HomeMy WebLinkAbout0055 CRESTVIEW CIRCLE - Health 55 Crestview Circle
Centerville P
A = 252 051015
i
No. 42101/3 ORA
10°l° (1
.� COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM
PART A 7APR
EIVED
CERTIFICATION
5 2002
Property Address: SSCrerst vlev-) C r.
('g!N Al e- m A TOWN OF BARNSTABLE
Owner's Name: per, HEALTH DEPT.
Owner's Address:
Date of Inspection: 10;1.
Name of Inspector: (please print).M:jm,#1 1<t le-E
Company Name: .9 e1✓o.r k E n✓crop mA rt�s.\ k nsw eel �o �CEL
Mailing Address: 'P.O.Bei6 9q b_
moo, t -cam.:• A LOT _
Telephone Number: L 8 -38S•7 0$
CERTIFICATION STATEMENT •
I certify that 1 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
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: o�
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
hu report only describes condittans:at the,time of tnspechon and under the condifzons of use atahat
tame Thts ruspechon does,not address how theaystem wilt perfam in fhe future undenthe same or different ',
Conditions of use.
Title 5 Inspection Form 6/15/2000 page i
OFFICIAL INSPECTION FORM—NOT FOR VULIMqTARy ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) .
Property Address:
Owner: Ick
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete an of section D .
A. System Passes:
l� I have not found any information which indicates that any of the failure criteria 1.described '
15.303 or in310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. 'n'IO CMR
.Comments:
IM
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" ection need to be replaced or
repaired.The system,upon completion of the replacement or repair,as appr ed by the Board of Health,will pass_
Answer yes,no or not determined(Y,N,ND)in the for the foll ing statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or th septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or faihire is imminent-System will pus inspectimif the
existing tank is replaced with a complying septic tank approved by the Board of Health.
}A metal septic tank will pass inspection if it is stru ly sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ilable.
ND explain: _
Observation of sewage backup or eak out or high static water level in the distribution box due to.broken.or .
obstructed pipe(s)or due to a broken,s led or uneven dis ition box.System
approval of Board of Health): will pass inspection if{with
roken pipes)am zeplaned
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system requ' ed pumping more tham4 times a.year due to broken or obstructed pipe(s).The system will.
pass inspection if(wi approval of the Board ofHeaith):
broken pipe(s)are replaced
obstruction is removed-
.
ND explai
Page 3 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: .S5 rc5 yi �'i rc4c
vt1 V r
Owner:
Date of Inspection: 3 o C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to d ermine 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 3 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health afety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated tland or a salt marsh
?. System will fail unless the Board of Health(a Public Water Supplier,if any)determines that the
system is functioning in a manner that protects a public health,safety and environment:
_ The system has a septic tank and soi absorption system(SAS)and the SAS is within 100 feet of a
surface water.supply or tributary to a s ace water supply.
— The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic and SAS and the SAS is within 50 feet of a private water supply well-
The system has a Sept' tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well . Method used to determine distance
"This system passes' the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatil organic compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ]Cf e,5�v i cc,J C-,rjQ_
Owner: Vc.� e 4
Date of Inspection:
Check if the following-have been done. You must indicate"yes"or"no"as to each of the followin
Yes No
_ Pumping information was provided by the owner,occupant,or Board of Health
J! Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows iti,the previous two week period?
y 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?
X _ 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) [310 CMR 15.302(3)(b)]
i
• i"GAG Y Vl 1 i
SUBSURFACE SEWAGE DISPOSAL SYSTEM Elm E%jSPFAL—MNj0RM
PART A
CERTIFICATION(continued)
Property Address:
taer ` �f
`(f11t/•il[P
Late of inspection: O
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for III inspections
Yes No
_ 3(( Backum of sewage into facilit-Y or system component due to overloaded or clogged SAS or cesspool
Iclogged or or cesspool
g of efr?uent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
It 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 tunes in the last year aOT 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-
_ J_ Any portion of a cesspool or privy is within a Zone I of a public well.Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.[This system passes if the well water analysis,
performed at a DE'P 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 ppms,provided that no other failure criteria
� tt are triggered.A copy of the analysis must be attached to this form.]
lR/t/ (Yes(No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15303,therefor the system fails_The system owner skald com=the Bann do.,,
Health to determine what will be necessary to correct*d;e failure- -
E. large Systems:
To be considered a large system the system must srsve a with a design floes of fl0,0t1t#gpd to 15,000
gld
You must indicate either`yes"or`no"to each of the fo' g:
(The following criteria apply to large systems in addi - to the criteria above)
yes zo
the system is within 400 feet of a drinking water supply
the system is within 200 fee f a tributary to a surface drinking water supply
the system is located ' nitrogen sensitive area(Interim Wellhead Protection Area—IATA)or a mapped
Zone 11 of a public ter supply well
If you have answered"ye to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section D abo e the large system has failed-The owner or operator of any large system considered a
significant threat un r Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15-304.The syste owner should contact the appropriate regional office of the Department.
4
Page 6 of 11
OFFICIAL INSPECTION FORM—NOTFOER VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL 5YS3XM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 53'6reAv;rcJ
2.
Owner: r f�oG
Date of Inspection: p
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): i v
Number of current residents: _
Does residence have a garbage grinder(yes or no): N�
Is laundry on a separate sewage system(yes or no):Xb [if yes separate inspection required]
Laundry system inspected(ye4or no):IVO
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):�
Last date of occupancy: I v r'
COMMERCIALIMUSTRIAL
Type of establishment:
Design flow(based on 310 CLIIt 15.203 • �pd
Basis of design flow(seats/persons/ etc_):
Grease trap present(yes or no):
Industrial waste holding tank ent(yes or no):—
Non-sanitary waste disch ,ed to the Title 5 system(yes or no):
Water meter readings,' vailable:
Last date of occup /use:
OTHER(des be): -
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part 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 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:
- 6 V Gc'S
Were sewage odors detected when arriving at the site(yes or no): A0
i
f
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: SCE 1Fv�ru5 �Pc�C
C'C
Owner:
Date of Inspection:
BUILDING SEWER(locate on site plan)
N
Depth below grade: 6
Materials of construction:_cast iron Y 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK:Y (locate on site plan)
Depth below grade:
Material of construction:l( concrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age conftrmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: t000 C' 4
Sludge depth: .7"
It
Distance from top of sludge to bottom of outlet.tee or baffle: 3D
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle:_W _
Distance from bottom of scum to bottom of outlet tee or affle: _
How were dimensions determined: /Yf p���/j�-P
Continents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as relatej tgoutlet invert,evidence of.leakage, tc.).LA *WtL w s j -heC5 jQkCC .4fJ-
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of construction:. concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top o utlet tee or baffle:
Distance from bottom of scum t onom of outlet tee or baffle:
Date of last pumping:
Continents(on pumping r ommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet inv ,evidence of leakage,etc.):
7
r 46c o kii t i
OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(conxinued)
Property Address: SS Lo,C f V f"M 60-rc(e
Owner: G(t�
Date of Inspection: 3 d}
TIGHT or HOLDING TANK: (tank must be pum time of inspec&i i)(Iocate on site plan)
Depth below grade:
Material of construction: concrete me fiberglass_____polyethylene' other(explain):
Dimensions:
Capacity: -pall s
Design Flow: ons/day
Alarm present(yes or no):
Alarm level: Al working order(yes or no):
Date of last pumping:
Comments(condition o arm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: e Vev)
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.):
_] AA b011 V.&-& ✓Gt 6t nJ faG4 a.�A A .st5Y► oar C4tr�`4�o✓P/1.
PUMP CHAMBER: (locate�onsplan)
Pumps in working order(yes o o):
Alarms in working order or no
Comments(note condi " a of pump chamber,condition of ptizps ands etc.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION(continued)
Property Address: 6rCreat-vj C,r_lk.,
6 �o6 't
Owner
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
�s ,,Q
Type
X leaching pits,number:
leaching chambers,number
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
inn ovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation,
etc.):
16
CESSPOOLS: (cesspool must be pumped as part tnspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool:
Materials of construction:
Indication of groundwater infl (yes or no):
Comments(note condition soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note conditio f soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM IIlVSPF=0N FORM
PART'C
SYSTEM INFORMATION'(continued)
Property Address: -57 GP6-f 11'e0 C i hc�cc,
'''' C.c ✓;Ike-
Owner. Sio II l
Date of inspection:
M '
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.
qb
36
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of inspection: ?.S 0-;L
SITE EXAM
Slope ND
Surface water NO
Check cellar �a
Shallow wells rO
Estimated depth to ground water ��� feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with Iocal excavators, installers-(attach documentation)
1( Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
No.. ......_.. FEB
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Applirativit for Uinpuial Wurlai Towitrnrtiun Varaft
Application is hereby made for a Permit to Construct (1/) or Repair ( ) an Individual Sewage Disposal
System at
e
`S l... ---••-. ---- -• •----- ---•- ------------------------------------------------------
�.J� -.. Local- i :% dress M', (/ or Lot No.
\ ................ . ............. --- -----�-'-"-�--- ------•-------- ............._CC .......
.......................................................................
W Ow ^.., Address
Installer Address
UType of Building Size Lot..........r-.��5?..Sq. feet
Dwelling— No. of Bedrooms------ -- ------------------------------Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building tit 'f�`A- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................... . .
W Design Flow--------------------------------14---..gallons per pa -per day. Total daily flow.-.-.33.6)............................gallons.
WSeptic Tank—Liquid capacity.--VB 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.
Other Distribution box ( ) Dosing to
z .
'~ Percolation Test Results Performed by............................�.��rR--..-_-..-.-.--............ Date-_..-..�.....�.....�..... ...
Test Pit No. 1. --minutes per inch Depth of Test Pit.-----_--_-_.-_.--. Depth to ground water-..-"4/0 ...
44 Test Pit No. 2................minutes per inch Depth of Test Pit-.------ .------.--. Depth to ground water--------------_-_-----
/�� ----•--••-------•-------•......................•-•------•---•----------------------------•--------•------------•------------------
0 Description of Soil------.ill f .. G4^^.....................•------------....------.---...-------------------------•----------------•--------------.......---..._..
V .......................•-----------•--------.....-•••-••-•••--•------•------....••--•----...---------•-----•----•-•-•-•---••.....--------•-.....•--•-•---------......-•----------•.....----•--•-•------
W
UNature of Repairs or Alterations—Answer when applicable............................._..-...._......--_-.-.-........ ...................................
-------------------------------------------------------------------------------------•.....••----------------•-•------------------------------•-----•--••-------------... ..............................
Agreement:
The undersigned,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental.Code—The and rsigned further agrees not to place the
system in operation until a Certificate of Comp ' ee issue by e board of lth.
Signed ............ ... .. . ....... .................. ....... .... ... . Je
Application Approved B ------------------------ --,,. ---Q '-----
PP PP y ---------- ...... ... .............-........ D�e
Application Disapproved for the following reasons: ...............................................................................
........ ........................... .... r ----- ------------ ------- ---------------------------
-----..
Permit No. ...V/...... ......... ....... Issued --------- ....��i.Kd..
Dare
FEa... !1D
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Apphratinn for 14-tip ial Workii Tottgtrnr#inn Prrutit
t Application is hereby made for a Permit to Construct (f/), or.Repair ( ) an Individual Sewage Disposal
System at
f �Q s- `
sl
. r
LocatioAn i\fidress U f1 or Lot No.
`
J.. a t_•7 ---------•----•-- --------- ----- -------••--•-------------------
W ................. Own. / � Address
Installer Address _
c�
Type of Building Size Lot............. ..Sq. feet
.t Dwelling— No. of Bedrooms--_--.-4C-_-_-------------------_.__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------- ----------------�--------------------------------------- ---••---•-••-----•••------•••••---•-•--•••-------•-•--------.
W Design Flow................................/�O.....gallons per pe -per day. Total daily flow.....33-0............................gallons.
WSeptic Tank—Liquid capacity-»e UgalIons 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 to ( �g
~' Percolation Test Results Performed by-------/ %L -�h. -------------------------- Date......./_-_3. _ _......_..
W
Test Pit No. L_.... --minutes per inch Depth of Test Pit____________________ Depth to ground water---A ....
44 Test Pit No. 2................minutes per inch Depth of Test Pit__-.-_-__._-___-.__. Depth to ground water........................
a /l
D Description of Soil------ -- il. ��`�`' ...---------------------------------------------•-----------......-•-•-••---
WI ` -------- ------ --- --- ------------ ------------- -----------------------------------------------
-•••--------------
---.
v ............................................ --•---••-•--------------------•------•••-------------••••-•-------------•-•••••----••---------•---••-.....------.
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement. I ,
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Coder The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by.the board of he'alth..
Signed --------
Application. f/ _....._
/✓ Date
Aroved B �. �.... --"' ........ -............. --........... - .Date..G 5:......
PP Y , ..
Application Disapproved for the following reasons- -------------------------------------------------------------------------- ---------------------------------------------------
.......... .................. ,� /.... .......� ........ _........ - - - -
/,, j Date
Permit: No. �,. l C/ Issued J/"?.._...... -
........?., ..
......f. / Date J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certifiratr of Compliartre
\.TH IS TO CERTIBY�That the 1n 'vidual�Sewage Disposal System constructed ( or Repaired ( )
by -- `[ }% (( - - - =..................................
a[ - ...... .. - - ------------------------ -...._.. ...__........ .....
has been installed in accordance with the provisions of TITLEf of he S ate Eny ronmental Code as described in
the application for Disposal Works Construction Permit No. 4- ` r { .( .. dated ----,__
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL
' FUNCTION SATISFACTORY.A' �,l
DATE.....-,-�"'.-.._1 .. - 3 ...... _..`.ill- Inspector --- `F..... _ /_" f-/ / �7
t V
�. --«ems..—.—..---------.e---- —�---a—4����ti �,�---------------- ---------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH s/
TOWN OF BARNSTABLE
1
No�-••................ FEE....._......---•--......
t t
Nspo`-s-�ttll nrki Tanot inn "antit
Permission is ereby granted..._V.......:.... ....................................1. _ _
to Constr t ( ) or Re.air ( an Individual Sewage Dispos System
at No..... ................
..._ -•--•-----------•................... .._....._ Street ---_)------- ---y��.�.............................
as shown on the application for Disposal Works Construction Permit No�:�1%fV 4a'ted------
--------•-----------•-•----------------------------------------------------------------------
Board of Health
DATE................................................................................
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APPLICANT,s '�BA`(SILZUiti� Go . INC. f
TOWN OF BARNSTABLE OP
LOCATION .k.7 f�/ Ck,6307 U rl t<-) C/f.SEWAGE#
VILLAGEC4J'V r0;e lJ/I_U ,, ASSESSOR'S MAP& LOT SG. - S
INSTALLER'S NAME&PHONE NO. �1 1reUXGi�?
SEPTIC TANK CAPACITY ,J!`22 roh C
LEACHING FACILITY: (type) U/7 AW 15*4 4, (size) bX6 '/f-ZO
NO.OF BEDROOMS
BUILDER OR OWNER L /W G�3
PERMITDATE: COMPLIANCE DATE: F
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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