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Home My WebLink About0058 CEDRIC ROAD - Health 58 Cedric Road Centerville P 4 A = 172 130 No. 4210 1/3 ORA Pendaflex' :►®4 1 00/0 r COMMONWEALTH OF MASSACHUSETTS `s EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS y o DEPARTMENT OF ENVIRONMENTAL PROTECTION w -- f E -+1 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION Property Address: 58 Cedric Road,Centerville,MA 02632 Q C T 0 1 Z 0 0 3 Owner's Name:Margaret aamenningerEastate TOWN Of- BARNjIABLE Owner's Address:58 Cedric Road,Centerville,MA or P.O-Boa 50 Barnstable,MA HEALTH DEFT. Date of Inspection: 9I 2003 Name of Inspector: REED C.ELLIS ml, p V"] `L Company Name: ELLIS BROTHERS CONST.CO. ----------. Mailing Address: PAR 23 ENTERPRISE ROAD, C eL o P.O.BOX 59,YARMOUTH PORT,MA 02675 LOT Telephone Number: 508-3624237 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper functi and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to 'on 15-1 0 of Title 5(310 CMR 15r000� The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails / Inspector's Signature: Date: 0 3 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT_ S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9/8/03 Inspection Summary: CbecoAC D or E/ALWAYS complete all of Section D A. System Passes: _a I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described I n the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacev ient or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please explain- The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfilh-atior or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank is approved by the Board of Health. *A metal septic tank will pass inspection if it is struct,rally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is ava able. ND explain: Observation of sewage backup or break out or iigh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneva i distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s) replaced obstruction is ren ioved distribution box i leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Heal ): broken pipe(s)are -eplaced obstruction is rem vexi 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:58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9/8/03 C. Further Evaluation is Required by the Bird of Ith: Conditions exist which require further evaluation the Board of Health in order to determine if the system is failing to protect public health,safety or the environm t. 1. System will pass unless Board of Health dote nes in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner wbich I protect public health,safety and the environment. _ Cesspool or privy is within 50 feet of a surfs water — Cesspool or privy is within 50 feet of a borde ing vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the ublic health,safety and environment: _ The system has a septic tank and soil absorpt system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface waten 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 deten aine distance **This system passes if the well water analysis,pe formed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates hat the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitro, en 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: 3 i Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J PART A CERTIFICATION(continued) Property Address:58 Cedric Road,Centerville,MA Owner.Margaret Menninger Estate Date of Inspection:9/8W D. System Failure Criteria applicable to all systems: You mast indicate`des"or"no"to each of the following for all inspections: Yes N _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool rtpcharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or gged SAS or cesspool atic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ,,/ ool A 1 iquid depth in cesspool is less than V below invert or available volume is less than%z day flow equired 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. 1//Apyportion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. 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 re triggered.A of the analysis m be a shed to this form.l A IL AOF-W(Y o�e} stem_ I have determined that one m more of the above failure criteria exist as X�h s3' 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 co ,the failure. E. Large Sy stems: ystems: To be considered a large system the system mast se a facility with a design flow of 10,000 gpd to 15,000 You must indicate either"yes"or"no"to each of the fo. owing: (The following criteria apply to large systems in additi to the criteria above) yes no — _ the system is within 400 feet of a surface dr' ` g 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 an a(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 e system is considered a significant threat,or answered "yes"in Section D above the large system has failed.Th 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 aPproPriatf regional office of the Department. 4 Page 5 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:91AM Check if the following have been done.You mast indicate`des"or"no"as to each of the following: No Ping information was provided by the owner,occupant,or Board of Health V - 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? Y _ Was the site inspected for i_ msp signs of break out? _ Were all system components,Aacluding the SAS,located on site? Y _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of a 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 maintance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on no Existing information.For example,a plan at the Board of Health. _ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 i e Page 6 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT_S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9/8/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):%3 Number of bedrooms(actual): ? DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): u Number of current residents:_g:Z Does residence have a garbage grinder(yes or no)W v Is laundry on a separate sewage system no�O[if yes separate inspection required] Laundry system inspected(yes or no):iw Seasonal use:(yes or no)�!� �0 Water meter readings,if available(last 2 years usage(gpd)� /. • Sump pump(yes or no):_.W/D Last date of occupancy: = 0.7 COM IERCIALANDUSTRIAL 11-14- Type of establishment: Design flow(based on 310 CMR 15.203):_ d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes r no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): LGENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the in 'on(y&or no): If yes,volume pumped/-j5Mj2WI0nS--How was uan ' determined? Reason for pumping: T OF —Y 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) _'fight tank —Attach a copy of the DEP approval —Other(describe): Ap ximate age of all �n ts,da eanstall�(if wn)ands ce of inform ct, - ��SLo.� 6✓ Were sewage odors detected when arriving at the site(yes or now /wl*�'*op"�'P'Owf �f oes Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9/8/03 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron /40PVC other( la' Distance from private water supply well or suction line: Comments(on n .III f j;-,Wts— vgI}tin evi f leakage,etc�� 4!! / ; SEPTIC TANK: locate onsite plan) .✓ m> `�rl� ��!/ Depth below Material of construction:Yconcxete metal fiberglass polyethylene /A�_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: Sludge depth: !� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_e�:) Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of oullet tee or baffle: ' How were dimensions determined: y%), Comments(on pumping recommen ons,inlet and oAlqt tee or biffle cofftion,structural 7, egrity,liquid levels as relat o 1 invert, of 1 e,;� lt�f GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction: concrete metal fiber ass_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 oj—b iffle: Date of last pumping: Comments(on pumping recommendations,inlet and outh t tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,eta): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM J PART C SYSTEM INFORMATION(continued) Property Address: 58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9/8/03 /v TIGHT or HOLDING TANK: (tank m pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete m fiberglass_,_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallonslday Alarm present(yes or no): Alarm level: Alarm in working order es or no): Date of last pumping: Comments(condition of alarm and float switch etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above 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.): 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,condition Df 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:58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9003 SOIL ABSORPTION SYSTEM ML4ocate on site plan,excavation not required) If SAS not located explain why: Twe Pleaching pits,number: !�� %/�G �f�- / �/O��y✓�� leaching chambers,number: ` ma�cc� / leaching galleries,number: / � '04xej A., lAi leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovativetalternative system Type(name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation etc.): AWA.4.r6A&XA-- Z#6 O&4A-ja X 144<4 /&a( 9,4a, rep"CE (cesspool must be pumped as o ' ionxlocate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool.- Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic fail ,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,, Property Address:58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspection:9/8103 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. A .3 6y . Al AI PL 10 Page 11 of 11 FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 58 Cedric Road,Centerville,MA Owner:Margaret Menninger Estate Date of Inspedion:9/8/03 SITE EXAMSlope 'Zel.'d Surface water it/wA/G, / Check cellar Shallow wells • Estimated depth to ground wateriCK K feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: O ed site(abutting property/observation hole within 150 feet of SAS) ticked with local Board of Health-explain: Checked with local excavators,installers- ch documpn) Accessed USGS database-explain: Ifc You m t you liphed the h groun4 water elevation: 71LA w 11 TOWN OF BARNSTABLE LOCATION 9 0 C'PC't"(- ►`-`-td SEWAGE # h S4rC� VILLAGE l) l 71 ASSESSOR'S MAP & LOT 17,1 I .36 INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY ,LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by P IS o 37'�" .......... qM-•ila z.... I& __ -7 . AN C�k ep No.... . Finc...�:�.:........ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 1 to .................... ....................OF................�.�.� ................................................................. Appliration for Uispoii al Works Tonstrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal System at: Location a !/L�S----- //✓7/A.:neco t f�!J_-----�--- t -8�•... ._� t .._ �'d '�7� Installer Address Y_ UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms.__..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water•-_-_--_-_______•--_--.. Lxt Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ..•--••••..............•----•-•---•.....--••---•-••••--••-----•-•....-•-----••--••..........-•------......................................................... 0 Description of Soil.............................................................................................. ------------------------................................................ W V ....•--•-••-•••---••-•---•-••••••--•-------•---•-••---.--••-•-•-•••-••••••----••---•••-•••-•-•-----•••••---•-•--•----•------•••----••••--•............................................. .................................................................................................................... .......... ... .J.._�V./._.___................ U Nature of Repairs or Alter —Answer when applic ble.___ " _____ .............f ool Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Ti IL 5 of the State Sanitary Code—The undersigned further agrees not to pl/__6 stem operation until a Certificate of Compliance has been issued by the board of health. 000, r Signed.--••-•• ¢��«---------------- •- ...-.... ... Application Approved By................. ...- a ---------------------------------- -•---•-•-- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- -------•----------------------------------------••-•---------•------------•-----••---•--•---•-------•-......•--•--------•------------------------------------------------------------------------------- Date PermitNo.-------�1------t-A--7--------------------- Issued_....................................................... Date `f o- 1 No.... FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C)W nj .. ............................O F.......................................... Appliratiun for Disposal Works Tonstrurtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (Y)an Individual Sewage Disposal System at• - ................ .%� 1��. v/Z . � '� ........... _._ ....._. � - -•...... .. .. Location ads `7 or t No. .....------ 1��' ?:.... l� .ti!N. -��--Ale.!c-:..... •...: ...��t''.�f�.�C....��':..--- ...�iv.��/ ....... . ................................. --........................... T..... ..G i Installer� Address UType of Building 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'ca.pacity......_.....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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Lit Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------.................. ......................................................-...................................................................................................... 0 Description of Soil........................................................................................................................................................................ / W ----•------------------------- •-----------------------------••--••---------•------------•---•••---•-----------.--- % �✓ -- ------ -- --a x ��ci U Nature of Repairs or Al ra io —Answer when app icable.... ------ ______ _ �� _ ti'�'� u ..._.......... Agreement: f The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TILT LEE 5 of the State Sanitary Code—The undersigned further agrees not to place the stem operation until a Certificate of Compliance has been issued by the board of Health. Signed......... - Xe•.....ar•_.. A lication A roved B .. _ •---------------------------••--•• ....•----•. ..^1_..... -- PP PP y-•-------•-••--•- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•----------------------••-••••-- -•.................•-.........-•-...••----••--•-•-•-------••-••••-•-•---.....---••••--•-••••-•-•-••-•-•--...••••••-••--••-••---•--•--•-• --------------------------------------------------------•------- Date PermitNo........ - '--------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / .........................I................OF ...........:......!/"� �'✓ ✓�� ...... s°p............................ (Entifiratf of ToutpliFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (Llfl by---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ` L ..rL�hstaller �f , at has been installed in accordance with the provisions of T_T."'7�; 5 of The State Sanitary Code as described*in the application for Disposal Works Construction Permit No-------K?l.........4_.;a�..-.2...... da.ted-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 1 DATE............................... .__ .f.. . ........................ Inspector................... .......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / 4 s No._..✓........-•-----•- FEE..................:..... Ropoual Works Tontr ion Fg,'Mit -emss= = Permission Is hereby granted_.,. . .f----------------- = -v to Construct ( ) or Re ail; (Vj-an Individual swage—Disposal S , tem at No Streetf'�� as shown on the application for Disposal Works Construction Permit No.(!..�yy_..Y_ _.____ Dated.......................................... T . �� DATE-------------------------•--------..._.---------......... Board of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE LOCATION fEQ�r�(E I►�ll�t SEWAGE.# v-f 7 VILLAGE 5c CEa2ic goL ASSESSOR'S MAP & LOT/JJ INSTALLER'S NAME & PHONE NO.4!5/6� Rga5 6ofysf" Co 36a�Ga37 SEPTIC TANK CAPACITY 1, 00 LEACHING FACILITY:(type) �� 1C-�2 (slze)d Oy NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER. OR OWNERQ DATE PERMIT ISSUED: �6 9 DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No V f Rc fv Ha list- cede,