Mathews
Owner's Addres,. 20 Valley Brook Road
Centerville,MA 02632
Date of Inspection: September 10,2002
Name of Inspector: TroyM. Williams
O MAP
Company Name: Troy Williams Septic Inspections PARCEL , _
Mailing Address: 19 Hummel Drive LOT
South Dennis,MA 02660
Telephone Number: (568)385-1300
CERTIFICATION STATEMENT
1 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
approN ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The SvItem
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authont)
Fails
Inspector's Signature: 7J,�� Date: g/1tj /o z
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection.certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
""This report only describes conditions at the time of inspection and under the conditions of use at that
time. 7 his 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 Hare I
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of Inspection: Gemma Mathews
September 10,2002
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 CNIR
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 rye/to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by It Board of Health,will pass.
Answer yes.no or not determined(Y,N,ND)in.the_ for the followin
explain. g stag men ts. if"not determined"please
�
The septic tank is metal and over 20 years old* or the septic tar (whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank fail is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approve y the Board of Health.
•A metal septic tank will pass inspection if it is structurally so d,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 o or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with
approval of Board of Health):
bro n pipe(s)are replaced
struction is removed
distribution box is leveled or replaced
ND explain:
The system requ' ed pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(w' approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of fiispection: Gemma Mathews
September 10,2002
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 15.30 1)(b)that the
system is not functioning in a manner which will protect public health,safety and the t"n`�ironment:
— 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 sal.marsh
2. System will fail unless the Board of Health (and Public Wa r Supplier,it any)determines that the
system is functioning in a manner that protects (tie public he th,safety and environment:
_ The system has a septic tank and soil absorption stem(SAS)and the SAS is within 100 feet of a
surface %%ater supply or tributary to a surface water upply.
— The system has a septic.tank and SAS d the SAS is within a Zone I of a public water supply.
_ The sN stem has a septic tank and AS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well"*. ethod used to determine distance
"This system passes ' the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volati organic compounds indicates that the well is free from pollution from that facility and
the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crite ' are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
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: 76 Camp Opechee Road
Centerville,MA
Owner: Gemma Mathews
Date of Inspection: September 10,2002
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 clogced SAS or cesspool
_,Z 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 day flow
✓ Required pumping more than 4 times in the last year NQT 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.
� (,q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply. ,
Ni4 Any portion of a cesspool or privy is within a Zone 1 of a public well.
zv/y Any portion of a cesspool or privy is within 50 feet of a private water supply well.
P4 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
,f,/o (Yes/No)The system ails. I have.determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303. therefore thr 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 sign 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 Grit a above)
yes no
_ the system is within 400 feet.of a surface drinkin ater supply
the system is within 200 feet of a tributary t surface drinking water supply
the system is located in a nitrogen sen ' ive area(Interim Wellhead Protection Area—1WPA)or a mapped
Zone II of a public water supply w
If you have answered"yes"to any ques 'on in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large s em has failed.The owner or operator of any large system considered a
significant threat under Section E failed under Section D shalt upgrade the system in accordance with 310 CMR
15.304.The gystem owner sho contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of Inspection: Gemma Mathews
September 10,2002
Check if the followine have been done. You must indicate"yes"or"no"as to each of the followinu:
Yes No
✓ _ f :;:,1 in� information was provided by the owner. occupant,or Buar,i of 1 iealtl.
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:
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)13 10 CMR 15.302(3)(b)J
S
Page 6 of 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of inspection: Gemma Mathews
September 10,NOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):2 Number of bedrooms(actual): .2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 2 Z v
Number of current residents: o C r p,: )
Does residence have a garbage grinder(yes or no): No
Is laundrN on a separate sewage system(yes or ni): A a [if yes separate inspection required]
Laundry system inspected(yes or no): NIA►
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 0 I : 1y,v uu �, n�,S U U _ 1/6 i ou �14 H,
Sump pump(yes or no): Ago —7—
Last date of occupancy: 6/3a /oz-
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 F
: _gpd
Basis of design flow(seats/ptc.):
Grease trap present(yes or nIndustrial waste holding tan or no):
Non-sanitary waste discharge 5 sys (yes or no):Water meter readings, if ava _
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: -�702�L�_f,.��.�_.�.,-�u.�
Was system pumped as pan of the inspection(yes or no):
If yes, volume pumped: gallons-- How was quantity pumped determined'?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system 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:
Were sewage odors detected when arriving at the site(yes or no): /W
6
Page 7 of I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of Inspection: Gemma Mathews
September 10,2002
BUILDING SEWER(locate on site plan)
Depth belu�% grade: 16 "4
Materials of construction: _cast iron _✓40 PVC ✓other(explain): / y h+ dw
Dktanc fron. private water supply well or suction line: 'V(J
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓(locate on site plan)
Depth below grade:
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: _ 4 e /oov
Sludge depth: ___ If
Distance from top of sludge to bottom of outlet tee or baftle: .2 /0"
Scum thickness: 4/ox/
Distance from top of scum to top of outlet tee or baffle: /Vo S ...,,
Distance from bottom of scum to bottom of outlet tee or baffle: o s
Ilow were dimensions determined: /: ebL _ _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
//as related to outlet invert,evidence of leakage, etc.):
or.(,w=-..�J;-�✓_.a 1n c�,_�
'-]34IL"'
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_p ethylene_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 r baffle:
Date of last pumping:
Comments(on pumping recommendations,inl and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leaka ,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of inspection: Gemma Mathews
September 10,2002
TIGHT or HOLDING TANK: (tank must be pumped at time of• spection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberg s_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flo%%. gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working er(yes or no):
Date of last pumping:
Comments(condition of alarm and oat switches,etc.):
DISTRIBUTION BOX:-Z' (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Continents(note if box is level and distribution to outlets equal,any evidence of solids carrygver, any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: __(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,co tion 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:
76 Camp Opechee Road
Owner: Centerville,MA
Date of inspection: Gemma Mathews
September 10,2002
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits. number: + w r1 2.'S fo:,
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.): n
.r.r�-•� O�" ✓�[ti I C yr S ti "/"1 A �.7 .,I.T I/�G✓-t. li tom.�l Ci} S
CESSPOOLS: (cesspool must be pumped as part of inspection)( cafe 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 aulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction: Xhydrau
Dimensions:Depth of solids:
Comments(note condition of soil,sign , level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 76 Camp Opechee Road
Centerville,MA
Owner: Gemma Mathews -
Date of Inspection: September 10,2002
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.
i Zq'
23 '
33 L
t7— �3�u
28'�°''
w; YL 2-'
�0
Page I l of I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
76 Camp Opechee Road
Owner: Centerville,MA
Date of Inspection: Gemma Mathews
SITE EXAM September 10,2002
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to.ground water /Y 2-feet Adjusted high ground water elevation_� feel
Please indicate(check)all methods used to determine the high ground s%ater elesatiow
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:fOt,.l zS 2 _Z C>,Vr v i , 1'-j-,4
You must describe stow you established the high ground water elevation:
.36
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SSA
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees, either expressed,written or implied, relating to the system,the inspection and/or this report.
11'
Fxs
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...........OF. ..................... ...............................................
ApplirFation for 11hipus al Warks Tnnitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: o
__..✓._... C� ----• .. ...•....... .........................................-..---- ----••------------
o � or Lot
_ OwnerAr
W / . —
Installer Address
dTypN of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
a Other—Type g _..._...... No. of persons............................ Showers ( ) — Cafeteria ( )
Other—T e of Building .................
Q' Other fixtures -------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length--------_--_- Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest 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........................
R+ • -------------
•- -----------------
--•-----------------------.-------
-------------------------------------------------------------
0 Description of Soil........
x
------------------------------------------------------------------•-•-•-------•---------
W
UNatur Repairs or Itera ' ns—Answer when a plicable._ _ .__.__. 6� . ._..
greement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acco ance with
the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be n iss by the board of health.
Sined. ----- --•--- •----••. . .............................. =�----------•- ��••�t�•.. ------
Application Approved BY ---- - --------------• . ---- ....--•---....----•-------•• •�•---------
Date
Application Disapproved for the following reasons:.................................:...
------•---•---•-•--••---•.-•-----------------•--••-•--•-•---•-----•-... ---------........-----------------•-------------•-------...---•-----------------------------------------Date ------------
PermitNo. ..................................�� Issued.......................................................
Date
RE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......-•"'".,,, ......7:.......0 F..:.:T...........:
ApplirFatiun for Dispoii al Works Tonstrur#iun amit
Application is hereby made for a Permit to-Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:,,n `f
�:. ... _. ......... . ....... . .•----. ... -- .---- ----- .��---..... -- -----..----- -
Lo ie� or Lot...o
....... ......... .. .....---....-•---
�� Owner AdT ss
... .tom... --*' -j---.�� ram-...�_. w "". . /........... �?t��"�s'f-.J--���A .....
..........
....•---•-------
Installer Address
U Ty� of Buildin Size Lot...._.......................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ....................:........ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -----•------------------------------=--•-------------••••---•-••-•••••••-••••••-•••-----•-•---••-••-•-•-.....•-••-•••-•--••-•-•.....--•----••---••--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--•••---••-•--•-••--••--••--•------••-•-------•-•••-•-•--••----•---••-•-• Date........................................
Test Pit No. 1................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....................---.
Ri c""". - ------------------------------------------
---•----------.......----------------•----------------
-------------------
•••--------------------
O
Description of Soil--------"-"``--Z......:. '.----•-------------------------
•----•---•------------------------------------•-•---------------------------------------
---------- - •--•----•-----
U --•....-•••---•-•-•••••-•-•••-•••-••••-•-••••----•...-•---- F •--------------------------- -- ------------•--•------ -----------•-•------------...--------...........---•--------------.
W •--...-----•----------------------------•-----.......--••--•--------••----••._............•.... t Tres r
- ------
U Natur Repairs or ter ns—Answer when plicable_ -- r,r, ✓ -� 4''
'
, `'" nr
greement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in acc r(lance 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�bbn iss d by the board of health.
Signe -•---- /
.r
' .�_ D to
Application Approved By. e`..... - -----'� �- ---I•-��-�---
.. Y Date
Application Disapproved for the following reasons:---••--•••--•--••• •-•-----•-•-•-••-•----•-•---•••••••----••-•-•-••--••••-•--•----------------•--------....._
-----•..............•------•------•-•-------------...----•---------------....---------......�........--•-•-.•-----------•-•••-•-•-•---•--•-•••--••....----•-•••••-••------••••--••••----•---•-•-•••--..----
_ �.. 3 Date
PermitNo........ - � ......... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........0 Fl ..................................................
Trrtifiratr of ToutpliFanrr
T IS S0 CER h t he Incjividua _ ge Dis osal System constructed ( ) or Repair
r ,
by ...... .............. .. ...........................
------------ ------- -------------------------------- --•-----
has been installed in accor ance with the provisions of TITIF ` of he State Sanitary Cods described in the
application for Disposal Works Construction Permit No._. :. "":. '`. dated_._..-.-' j.: _ '°' ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. <
DATE..................... �..�.(-ZO�.�1 �-------------•--•------ Inspector.......------------ -•----.....
THE.COMMONWEALTH OF MASSACHUSETTS
BOAR-15""OF HEALTH
OF
N ... FEE .--•--•- .........
Diu aa1- urk�
Permission is hereby granted__. _.
to Cons n ( • ) Repair } as S vt= DsposSystem r
---------------------
Street, a- z. _
as shown on the application for Disposal Works Construction--Peer t -`"''3'Dated.....
s .............
,.... P+
Board of alth
DATE.
FORM 1258 - M. SULKIN, INC., BOSTON ,
C'' TOWN OF BARNST $. 6 v <\
LOCATION `�� SEWAGE #�
VILLAGE -70l rvl/d���
ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE
SEPTIC TANK CAPACITY
LEACHING FACILITY:(typeca��V f _ DES(size) l Po`"
NO. OF BEDROOMS - PUBLIC WATER
BUILDER OR OWNER Y` ! 4- o,6/z4'D
DATE PERMIT ISSUED: 7
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No y
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