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0014 CAP'N LIJAH'S ROAD - Health
14 Cap'n Lijahs Road Centerville A= 192 - 187 i I UPC 12534 No.2 53LOR W.iTINOi.Mll SENDER:COMPLETE TNS SECTION COMPLETE THIS SECTION ON DELIVERY ■ Complete items 11-2,and 3.Also complete A. ;Sijginako I Rem 4 if Restricted Delivery is desired. ) ❑Agent ■ Print your name and address on the reversd ❑'Addressee so that we can return the card to you.. B. Rec 'ved by Printe Name) C. Date of elivery ■ Attach this card to the back of the mailpiece, © or on the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑N 11;/ 3. Service Type Q Certified Mail ❑Express Mail ❑Registered ❑Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number (VO 0 6 21,1'5 2 10b 0R2 t 10' i 14 _ i (rransfer from service label) PS Form 3811;February 2004 '' Domestic Return•Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE ' mow • Sender: Please rent our name, address, and ZI + n this box • i P � Y 4faw N i S , wci- 0 aCQ 0 �1ilI1?:Ei!{E1llillEi?iEt��E�l?111EEF�Ii:E.lii�li'ti{{11{E19.fiili I Postal (DomesticCER�IFIED M, AIL, RECEIPT Only, ►1I For delivery information visit our website at wWw.usps.comD r- I OFFICIAL ' SE rq 0 Postage $ ra ,y bpi Certified Fee r, f1 I o Pos rk p Return Receipt Fee c�v Here O (Endorsement Required) Restricted Delivery Fee CL I Cn (Endorsement Required) N J E3 G L 7 � Total Postage&Fees r E, I'Ll r7 E3 ••-•------ .` 11�! ` � '.,`treet Apt.No• or PO Box No. S State ZI +4 & 6��� PS Form :rr August 2006 See Reverse for Instructions Certified Mail Provides: ■ A mailing receipt , e A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mall®or Priority Mail®. e Certified Mail is not available for any class of International mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured'or Registered Mail. • For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Retum Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". a If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. It a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an Inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 ���YCS�C1 0 _ CC�'�ry��-ems U�� ��YJ- �� 6 J Town of Barnstable Barns#able Oft Regulatory Services Department �ca cft i 9 BARNSrABLF- 7$ ,m�' Public Health Division � 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO July 7, 2008 Robert Stevenson 14 Cap'n Lijahs Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 14 Cap'n Lijahs Road, Centerville, MA was last inspected on June 2, 2008,by Mark Nardone, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Heavy sludge carryover, staining on sidewalls of leaching pit above inlet invert, system in failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH mas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 7514 Q:\SEPTIC\Letters Septic Inspection Failures\14 Cap'n Lijahs Road.doc Postal CERTIFIED MAILT. RECEIPT O (Domestic Mail Only; E' Er' For delivery information visit our website atAww.usps.como rl p Postage $ Certified Fee o ni ���Postmark 2�0 p Return Receipt Fee O Here p j 0 (Endorsement Required) (� U �oo$ p Restricted Delivery Fee Jt1� O (Endorsement Required) r-3 Total Postage&Fees $ ru 0 r�s `fir tic C3 �" p street,ApC l PO Box No.' 5 1 � -- ..... ................... ........................ N or PS Form :.r August 2006 See Reverse for Instructions Certified Mail Provides: ■ A mailing receipt ,, ■ A unique identifier for your mailpiece ■ A record of delivery kept by the Postal Service for two years Important Reminders: e Certified Mail may ONLY be combined with First-Class Mall®or Priority Mail& a Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 38111 to the article and add applicable postage to cover the fee.Endorse mailpiece Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSO postmark on your Certified Mail receipt is required. r For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". • If a postmark on the Certified Mail receipt is desired,pfease present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT-Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 SENDER: CO 3C"TION COMPLETE THIS SECTIONDELIVERY ■ Complete items 1,2,and 3,Also complete A. Si Zby(Prfnted Item 4 if Restricted Delivery is desired. Agent ■ Print your name and address on tFie reverse X Addressee so that we can return the card to you. B. Re Name) C. D to of eli■ Attach this card to the back of the mailpiece,or on the front if space permits. Is deifferent from item 14 ❑ es 1. Article Addressed to If YES,enter delivery address below: ❑No 3. Service Type 13 Certified Mail ❑Express Mail 0 Registered ❑Return Receipt for.Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Y- 2. Article Number (Transfer from service labei) { ; 7.0 0 6 21'5 0 10 d 2� 10 4 9 9 9 0 i PS form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 1 Y UNITED STATES. TAL �RICE j 411 i S � • Sender: Please print your name, address, and ZI — �s PP)MMis box own aoc NNc- L1,«,tiiIIIII Moll,Ili„f11„13.111ii,t;il,F,►l,l�l '(KE r ti 'own of Barnstable Barn Regulatory Services Department mica j BARN STABLE, MAC i639• Public Health Division �� MAC A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO July 1, 2008 Prestige Properties 340 Belmont Street East Bridgewater, MA 02333 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 14 Cap'n Lijahs Road, Centerville, MA was last inspected on June 2, 2008,by Mark Nardone, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: Heavy sludge carryover, staining on sidewalls of leaching pit above inlet invert, system in failure. You are ordered to repair or replace the septic system within sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL#7006 2150 0002 1041 9990 t d Q:\SEPTIC\Letters Septic Inspection Failures\14 Cap'n Lijahs Road.doc A pt a1 1 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable C.0 Y-, �' . MA 02632 6/02/08 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. i Important:When filling out forms A. General Information E _, on the computer, r - -- use only the tab f, 1• Inspector: key to move your cursor-do not MARK NARDONEuse —J ke the return Name of Inspector }. .x y BRIDGE HOME AND SEPTIC INSPECTION SERVICE ;Ci Ir11 Company Name tv cc 27 TIFFANY CIRCLE Company Address ---- ---.------------- -------...------------ --- -----�--,m----- WEST BRIDGEWATER MA 2379 City/Town State Zip Code 508-580-0465 S13895 Telephone Number License Number n B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the arc information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/02/08 I ctor'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. `�14 capn 6ahs rd.bamstable not released•12007 Tdle 5 Offidal Inspection Form:Subsuface Sewage Disposal System•Page 1 of 15 4 •I • 1 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owners Name information is required for every Barnstable MA 02632 6/02/08 page. Cityrrown State Zip Code Date of Inspection B. Certification (coot.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found a y information which indicates that any of the failure criteria described in 310 CMR 15.30 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Pass ❑ One or more system compon nts as described in the"Conditional Pass" section need to be replaced or repaired. The syst m, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined ( N, ND) in the❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 0 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits subst ntial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the ex ting tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspecti if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ess than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or hi static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, ettled or uneven distribution box. System will pass inspection if(with approval of Board of Health): , ❑ broken pipe(s)are replaced ❑ obstruction is removed 14 capn lijahs rd.bamstable not released-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 r I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is Barnstable MA 02632 6/02/08 requiredd for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) B) System Con itionally Passes(cont.): ❑ distrib ion box is leveled or replaced ND Explain: ❑ The system required umping more than 4 times a year due to broken or obstructed pipe(s). The system will pass insp tion if(with approval of the Board of Health): Elbroken pipe(s) re replaced ❑ obstruction is re oved ND Explain: C) Further Evaluation is Requir by the Board of Health: ❑ Conditions exist which require fu er evaluation by the Board of Health in order to determine if the system is failing to protect pub' health, safety or the environment. 1. System will pass unless Boar of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not unctioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 f of a surface water ❑ Cesspool or privy is within 50 fee of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of akh (and Public Water Supplier, if any) determines that the system is functionin 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 L14pn lijahs rd.bamstabte not released•12 07 Tills 5 Official inspection Form:Subsurlace Sewage Disposal System-Page 3 of 15 I I Commonwealth of Massachusetts WNWTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for very Barnstable MA 02632 6/02/08 e page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has septic tank and SAS and the SAS is less than 100 feet but 50 feet or. more from a priva water supply well". Method used to dete ine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided tha 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%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 SAS, cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 14 capn 6jahs rd.bamstable not released-12I07 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 15 I 1 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Properly Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. 14 capn bjahs rd.bamstable not released•12l07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Citylrown 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 ® El 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)) 14 capn 6jahs rd.bamstable not released•12/07 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 r Commonwealth of Massachusetts vim Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. CityfTown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): — -- Number of bedrooms(actual): 2 --- DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 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, d available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: unknown _ Date 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: Last date of occupancy/use: Date Other(describe): 14 capn 6alrs rd-barnstable not released-12#07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 r - , t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: unknown 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: ® 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: 32 Years Were sewage odors detected when arriving at the site? ❑ Yes ® No 14 capn 6ahs rd.bamstable not released-17A7 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 Commonwealth of Massachusetts Wome Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments " 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: -- ---- feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: e - -- - - - - -- feet Comments (on condition of joints, venting, evidence of leakage, etc.): good condition Septic Tank(locate on site plan): Depth below grade: �t 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: 8x5x4.5'D Sludge depth: 14" ----- - -------- ---- Distance from top of sludge to bottom of outlet tee or baffle 16" 6" Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 6„ How were dimensions determined? probe 14 capn lijahs rd.bamstable not released•17107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 cam\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. 14 Cap'n Lijahs Rd. Properly Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. City/Town 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.): Tank leaking, liquid level 12"below outlet invert, heavy solids in tank , outlet baffle in place some corrosion Grease Trap(locate on site plan): Depth below grade: N/A p g 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 pumping: Date 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): N/A Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): 14 capn 6ahs rd.bamstable not released•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 t � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cunt.) 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 Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert N/A 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 14 capn lijahs rd.bamstable not released•12t07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: 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.): Heavy sludge carryover, staining on sidewalls of pit above inlet invert , system in failure 14 capn 6ahs rd.bamstable not released-12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 r - - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A - 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: N/A Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 14 capn ijahs rd.bamstable not released•12107 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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. N�vS r F4G0 i ro 3 Al -�3 �3 3� 14 capn lijahs rd.bamstable not released-12A7 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 15 J I ' t 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Cap'n Lijahs Rd. Property Address Homecoming Financial Owner Owner's Name information is required for every Barnstable MA 02632 6/02/08 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: none @ 7 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: depth of basement dry and elevations of lot 14 capn 6ahs rd.bamstable riot released•12/07 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 r , a s o Regulatory Services =ARNSTABLE. « Thomas F. Geiler, Director v 63&& �''rEnr •�"' Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. QASEPTICUsclaimer Private Septic Inspections.DOC I 00O M MEN ■■■ ■■■■■■■■■■■■■■■■■■■ .�:�I■�►_I-NONE■■ ■■®■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■ �r■■�■■�e��■�'ed■e■�■■e,■■■■■�■■■■■■�NOON■■ ■■■■■■■■n�:�■■■■■■■■�■■■■■■■■■■■■ NOON■■■ ■■■wfA■ilk1■ '�1' iC�■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■1n,�.�r■1�laL �■����■■�h■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■� � I■ ■■■■■■■■■■■■■■■■■■■■■■■ l�■■■■■■■ ■u ■■■■■■��■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■ ■�■■■■■■■■■ M- ■■■■■■i■ ■■■■■■■ �■■■ ■u■�NOON■ , NONE�111■OWN ■■M■■O■■■■■ ■�■■■■■■■■■■■■■■ ■■■ ►►.SE.■■■■■■■■■■■■■■■■■i�!, ,n ■■■■■■■■■■■ ■��: .an ■r� ■■■■■■■■■■■■■■ ti■■■■■■ ■[�■■■■RNS■■■■■■■■■■■■■■1 ■f/I■■ _,■■■■■■ iNow■®■■■■■■■■■■■■■■■■■ MEN■■■■■■■■■■■■■NOON■ ■■ ■■■■■�■■■��■■r■■■om■■■■■: ■ ■■■ ■■■■■■ PIN, ml ME ■■■■■■ ■■ l■■! .f '■■ ■■■■■■ �ili■ �M■■ i■■■■■■■ !■■■■■■EE_�``�rlr %■■■ ■■■■■■■ ■■■■■■■■■■■■■ i■■■■I1■■. ��1■■■ ■■■■■■■■■�lr' #■■■■■■■■■■ MEN ■■ ■■■■■■■IR"'u ■■■■■■■■■■■■■■■■■■■■■■■ ■!!■R��il�■■■■■■Obi■■■�■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■O ■■■■fly■�■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■ WIN■■�r��■■�■■■■■■■■■■■■■■■■■■■■■■■■■ room M r • • • sor's map and lot number .../... �.n(.'.�..�5�. ............ 1 A - �F; P'F1— ;wage Permit number ............................: J/ o - Y House number ....... fa MAi a' TOWN OF BAR.NSTARLE ILI I SP CTOR '9 APPLICATION FOR PERMIT TO .... ..........�� . ................................. TYPE OF CONSTRUCTION ............ ......... ..... ....................... .... .......................... ................................................19. . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the fall o i g inform // �y IV r ` ............... Location ....�. ........ ... % ` /�. ProposedUse ......TQ........ �.......T'��?. :.................... ... ..... ........................................................ Zoning District .........................Fire District v Name of Owner Q.R. !�0 .... .:... Rc. e.k4r.........Address ..) ....4 . !! ..... `, •? >`s....��!!`.................... Nameof Builder .......Q ?. ?.............................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ................ .. .............................................Foundation .l'a/ ...l°t'llr�'�........pnm E( jV!44.(,'dk. Exterior .)�xt? E... '..I)..........................................................Roofing ........ Floors ............................................ ....Interior .....54,,T 2ocK ...................... .................................................................... 41� Heating IZ-K-p........1'.6T..... ...................................Plumbing ............. 11.......................................... Fireplace ...........flV.off.G...........................................................Approximate. Cost /Di,O U 0...,.......... Definitive Plan Approved by Planning Board ------------ `� O ---- - 9 -- - Area Diagram of Lot and Building with Dimensions Fee `�� ' ...... .. ................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding a ove construction. Name ✓r' �/ .. ........ ....... i t IJ1 ._.....____ i � l v I i d i OD � ' - _ - I EXISTTNCr &)IUD i 1 G I ~ I i I i �ToRAG F - I _ _ I EA G . I I io- 6 V.op and lot number SEPFl MUST-BE 7� INSTALLK IN CONIPL.IANC5 �j . � V1T1 AlI ' umber ......... �E l STATE Permitn ...... ... Sr",ia ITA?y CODE AN"D TOWN F BAR ►T `LE yFTHETOWN O P EABMA98 LF�, • � ,... BUILDING 1NSFECTOR O;YPY a` s. APPLICATION,FOR PERMIT TO ... Q n6 ...... .. l�l.�;�?� A.trm� ..... dm �•�� � TYPE OF CONSTRUCTION ° .. 19. la c; TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the folllnl�ow��ing. ``information: Location .... . -( . ,3... ......C. .j!1.......�.1..}&;h...R.d:. 1.�K`Y)-1' ... ........................... ProposedUse ... ................................................................................................................................... Zoning District 0....... ...I............................. Fire District ...12.✓1 ".2 .. Name of Owner �.i.A..Q..RC�.P.lY1:....-t", 1� Y..�VLR�... . address �..:.S�C?- AJ?.. hK.....tC Nameof Builder ........ ......................I.....................Address ......................6 /.Y.Y.i�'.r........................................ Nameof Architect ...... ......................................Address ......................-, !Y.. .....................I..........: Number of Rooms ........................1�.......................................Foundation ..... P.0.4 Exlerior ......511......U.Ghah-1.....a6.4. j90 ......Roofing ....<;Z3,a...>5 L......L.p.h&L,........................ Floors ......... ......... :(�.1...................................................Interior .......1�........r1 .P-ac IC._....................... ...... Heating .........EWA..-....9. D................:......................Plumbing ...........�.:.,1�.�1�.i�L6.................................... Fireplace ..... ........1.- .L....................Approximate Cost ............1.44.1.P:J0.:..U................ Definitive Plan Approved by Planning Board ________________________________19________. Area .......... :�!..:.:........ Diagram of Lot and Building with Dimensions Fee ........Z. SUBJECT TO APPROVAL OF BOARD OF HEALTH f� t l9/ Town of Barnstable b e P# v �y De artiment of p Regulatory Services Public Health Division Date >U. —** 9 i6Jq n�i 200 Main Street,Hyannis MA 02601 D Date C � 00 Scheduled edt Time t/ Fee Pd. I � c Soil Suitability Assessment for Sew a a D's osal 1P. Performed By: Witnessed By: I D Y � I l LOCATION& GENERAL INFORMATION Location Address J) I C0P,Yf: 1 a ��..A�l S Owner's Name F�jn{w_ O r 9kh K-k-4? s�t� M`"7 Address S CITIOL Assessor's Map/Parcel: 3v /O G Engineer's Name CPatAE14 W' y NEW CONSTRUCTION REPAIR Telephone# SO�}^ a�l `pep Land Use I(Nef1A-SGt\ Slopes(%) Surface Stones_ , Distances from: Open Water Body ft Possible Wet Area 44q-- ft Drinking Water Well MIA. ft Drainage Way ft Property Line eft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) C= cif,. N tx, �13 R'A m Parent material(geologic)_n J'tC)_- Gs Depth to Bedrock 14 it Depth to Groundwater. Standing Water in Hole: L Weeping from Pit Face Estimated Seasonal High GroundwaterD DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: __— in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level,�_ Adj.factor- Adj,Groundwater level, PERCOLATION TEST bete 2jr2,P.1 Thne 1G'o o" Im Observation Hole# Time at 9" •i�^ .�,__� r r `I Depth of Perc AD 55' Time at 6" Start Pre-soak Time @ ;D� Time(9"41 M 1 End Pre-soak Rate MinAnch Z-p1 M P� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPrICU'ERCFORM.DOC . 5 DEEP.OBSERVATION HOLE LOG Hole# I . Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistencv.%Gravel) Ira- 00-)ab C, DEEP OBSERVATION HOLE LOG Hole#_; Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%Gravel) n Q �� LS JOtj'Q-S i G�12 t is Y1 L� DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other. Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consist Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi material exist in all areas observed throughout the area proposed for the soil absorption system? 's the depth of naturally occurring pervious material? _.. If no what r Y t, P Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Enviro n Non d that the above analysis was performed by me consistent with . the required training x se a d e p ie ce described in 310 CMR 15.017. Signature Date f r n Q:4SBPT10PERCFORM.DOC No............ Fps.,. .. .�.... THE COMMONWEALTH OF MASSACHUSETTS �� I �------ BOARD OF HEALTH �� 04 v�� Appliratinn -fur 43i,ivuiittl Works Toustrnrtinn Prrmit Application is hereby made for a Permit to Construct V ) or Repair ( } an Individual Sewage Disposal Systemat:� ���-»:�.. -------- . ....... •--•••••...-s w••-•---•--_..... •--•--•-••-•---•••-•-••-••••••-••••---•---•--•-••-••-••------=••-•-••-•.._...--•-•-....•••-•---- Location_AaAftss or Lot No. O er Address f2ze"'--------------................................................................ .................................................................................................. Installer Address UType of Building Size Lot.lSq. feet Dwelling—No. of Bedrooms.__ _____ __ ______ ____Expansion At is ( ) Garbage Grinder Other—Type of Building _ !!=�K_ i_" No.- of persons-..____ ___.____._. Showers ( ) — Cafeteria ( ) Q' Other fixtures W Design Flow..............._T_P__ ________________..gallons per person per day. Total daily flow............. ���°_____._.._..__,gallons. WSeptic Tank—Liquid capacit�eV��galions Length________________ Width................ Diameter__.___._...____ Depth._.______._.... x Disposal Trench—No- ____________________ Width------------------.. Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No...../.......... Diameter......dAeq6._ Depth below inl ___. ......... Total leachill area------------------sq. ft. z Other Distribution box (c,< Dosing tank aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------- a Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_._---.___-.-_____---. (� Test Pit No. 2----------------minutes per inch- Depth of Test Pit-------------------- Depth to ground water__._.._-____-_--__.__--. R: ,� } n Descriptio nof Soih U�C' 1/LAf '�'!_;- tl: '�-;---V-l1,_ - --------------------------�---------------"---------------------- - W tom : VNature of Repairs or Alterations—Answer when applicable-----------------------____________________________________________________________._--___---- t :+ ________________________________________________________________________________________________________________________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual.-Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu y the board of � -----•l- f Signed _ - ate / e / Application Approved BY---------- ---�--- -- ---- - -- - --- - -- --------------- --------- Date Application Disapproved for the following reasons_----------_.............................................................................................. _...... __._...---•---•••---••----------•--------•---------------------••----------------•-•-•••••-••-----•- Date PermitNo......................................................... Issued........................................................ Date - *� t� ;_L 7 3 2 o �Co # 46 U , \' 0 ,5 / r s / �. S/L.L ELE✓..______ FEET 400✓E EVAD PLOT" PL. A I/ LOCAT/ON: PLAN A/C E :F5G,,tir LGT EP`S H OF c€0ac J A162E45y CEPT/FY TA-IA T 7A E EXi-5 - Low //VG F-0UNDA7/OA/ LOCOT/ON /SCozAeZ Al- 4 /' .45 5WOWN gND_DcEsCONFOZ,-f W/TN ,o%� p S�R � Ts-/E 8U/LDiNG S �t3AC'e 7zE�UiPEMF,t/)' OF Tfi l TOWN �C+��.C��r� ��`�-,---� �C�l2� 61/6174 t^ q �2EG �L�B SUP t/E YOQ - L G, EGM� B bt//GLOM/ST. yAeQMO UT�/��'QT,N1A: No.-------' Fi$............................ y THE COMMONWEALTH OF MASSACHUSETTS ._BOARD OF HEALTH App iratiun -for Dhipviitti Works Cnnnstrurtion Vrrnlit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system at: -- -- ------- -- - - - Location-4 deess or Lot No. O .. O er Address .. Installer Address ��� Type of Building Size Lot..:� ��7_Sq. feet .-I Dwelling—No. of Bedrooms--._.___. _________________________Expansion At 'c ( ) Garbage Grinder J414 Other—T e of Building ._ .11..�i o. of er�on�-......... Showers — YP g r P ---•--•------ ( ) Cafeteria ( ) Otherfixtures --------------------------- . --------------------------------------------------------------------------.-._--.---------------------------------- W Design Flow----------------J_.�'--•--__________--.-gallons per person per day. Total daily flow.....__._.._ '---------- WSeptic Tank—Liquid capacitv/"' vallons Length---------------- Width................ Diameter................ Depth.._...._.----- x Disposal Trench—No_____________________ Widtl--------------------- Total Length...................- Total leaching area--------------------sq. ft. Seepage Pit No------.----_-___- Diameter.......4! Depth below inle ..... ............ Total leachin area.--_.:-__-_-.-_-_sq. ft. Z Other Distribution box ( &<! Dosing tank ( ) 0 6, ���- 3 I `/- 7 Percolation Test Results Performed bY-------------------- ..................................................... Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.........--.-----..----. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water.........------.--__---- �i ......--- - - --:----- - /� Description of Soil.-- i� U -r'•-- U-4�' 'r1- - u V - `- t., ---------------2-f...... 1 d VW = /---------- �= --! ------..... -s- ------------------------------------------------------------------- --------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu the boar, of hem1th� 57 ----- ------- } ------------------------ at"e Application Approved BY •--•-------- ... ' 7 (/ Date Application Disapproved for the following reasons-------------•......-------------------•-------•-•-•-•--•--------........-•--------......._--------.....--------- .. ..--••------'----••------'--'--•---............................................ ------------------------------------------------------------------ Date PermitNo....................................'----•--••-•--•---- Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �rrtif it r gf f�rrm�Iittnrr THI 0 CERTIFY/ hat the Dual Sewage Disposal System constructed ( or Repaired ( ) by, �/ In ller, at_.._C./S_��'`--------------- --------------------- �.�, --------- �• 'a '---------------------------- • -- -•----------------------- has been installed in accordance with the provisions of Ar ' ll I of The State Sanitary Cocl as described in the application for Disposal Works Construction Permit No_____ _............ ...... ated.-------- _'__�_S_`_' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISF T RY. DATE---------0.' ..-.. . . .... Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c/ ........��-✓....................OF., .•�,J N ..........-- --•---• .. FEE..••--••-•---._..... Di>ivalittl rk,s Tanitrnrtina rrntit l��/' ��� 1_ Permission is hereby granted 'f �� ....... ... ..................•-`.-e-- ----...------......------'-'...---------........------ to Construct ( �ef Repair ( ) an Individual Sewage' poso System .�' •� at No. ---------------------- --••---•----•-•----------------•----.---- -••-------•---•-----•---•---•-./.---•-- as shown on the application for Disposal Works Construction P r it Dated______....................................�(O u ---- .--................................... - Board of IIe th DATE------------- ------------- FORM 1255 HOBBS & WARREN.'INC.. PUBLISHERS