HomeMy WebLinkAbout0056 FERNBROOK LANE - Health 56 Fernbrook Lane
Centerville P _ C
A = 208 085013
ford, N0. 152 1/3 ORA
O/c / \
... ,_ ,:Tam �.s_>.:. x._..:..- _.�.�.•.v�.�.� - m+r."
,r TOWN OF BAR�NSTABLE
LOCA;,ON G A SEWAGE #
VILLAGE Cf 4:-0-�- % , (� ASSESSOR'S MAP&FOT o
INSTALLER'S NAME&PHONE NO. 1`O4 ,AIJ,o
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type);, 5 4 - �, (size)
NO. OF BEDROOMS I
BUILDER OR OWNER L .ti Lc
PERMITDATE: 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) Y Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of lea ng facili / Feet
Furnished by ! �91
1
,b.
.� 3Q ,
60 _
1 � .
<Lx <t I1 (94%
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROT C'111010EIVED
NOV 5 2003 .
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 56 Fernbrook Lane
Centerville, MA 02632 MAID
Owner's Name: James Keane PARCEL
Owner's Address:
SOT �W
Date of Inspection: October 28, 2003
Name of Inspector: (Please Print)James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49
Osterville,MA 02655
Telephone Number: (508) 862-9400
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 function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuani'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: October 29, 2003
The system inspector shall submi 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.
Title 5 Inspection Form 6/15/2000 page 1
f
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, AM
Owner: James Keane
Date of Inspection: October 28, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 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 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.
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 exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is 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 Health):
broken pipe(s)are replaced
obstruction is removed
ND explain-
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, MA
Owner: James Keane
Date of Inspection: October 28, 2003
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety 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 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 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.
_ 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 determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
r
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, AM
Owner: James Keane
Date of Inspection: October 28, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/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 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.
✓ 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 56 Fernbrook Lane
Centerville, AM
Owner: James Keane
Date of Inspection: . October 28, 2003
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 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)].
5
f
Page 6 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 56 Fernbrook Lane
Centerville, MA
Owner: James Keane
Date of Inspection: October 28, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15,203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCLUJINDUSTRUL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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 or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection (yes or no): 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:
Jun. 26100-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, MA
Owner: James Keane
Date of Inspection: October 28, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron _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: ✓ (locate on site plan)
Depth below grade: 2"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 gal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (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 of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, AM
Owner: James Keane
Date of Inspection: October 28, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no): -
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was clean. No solids were present.
PUMP CHAMBER: None (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 of pumps and appurtenances, etc.):
8
f
Page 9 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, AM
Owner: James Keane
Date of Inspection: October 28, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 2- 12'x 25'x T per as built card
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.):
There did not appear to be any signs of failure. The bottom to grade was 3'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(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 inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY: None (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 ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, MA
Owner: James Keane
Date of Inspection: October 28, 2003
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
A3
aC) a9 3 O a
3
3 3 L 39 o
y
y 7 y
10
Page I 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 56 Fernbrook Lane
Centerville, M,1
Owner: James Keane
Date of Inspection: October 28, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- 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: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: _
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing
approximately 25'+/-to ground water at this site
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
TOWN BARNSTABLE /
LOCATION , _r^ 6 r F SEWAGE # 00 c;1/9
VILLAGE Cent er1J,I LIL ASSESSOR'S MAP & 1,01:�09" 0
INSTALLER'S NAME&PHONE NO. B i,
SEPTIC TANK CAPACITY ���1SW r
LEACHING FACILITY: (type) o, Lam. G�a,SwJ (size) lax a 5-,A a-
NO. OF BEDROOMS 3
BUILDER OR OWNER kiAlol
PERMITDATE: 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 leachi g facility) Feet
Furnished by /1 Saccrie-1 br
A �
A �
i a9 al
a 3�� 3
3 3L 39El
. . y
Y 116 y7
No. Fee��
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �.
Yes
PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migozaf *p9tem. Con!truction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) O Complete System O Individual Components
IN
L c tion Addre or Lot No. Owner's Nam A
e, ddress and Tel.No.
Fern rook Lane , Centerville James / Phyllis Keane
Assessor's Map
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
m. E. Robinson Septic S rvice
P 0 Box 1089, Centerville
Type of Building: j
Dwelling No.of Bedrooms J—:-3' Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Natue a of Repairs or Alterations(Answer when applicable) Title-5 septic System, consisting-
Of a tank. D-box and 2 chamber.-, all around..
^�.n.c.r e t-ems With—s�-e
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th=arHealth.Signed 12, 1 d, /� Date 1
Application Approved by S4 9 ftV 4 1 n Le.. Date
Application Disapproved for following reasons
Permit No. '104ne — 1 B Date Issued
No. 020� �+1 1 1 Fee 50
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
-TOWN OF BARNSTABLE., MASSACHUSETTS
PUBLIC HEALTH DIVISION
2pprtcatton for Mtgoa f *p5tem Conetructton Permit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) El Complete System ❑Individual Components
3
ti Addre or Lo[ o. Owner's Name, ddress and Tel.No.
Fern rOO Lane, Centerville James /A Phyllis Keane
Assessor's Maple} r �
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Vm. E. Robinson SeptictS ry ce
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures i
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
`. Description of Soil Sand
e
Natufe of Repairs or Alterations(Answer when applicable) Title-5 septic system, consist 1ng
a tank, ID-box and. 2 chambers , concrete, with stene all around.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system"
in accordance with the provisions of Title 5 of the Environmental Code#and not to place the system in operation until a Certifi- '
cate of Compliance has been issued by this ar Health. I a
Signed _iL/ I(_ Date " C� �✓
Application Approved by aid s Date T&- nc2
Application 15isapprov d for following reasons t
Permit No. Date Issued.
—————————————————————————————— ——————
THE COMMONWEALTH OF MASSACHUSETTS
Keane BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( )
"'Abandoned( )by Wm. E Robinson Septic Service
at 56 Fernbrook Lane, Centerville has been constructed in accordance .t
with the provisions of Title 5 and the for Dis y osal System Construction Permit No.��1;2�-`oZ 1 dated �
Installer Wm. E. Robinson Spr.. Designer
The issuance of.this permit shall not be construed as a guarantee that the sysfiii will function as designed,`
,✓ `' E -s
Date > r Inspector
I
No. Fee_50
THE COMMONWEALTH OF MASSACHUSETTS
Keane PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ltzpogal *pgtem Cow5trurtton Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade,( )Abandon( )
System located at 56 Fernbrook Lane , Centerville
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.
Provided: Construction must be completed within three years of the date of this permit.
Date: Approved by
4,aa
r
1/6199
NOTICE: This Form Is To Be Used For the Repair Of Failed _
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, 14 , , , hereby certify that the application for disposal works
construction permit signed by me dated 6-6 , concertung the
property located at 56 Fernbrook T ane,Centgryil�@ meets all of the
following criteria:
• The failed system is connected to a resident dwelling only. There are no commercial or business —
uses associated with the dwelling.
• The soil is classified as CLASS I and a percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 eet of the proposed septic system
• There are no private wells wi * 150 feet of the proposed septic system
• There is no increase in flow d/or change in use proposed
• There are no variances re ested or needed.
• The bottom of the prop sed leaching facility will not be located less than five feet above the
maximum adjusted undwater table elevation. [Adjust the groundwa4er table using the Frimptor
method when appli blel
• If the S.A.S. wi be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facil. will not be located less than fourteen(14) feet above the maximum adjusted
groundwate table elevation,
Please complete the following: _
L G/U
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the iVikK High G.W. Adjustment.
DIFFERENCE BETWEEN A and B y
SIGNED : �Z/L l� DATE:
[Sketch proposed plan of system on back].
q:health folder:cert
61 rl
1
I'
a
� h
* 4
P
obi
TOWN OF BARNSTABLE
..... ..LOCATLON �. SEWAGE
VILLAGE c.r^� / ASSESSOR'S MAP & OT
INSTALLER'S NAME&PHONE NO. Rob /v15 n f-- -7 7 S- 9 1 'I 6
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)rz4_S' c`7,-e ;L .L (size)
NO..OF BEDROOMS j
I
BUILDER OR OWNER L��s'A,;,-L�
PERMITDATE: �/ /� -C� 0 COMPLIANCE DATE:
Separation Distance Between the: j
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 facili Feet
Furnished by. �
1'� = CO�IZiO\'WE4I,TH OF MASSACHL;SETTS
_ EXECUTIVE OFFICE OF E1'VIR0NMEN TAL AFF:AIP.S
F DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE RZ\TER STREE':. BOST0N 11Lk 0210t; t61"i 292-550o
TRL DY CO-L'
Secretar.
ARGEO PAUL CELLLCCI DAVID B STR'-* S
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 55 Fernbrook Lane Name of Owner Phyllis Keane
Centerville Address of Owner:
Date of Inspection: C—; G
Name of Inspector:(Please Print)Wm. E . Robinson S r.
1 am a DEP approved systerrl inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
CornpanyName: Wm. E . Robinsoneptic Service
Mailing Address: P4 Box 1089, Centerville , MA
Telephone Number: 7 5—8 7 7
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on•site ge disposal systems. The system:
_sewaPasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: /-V P� Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
k
NOTES AND COMMENTS
' f �
revised 9/2/98 Page IorII
n
V.i -.^!ed o�.Recvclyd Panr,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION(continued)
'rop"Address:56 Fernbrook Lane , Centerville
Jwrw: Phyllis Keane
Date of Inspection:
o-
INSPECTION SUMMARY: Check 9)8, C, Or D:
A. SYST'F�IA PASSES:
(�IIhhave not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. STEM 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 y , 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 as
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
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revise 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 56 Fernbrook Lane , Centerville
Owner: Phyllis Keanr ..
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) YSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMIR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
1 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 PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
OTHER
revise.^,. P2ge3oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Eer brook Lane , Cente rville
Owner. Ph 1 is e ane
Date of Inspection:
D. SY FAILS:
You must dica'te either "Yes" or "No" to each of the following:
I ave determined that one or more of the following.failure conditions exist as described in 310 CMR 15.303. The basis for this
de ermination is identified below. The Board of Health should be contacted to determine what will b6 necessary to correct.the failure.
Yes No
Backup of sewage into facility or system component due to an 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 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipels).
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 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. If 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. LAP 3E SYSTEM FAILS:
You mus 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 serves 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 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)
The b ner 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 Pagt4of11
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Property Address: 5.6 Fernbrook Lane , Centerville
Owner: Phyllis Keane
Date of Inspection: _ L
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal 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 NIA.
_ 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 for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on 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)
(1.5.302(3)(b)1
_ The facility owner (and occupants,if different from owner) were provided with information on the proper nwintenaac.&-of
Subsurface Disposal Systems.
re—'Lsed 9/2/98 Page 5ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C
SYSTEM INFORMATION
aoperty Address:56 Fernbrook Lane , Centerville
Owner: Phyllis Keane
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 1S a g.p.d./bedroom.
Number of bedrooms(design): Number of bedrooms (actual): 3
Total DESIGN flow!-/ a
Number of current residents:
Garbage grinder(yes or no): ;�— v
Laundry(separate system) (yes or no):_V If yes,separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): A, o
Water meter readings, if available (last two year's usage (gpd): 1999 147 , 000 gal.
Sump Pump (yes or no):--Z-- 6
Lest date of occupancy:--"— 1998 169, 000 gal.
CO ERCIAL/INDUSTRIAL:
Type o establishment:
Design low: qpd ( Based on 15.203)
Basis o design flow
Grease rap present: (yes or no)_
Industr al Waste Holding Tank present: (yes or no)_
Non•s nitary waste discharged to the Title 5 system: (yes or no)_
Wate meter readings, if available:
Last a of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
0-q `) `7
System pumped as part of inspection: (yes or no)X- 6
If yes, volume pumped: gallons
Reason for pumping:
TYPE 9f SYSTEM
1/ 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known)and source of information: J-- 6
/�' -- �—�`
Sewn"odors detected when arriving at the site: (yes or no) A-- (� ,,, 0 G
,.
revised 9/2/9c Page 6of11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
�rop"Address:56 Fernbrook Lane , Centerville
Owner: Phyllis Keane
Date of Inspection:
BUILD, G SEWER:
(Locate n site plan)
Depth b ow grade:_
Material f construction:_cast iron_40 PVC_other(explain)
Distan a from private water supply well or suction line
Diam ter
Corn ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
bi
Depth below grade:
Material of construction: I.Eoncrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is.age confirmed by Certificate of Compliance_(Yes/No)
e
Dimensions: (0 oe 1 V
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle: I-
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: �S
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of ligyid level in elation to out t invert, stf uctural integrity,
evidence of leakage, etc.) _ �i Ll� 6" j ! rye
O161
GRtX,SE TRAP:
(locat on site plan)
Depth elow grade:_
Materia of construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimensi ns:
Scum t ckness:
Distant from top of scum to top of outlet tee or baffle:
Distant from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Com nts:
freco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evid nce of leakage, etc.)
revised G/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
srop"Address: 56 Fernbrook Lane , Centerville
Owner: Phyllis Keane
Date of Inspection: C — .C.—lr-+✓
TIGII
OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(looat on site plan)
Depth )elow grade:_
Mated I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimen ions:
Capac ty: gallons
Desig flow: gallons/day
Alar present
Alar level: Alarm in working order: Yes_ No_
Dot of previous pumping:
Co ments:
(co dition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:Ll
(locate on site plan)
Depth of liquid level above outlet invert: d
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locat on site plan)
Pump in working order: (Yes or No)
Alarm in working order(Yes or No)
Com ents:
(not condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 5/2/58 Page 8ofII
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 56 Fernbrook Lane , Centerville
Owner: Phyllis Keane
Date of Inspection: 6
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydr ulic failure, I vel of ponding, damp soil, condition of vegetation, etc.)
fi
G
CESSPO S:_
(locate on 'te plan)
Number and onfiguration:
Depth-top of iquid to inlet invert:
Depth of soli layer:
)epth of scu layer:
Dimensions of esspool:
Materials of co struction:
Indication of gr undwater:
inflo (cesspool must be pumped as part of inspection)
Comments:
(note conditio of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate o site plan)
Materia of construction: Dimensions:
Depth of olids:
Comment
(note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
—C'V Lse S/L/7E
Pagc 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Noperty.Address: 56 Fernbrook Lane , Centerville
)caner: Phvllis Keane
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
1 i
m
_ I
f
revised 9/2/9R Page 10ofII
r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cortfinued)
Mp"Address: 56 Fernbrook Lane , Centerville
Owner:
Phyllis Keane
Date of Ins
Pethon: L tea-G—O—t1
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 O`
oR' Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revises 9/2/96
Page 11 or 11
LO CAT IONIg �, SEWAGE PERMIT. NO.
el,
l
VILLAGE
I N S T A L R NAME i DRESS
- /e
d U I L D E R OR OWNER
DATE PERMIT ISSUED
QDATE COMPLIANCE ISSUED
T
0
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... _ ._ _.. _......_...OF ............
Applirntion for Disposal Works Tonstrurtion Prrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
----••-•........................................•---.....--••-------............--•-----•----••--
Location.Address
or Lot No.
......................--.......................................................................... -••••.....-•••--•••-•---•......•----.......................---••..................................
W Owner Address
•---•-•.............••-----•-•......•..........._........:
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
pP-, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
C1, Other fixtures --....................................................................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow----------------------------------------....gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.-.-_--_----_ ------ Diameter-----------------_- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. I--..--.-_--_--_minutes per inch Depth of Test Pit.................... Depth to ground water--_-----.-.._•__---_.--.
f1 Test Pit No. 2----------------minutes per inch Depth of Test Pit................_--- Depth to ground water-.-._.__---..----_--_--.
9 .•--••-------•---------------•---._.._..---••--••---....---•---•••••------......-----•---------_.............................................................
0 Description of Soil........................................................................................................................................................................
U ----------- --------- ---••.._..---------••-•---------------•-•--•••---•-•••-------•••------•-•---------•-------------------------------•-----------------------•-----.................................
W
x ------- ---------------------------- --------------------• ---------.._....---------...•------•------------•-------------•-------------•-•-----•.....--•-••---•---•-••---•---......---------•----••-•••-
U 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 TITL i, 5 of the State Sanitary Code— The undersigned further place agrees not to lace the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ...............................
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons:--••---••----------------------•-•-•---------------•---••----...._..---•------•-----••-------•-•---•---••.......
...........................•-•--•----•------•---•---•----•--••---•--••----------------•------•--••--_...._
-----...-•----•---
Date
PermitNo......................................................... Issued...................... ................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................OF..................... ................................
Trrtifiratr of Tontplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by................................................................................................------------------------------------------------------------•------------•-•-----------------------
Instal ler
at.........................................................................----------------------------------------•-------------------
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit -•................... dated-_7---.-.-.-_--__-.-.-----_-----------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W4 *L F"CTION SATISFACTORY.
DATE...''-A_f/ =--�....••----------------•--•-----•----------------..... Inspector.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c ..........................................OF......-..........-••..._........_......._ ...
No.. ..... 4. . --••-• FEE• ...........-••-.•--•-
Dispoonl Works Tonotrudion "rrntit
Permissionis hereby granted----------------------- -------------------•-----------------------------------------------------------------------------•-----..----•---•---
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No.. r�
Street �% f /�
as shown on the application for Disposal Works Construction Permit No.-__�-------- Datedt�,,.";".,/i..................
101
C Board of Health
DATE....
FORM 1255 A. M. SULKIN, INC., BOSTON
6IN61-G- FAMILY
LJo GARO�►G6 �jQ,INDE2 •'- .{• �'i
D�►L.r: �.uc W s I10 X 3 = 2'>3v t;.R4
5E PIT%G TAwK a Z309150'/• sA95G.P. o �-
t uSE• %000 GAS.• %'s
15 Pv5 A.L. P 1-r US E- eCkn G .1f-3 _5 Im91=
9,9 ���,� ���• z � .. ._ ?"`.?
.3arztok{ AeC-A = 113 5. F. : I
113 x- I .c� _. II,3•G.PD. E
:DEs'l&t4 `�43 G.P n. •- T.v. Ap/.77
1�,
Ta►'rAL px"Y' fz4� = 330 6.1 ..>- /
j Ip'y ENO. .\
97
Of
ILLIAM
ALAt, \ 97
o N Y E y '' o. JOPIES . .
No. 19334
�r��,-1-ER��4 .. o � ' •'c,�,T'� •'gin 9B-g - -• 5�•9�----fiC L_
TOP FWD
'y�0*y�,�'J 5U�yk' ; E/ J/;�� �� /C��T/1�.8t�1 '' f`. /L/�C• ` . .
•
IM/• S
P►5 OAS. 7,
/ Gav 00X INS. �it.PTIG
T.
�y,q� • �•/ TANK 3.
c0i� t.-. , • 77-1 IVY. INV.
9-2
,c�,y� CERT► F1Gp PLoT P1_A►J
P R p F i Lf=
9G'v NO SGP.LE 5CP,LE / ..-
� P r�sr� �uO wNREF E1ZEN GE
GEcZT�FY TN�►T TN �O '
�{6.RE.01.1 GOMPI.YS YJITN"THE S I o6L11.1
'ro W►� o F HA1Zi,L5-r'�L-ice A rt'D 1 S ►Scn' •C•G. /'f / 7 Z'
I.00p.TED W1•�-NIN ;%.0_00 PLAIN
DATe: c/.- BAxTEcZ.e 1.1`{E INC.. F
K.E6 I�'T iccQ6� 06 u
r•ult$ Q T B5czcEt Id AN os�rESZVIL.I� - S5• :
IN5-I�R.utAC_ 5V2V6�( 'THE p►=F�E'r5 6uou� APPLICA►-IT
No-t pE 'u5Gp'Td �e'TER/^11.1E LcT -INES � . �?
:
f ,
,
� I
r-
t -
:
aE
E --•w.
71
EE
---------------
�—Up
J t
Z
CL
• � T
i
Y
� r j
U -
a
Z
0
o ,
W
H
2 1
d
0
a
DRAWN BY
p _.- .----- REVISED
W
2
Q
DRAWING NUMBER