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Home My WebLink About0144 ELLIOTT ROAD - Health LA EL LIOTT RD., CENTERVILLE 7IZGlitC y UPC 12543 o a No. 5,3LOR HASTINGS. MN TOWN F BARNSTABLE IQ LOCATION � 1 � SEWAGE # VILLAGE �' ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY Z' LEACHING FACILITY: (type) ' v (size) NO.OF BEDROOMS BUILDER OR OWNER -U- - PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Pr vate 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 o Facility) 'Feet Furnished b A r r • , f 1, - 1 DATE: 6/21 /99 PROPERTY ADDRESS:----------------------- 144 Elliot Road ------------------------ Centerville, Ma. ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1500 gallon septic tank c� 2. Leachfield 12 ' X 50 ' X 1 ' 3 . 1 -Distribution box Based on my inspection, I certify the following conditions: 4 . This is a title five septic system. ( ( 95 Code ) 5• The septic system is in- proper working order at the present time . 6 . System installed in 1996 SIGNATURE:f Name:-1 ,PL,Macomber _,J ------- Company: Jose2h_P . Macomber_& Son , Inc . Address: Box—66 ---- --------------- Centerville , Ma . 02632-0066 -------------------- Phone:-- 508-775-3338 ------------------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 1-9 A � JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds �p Pumped & Installed JUL 1 3 1999 — Town Sewer. Connections S � N P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 AEpr ' ti E ti 1 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 TRUDY COX Secretaj ARGEO PAUL CELLUCCI DAVID B. STRUH Governor Co�:,ss:oar SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM PART A CERTIFICATION Property Addrass:1 44 Elliot Road Name of owner Lisa Lawrence Centerville Address of Owner: Date of 4upoct o= / Name of Inspector:(A"lF.4iVioseph P. Macomber Jr. I am a DEP approved system irsspactor pursuant to Section 15.340 of Thia 5(310 CMR 15.000) Company Name: Joseph P. Macomber & Son, Inc. M&TanAddress: pox rPnter3Zj11P, Ma 02632-0066 Tdaphona Number: .5 7�_'2'2'2 8 CERTIFICATION STATEMENT I certify that I have personally Inspected the sewage disposal system at this address and that the Information reported below is true. accurate and complete as of the time of Inspection. The Inspection was performed based on my training and experience in the proper function and maintenance of on•sitesesewage disposal systems. The system: Y Passes Conditionally Passes _ Needs Fur-that E�valation By the Local Approving Authority Fails lrupector's SignatuZhII Date: The System Inspec submit a copy of this Inspection report to,the Approving Authority (Board of Health or DEP)within thirty (30) days of completing this inspection. It 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 Department oh£nvlronmerttal Protection. The original should be sent to ma system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 (�, Printed on Recycled Prep y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 144 Elliot Road, Centerville Owrw: Lisa Lawrence Date of I" I"dw: 6/21 /9 9 INSPECTION SUMMARY: Check A, B, C, o/ D: A. SYSTEM PASSES: *�have not found any information which Indicates that any of the failure conditions described in 310 CMR 1.6.303 exist. Any failure criteria not evaluated are Indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes,-no, or not determined (Y, N, or ND). Describe basis of determination in all Instances. If "not determined", explain why not. The septic tank Is metal, unless the owner or operator has provided the System Inspector with a copy of a Certificate of Compliance (attached)Indicating that the tank was Installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, Is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure Is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank es approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced 40b - The system required pumphig-inore than'four dmes ayeardue to broken or obstructed pipe(s). The Tmerm wiRyesr inspection if(with approval of the Board of Health): -- broken pipes) ere replaced obstruction is removed revised 9/2/98 Page 2of11 t , 4� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (wndrxsod) PToG+nYAddr.ul 144 Elliot Road, Centerville °F. Lisa Lawrence , �� 6/21 /99 C. FURTHER EVALUATION LS REQUIRED BY THE BOARD OF HEALTH. Conditions exist which roqulre further svaJuadon by the Board of Health In order to datern-Jns If the system Is falling to protect me public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERIMINES W ACCORDANCE Y% TH 310 CUR 16.303 (1)(b) THAT THE SYS LS NOT FU N CTION W O W A WANKER VvT CH..WILL PR OIE.C1 THE PU B U C HEALTH.AN D S A.FfY dN D THE DC�O Nl.LER: Cesspool or privy Is within 60 leat-of surface water Cesspool or privy Is within 60 feet of a bordering vegetated wstiand or a salt marsh. 2) SYSTEM YAU FAIL UNLESS THE BOARD OF HEALTH WID PUBUC WATER SUPPLIER, lF ANY)DETERMINES THAT THE SY57R7 FUNCTIONWO W A MANNER THAT PROTECTS THE PUBUC HEALTH AND SAFETY AND THE ENVIRONWE(T: The system has a sspdc lank and toll absorption system (SAS) and the SAS Is within 100 feat of a surface water supply tributary to a surface water supply. The system has a asptia tank and toil absorption system and the SAS Is within a Zone I of a,public water supply wall. The system has a soptie tank and toll absorption system and the SAS Is wlthln 60 foot of a private water suppry wsu. The system has ■ sspdc tank and toll absorption system and the SAS Is less than 100 foot but 60 feet or more from a private water supply wall, unloss a wall water analysis for colllorm bacteria and volatile organic compounds indicates tru well Is free from pollution from that facility and the pros nce of•mmonla nitrogen and nluato Nvogon Is rqu&J to or let, than 6 ppm. Method used to determine dlstancs _ (approxJmation not valid).• 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Pro9ertyAddreaa: 144 Elliot Road, Centerville Owrw: Lisa lawrence Drte of lrupocdon:6/21 /9 9 D. SYSTEM FAILS: You r,Rust Indicate either 'Yes' or 'No" to each of the following: I have determined that one or more of the following failure conditions exist as described In 310 CMR 15.303. The basis for this determination is Identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes Backup o+sewage IRtoiacility-or•vYetbrrt component•dueKo en overloaded orcbgged'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 li uid leve In the d stab tion box above outlet Invert due to an overloaded or clogged SAS or cesspool. rrl A .,ejj : 6 to >V r'X 1' Liquid depth in caa*pevl Is less than 6" below Invert or available volume is less than I(2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. _ Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy Is-within a Zone I of a public well. Any portion of a cesspool or privy Is within 60 feet of a private water supply well. Any portion of a cesspool of Privy Is loss-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. It the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic-compounds, ammonia nitrogen and nitrate nitrogen, - E. LARGE SYSTEM FAILS: You must indicate either 'Yes' or 'No' to each of the following: The following criteria apply to large systems in addition to the criteria above: The system $erves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system Is within 400 feet of a surface drinking water supply the system•Irwlth.;n 200 leetot-a t+butery toe curlaoa- 14-.kwsg•watersupply •- --- the system Is located In a nitrogen sensitive area (Interim Wellhead Protection Area -IWPA) or a mapped Zone If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4of11 J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 144 Elliot Road; Centerville Owner: Lisa Lawrence Date of Inspection, 6/21 /9 9 Check if the following have been done: You must indicate either `Yes' or 'No' as to each of the following: Yes No �t Pumping Information was provided by the owner, occupant, or Board of Health. ..Nona of the systemcompoaants.kawa.b"n pzxnpocl4oFat-Jeast twowes,"an&the•system hasb"zeceiuwg.«aal flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this Inspection. As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non sanitary or Industrial waste flow. The site was Inspected fou�rr,signs of breakout. All system components,Auluding the Soil Absorption System, Nave been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septic tank was inspected for condition of baffle Of tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System orr the site has been determined based on: Existing information. For example, Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C Is at issue, approximation of distance is unacceptable) / 115.302(3)(b)) The facility owner.(and.ocr,1pants.Jf difiarant from wacnar).acere pzvsided.wiih lnlntmatior�Dn.t�rr�rrhA p� m�ntn��', of f SubSurface Disposal Systems. I revised 9/2/98 Page scru 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 144 Elliot Road, Centerville Owner: Lisa Lawrence' Date of Inspection: 6/21 /9 9 FLOW CONDITIONS RESIDENTIAL: Design flow:V_g.p.d./bedroom. Number of bedrooms(desig Number of bedrooms(actual): Total DESIGN flow Number of current residents: Garbage grinder(yea or no): Laundry(separate system) ( s or ;. If yes, sepacate.Inspection.required Laundry system Inspected e r no) Seasonal use(yes or no): /, Water meter readings,if eva able (last two year's usage(gpd): 7 `7 Sump Pump(yes or no): L 7 Last date of occupancy COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: d ( Based on 15.203) Basis of design flow Grease trap present: (yes or no).&W ''II Industrial Waste Holding Tank present: (yes or no)/vR Non-sanitary waste discharged to the Title b systerp: (yes or noV40 Water meter readings,If ava a e: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RE ORDS and�so rce information: System pumped as part of i pection:(yes or no) If yes, volume pumped: gallons Reason for pumping: TYPE SYSTEM 7Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous Inspection records,if any) I/A Technology et Attach copy of up to date operation and maintenance contract Tight Tank `Copy of DEP Approval Other APPROXIMATE AGE of all components, date installediif known)•and source of40f0rmation: Sewage odors detected when arriving at the site: (yes or no) � i revised 912198 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (con-drwod) Pt�ertyAddn.aa: 144 Elliot Road, Centerville owrw: Lisa Lawrence., Date Of lrtspocdon: 6/21 /9 9 BUILDING SEWER: (Locate on site plan) �y/l Depth below grade:1N/ Material of construction:,_cast Iron 40 PVC—other (explain) Distanca ho ,private water supply well or suction Ilnow-f Comments: (condition of Joints, venting, evidence of)aokage,-etc.) e SE➢TIC TANK: S (locals on site plan) Depth below grade:�O Material of constructl concretoL#matala-FlbergiassV4polyethylene4Z4other(expla(n) If tank Is instal, list age Js.age.conrtrmad by Certificate of Compllanc (Yes/No) , Dimensions: Sludge depth:_ &L_ Distance from top of s{ydge to bottom of outlet tee vrtraffle: C/ Scum Wcknsss:,y! !( Distance from top of scum to top of outist tee or baHlo: Distance from bottom of scum to bonoatro�o�djt��or ba a: ld How dimensions wets daterminsd: /�S Comments: (recommendation for pumping, condition of Inlet and outlet less ot•baffles, depth of liquid lave!In relation to outlet nv�r�, �vucturm:�,c.�rit, evidence of leakage, etc.) Pump tank PVPrg 3�.®IFS. �is1 e1 eutiet tees are 1Ai1 lac v CREASE TRAP: (locate on site plan) Depth below grade:" Material of con&uuct!onAKconcrstseAatall IberglassAloPolyethylens4�Ather(explain) Dimensions: Scum Wcknesa: Distance from top of scum to top of outlet tas or baffle: /A Distance from bonom of a to bonom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of Inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert. tttucrural integnt, evidence of leakage, etc.) tlEase rap is not present , i revised 9/2/98 Page 7of11 (f% SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (corttirwed) PropertyAd&a": 144 Elliot Road, Centerville Owrw: Lisa Lawrence D" of Inspection: 6/21 /9 9 TIGHT OR HOLDING TANK:;eTank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: Material of construcdon/Aconcreteoo4metat�(/,OFibergla3voylPolyethylene7(4other(explain) Dimensions: AO Capacity: gallons Design flow: gallons/day Alarm present Alarm level: AlarrmIworking order:Yo&,&No Vh Date of previous pumping: Comments: (condition of Inlet tee, condition of alarm and float switches, etc.) Tight a-r—toidin 171an s are are not presen DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet Invert: 10 Comments: (note if level and distribution Is equal, evidenoe of solids carryover, evidence of leakage Into or out of box, etc.) —evidence — e Inro or PUMP CHAMBER:"e— (locate on site plan) Pumps in working order:(Yes or No)_N_A_ Alarms In working order(Yes or No)—N-9- Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) _ um c am rev—ised 9/2/98 Page 8of11 i SUBSURFACE SEWAGE DIS PART C SYSTEM INSPECTION FORM SYSTEM INFORMATION (cont-0d) propertyAddras : 144 Elliot Road, Centerville Owner: Lisa Lawrence Dau of Irupeco«,: 6/21 /9 9 r (; Q � SOIL ABSORPTION SYSTEM(SAS):_ roximated by non-intrusive methods) (locate on site plan, It possible: excavation not required,location may be app If not located, explain: Type: leaching pits, number: leeching chambers,number.—vp1� leaching galleries, number:_g th: leaching trenches, number, leng leaching fields, number, dime ons: overflow cesspool, number: F22 ( Alternative system: Name of Technology: Comments: of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) (note condition of soil, signs Lo and . oi2n.5 Of s r e (locate on site plan) Number and configuration:__ q 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 (cesspool must be pumped as part of Inspection) ass , Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of.vegetation, etc. spoo s ar , PRIVY: (locate on site plan) Dimensions: Materjals of construction: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation; etc.) ivy is not revised 9/2/98 Page v or u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (c,ondnuad) P�, cyada�.s 144 Elliot Road, Centerville ouvr..: Lisa Lawrence DouorIr"P`6n: 6/21 /99 SKETCH OF SEWAGE DISPOSAL SYSTEM: Includs tlas to stl•ut two permanent re(srsncs landmarks or benchmarks locate all walla wIWn 100' (Locate whirs public waLar supply comas Into housa) Centerville 0sterville Marstons Mills Water Company 428-6691 r � �a3r 1 X b 01C I l \b � i Icy, 0. -- -- - �01- 0 O revised 9/2/98 Pataloo(II f 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address: 144 Elliot Road, Centerville Owner: Lisa Lawrence Date of Inspection: 6/21 /9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater /Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed. 'te (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps 7Z'Checked pumping records /Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Use water contours map . Gahrety & Miller Model 12/ 16/94 revised 9/2/98 Page 11of11 e , r.rn�r•n itin�rranrAw•n.w�+.+r.nr�.mn�.+w��nm r.rrw�u r.r�rrn we .. � � TOWN OFBARNSTABLE WARD OF HEALTH 1 SUItFACF 9BK�OF DISPOSAL SYSTEM INSPECTION FORM - PART D .- mcriFICATIONr^ - -TYPL OR PAINT C UARLY— PI?OPERTY INSPEC7'ED STREET ADDRESS 144 Elliot Road Centerville ASSESSORS MAP , DLOCK AND PARCEL # RI OWN i E s NAME Lisa Lawrence PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber- Jr. COMPANY NAME Joseph P Macombe r' & Son Inc. COMPANY ADDRESS Box 66, Centerville, Ma. 0263.2-0066 Stravt Town or City Stag LIP COMPANY TELEPHONE (508 )775 -3338 FAX ( 508 )790 -1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time ofinspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check ne : Systeui PASSED The inspection ►ihich I have conducted has not found any inform which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 , Any fail re criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* , The inspection which I have con ducted has found that the system fails to Protect the }-)tlblic health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date n'ecopy of this certification must be Provided to the OWNER, the BUYER wherapplicable ) and the DOARD OF HEAL1'lI, If the inspection FAILED, thb owner or"`oporator ahalI u pg Within one year of the date of the inspection , unless allowed dorthe requiredm otherwise as provided in 3.10 CMR 16 . 306 . partd . doc r No. Fee -RL. x _W X1 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pphration for Mtoonl *raem Construction Permit Application is hereby made for a Permit to Construct( or Repair( )an On-site Sewage Disposal System at: L1ocattiio�n•Address or Lot No. c Owner's Name, — �j Address and Tel.No. t "]��—�(Xj � tj 4--P—v— u t tqit�a kg Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G —,?— Yn 14I L) Type of Building: welling No.of Bedrooms Garbage Grinder Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow c gallons. Plan Date Nurilber of sheets :;�_ Revision Date r Title C�-42 ? tW: ell Description of Soil d—t t Cam ✓/ ��1>�L� IC2 Ina S'A!' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to en the constructio and maintenance of the afore described on-site sewage disposal system in accordance with the provisions itl 5 of the iron ntal Code and not to place the syste in operation until a Certifi- cate of Compliance has been iss is$oar e Signed [ Date G•2 C f Application Approved by Application Disapproved for the following reasons Permit No. vDate Issued '100 No. I Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE,�MASSACHUSETTS Zippricat on or Migpoga[ *pgtem Congtruction Permit Application is hereby made for a Permit to Construct O or Repair( )an On-site Sewage Disposal System at: - Location Address or Lot No. Owner's Name,Address and Tel.No. 1 f G(_JG>3 �x4,, , I, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � a fix iZ�i_'. � N�r�, I PC- L-1 Type of Building: 4-""-Dwelling No.of Bedrooms Garbage Grinder O� Other Type of Building No.of Persons---- Showers( ) Cafeteria( ) Other Fixtures !_� Design Flow c ki(--)-gallons per day. Calculated daily flow- ' gallons. Plan Date.— �1 1 Nu her of sheets �, Revision Date. Title C74>y- i i t-t e,,1) V(..a 1- 1�( �d " l ��t n-L)� Jj`� �fl4 0 �}L ICG•/J� r(- '7 Description of Soil U t� O� t �� 1 .��-' J✓U/�- , /,�? /V ey EAU 4' t Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to en the constructio and maintenance of the afore described on-site sewage disposal system in accordance with the provision itle 5 of the. ironTental Code and not to place the syste in operation until a Certifi- cate of Compliance has been issu b his$oa`r e 'Signed [[,,��~ (( / Date 6 .1c Application Approved by Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS G Certificate of (Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System instal le (/ or repair d7replaced( )on by „ a.�w Jam--�-�^ CG y `. d AfX q for ' t fv �r as h n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated " Use of this system is conditioned on compliance with the provisions set forth below: t_1 No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mioogar *pgtem Congtruction Permit Permission's h reby granted to to construct( )repair(/ )an On Sewa a System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must jbe completed within two years of the date below. Date: ` T �� .Approved by DE�� DATA FAAAL14- 5maa'�K E . pL.AL1i. otJ BAGK. =fir -PMUy FWW xr .4-•x to -44o sr.rnc TA14t• LE" Paz> ,&ffvcAroN AM& 2=b• a"t�Yc. PetZ PIPE . d-`I PI ado GPI s 5F s 6q 5 st �IPPLIG�.TON A¢6A A c.L ,P1 P6 Tv 06 4 Odd Sctla..4O Stt�wAc.I_ AMA- O r/� ZA $oZTotil ARC OF � , ' PMMOLAT. P4 amG 5'K'u�t SULLIVAN NO.29733 SOIL. G.dr CIVIL a� 31 N u N rcl t Yz S R51-3E 4 PVG "�C:c tom' D�4G,�.� - �• � 34'�' • ��i�5 7-,doP`t1 a- -uwc ov ��z,a �t, op r� 3 lz M .. 1►ctJ..�� _ 3L�'A t 1G Cu Nt�Pv�ArNT bc..,�Tt"1 a V tom... A A-►. U R-1 I�'�. 1't� (� 'Vt�1 . ...QZpFItS +r p`•.: ,i ti' i=D ROT FLA -1 ILLIAM �v V gyp' No. 19334 .O 4d13 ate; 7 -85. Q,sTE�ya4 54►t� ; �Z I)CMP 6 {{ N C4wlR`li► i W ITu °rilar 'SIDmuNIa AMP cic. 2gpu�2r.,M6u'r of TUG 'm wN OF MAP PA- �J �1�21�5 t�P� b► t7 1 f.uor L.Oi ATiD W!Tu I N A 'mA �m- f Nyet lJG . Spt:ta4L Flste7D 4iA►'T�-� zoN>C. I,At,fn Sv�v�Yt� •W�r�tt�f � � I , \�� C:t��--' QL�`' 04TfiZVILL.Cr • MAy• opF3e1"� 1�oM �uti.DtNb6 iNa�ILA NOT' et"s. APQ(JG4NT: P�cS•T IG� l pt'1�-IZ�`, Iat�C, usaD "-Mdust PRo Fm l L►�.Ietf: ,7-4 _ r000, w� 30 i5 ado loolo jkl SVi OF/00 qs WfILLIAM CNIL` e • I � NYE u tv. No. 12334 1 � � �? �� , : . _ r� .0 •aa Ids uP �n �'� ;�; P LocATto*W . _ 1 . .: - .: P�t...A►,1 Rol=E2E�cE ilk�L � �,•l�t�o� 3 Gp,N�PL�lS v�/lTN THE 51v`�.Ll►-�� T A�JD SET$AE1C R�QVtRE EATS bF TNrc ��AP 24b Lv`r'" •LoG•A'CE� : w�-ru� N aa.xTccz � ��• I�.,c. REGlSCC1Z1cD 1�.�.ip SUevcYov- d'�'T� � OSTEfL�/1l-l.� o MASS. � T4-I 15 ;D C..A N (S��.!OT BQ•S E'0 _U A�•J . T11C_ oFc-: APPt_t GA.t�IT' • �•f(( EvQ� US C:l TU;. e:T C vl{J Ca C I TOWN OF BARNSTABLE L0(,, rlON 3 jClli v t ,�,� SEWAGE # 9V VL..LAGE C�✓z ��'✓ �/� ASSESSOR'S MAP & LOT 2YB-DS'j_d-4 INS fALLER'S NAME&PHONE NO. u f�� SEPTIC TANK CAPACTrY LEACHING FACILITY: (type) /%;a�� (size) NO.OF BEDROOMS_ BUILDER OR OWNER �re S 7i S� f�/vhi P S PERMITDATE: COMPLIANCE DATE: 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 P X �Ae4W