HomeMy WebLinkAbout0084 HELMSMAN DRIVE - Health 84 Helmsman Drive
y Centerville P
A 193 237
No. 42101/3 ORA
ESSELTE
10%
0 0 0 0
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
y DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL
TITLES i OT
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
'SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: �/ llelN7 J✓''/Av/ �i/vG
Owner's Name: eN 0-v,e
Owner's Address: s —
Date of Inspection: e.4 rr, CU 6 .��
Name of Inspector: (please print) ,zr o i D E C 1 2 2003
Company Name. C ` /Se //j
Mailin Address: d C ; 'c
g �� d� J �, JF BARP.�TABLE
HEAL,H DEFT.
tis h pd G �.C,
Telephone Number. 08
CERTIFICATION STATEMENT
I certify that I have personally inspected the sage disposal system at this address
and below is true,accurate and complete as of the time of the that the information reported
mn ethos The inspection was based on my
training and experience in the proper function and maintenance of on site sewage disposal
approved system inspector pursuant to ' n 15.340 of Title 5(310 CMR a disp ems.I am a DEP
). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
F '
Inspector's Signature:
Date: �� /
Z4-9
The system inspector shall submit a copy of this o inspection report to the
DEP)within 30 days of completing this' Approving�o�y(Board of Health or
�or greater,the inspector and the system owner shhal�j a system is a shaved system or has a design flow of 10,000
DEP.The original should be sent to the submit the report to the appropriate regional office of the
authori system owner and copies sent to the buyer,if applicable,and the approving
Notes and Comments
'""This report only describes conditions at the time of ins
pection anof use that
time.This inspection does not address how the system will perform oche future derunder the �the same or tions at
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM MSPECTION FORM
PART A
(J CERTIFICATION(continued)
Property Address: O
e
Owner. CC o H
Date otInspection; ps'
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
a sy
I have not found any information which indicates that
15.303 or in 310 C1vIIt 15.304 exist anY°f the failure criteria described in 310 CUR
Any failure criteria not evaluated are indicated below.
Comments:
B• sy Condidonally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
mired-i Tbe 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" Iease
explain. P
The septic tank is metal and over 20 years old"or u the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent,System will
existing tank is with a complying septic tank as a l inspection if the
*A metal septic tank will pass inspection if it is structurallPP�ed by the Board of Health.
indicating that the tank is less than 20 years old is available. 'not leaking and if a Certificate of Compliance
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
owed pipe(s)or due to a broken,settled or uneven distribution box, System will pass inspection if(with
approval of Board of Health):
broken pipes)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 stem
Pass inspection if(with approval of the Board of Health): sy will
broken psPes)are replaced
obstruction is removed
ND explain:
Page 3 of It
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: P�yyS 4�z
Owner. U
Date of Inspection: /
C. Fu er Evaluation is Required by the Board of Health:
Conditions exist which-
regtnre er evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the envmi mnent.
1. System will pass unless Board of Health determines in accordance with 310 C1►Ht 15.303(i)(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 pusses 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.
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
�'oPe1'h'Address: �� /l 411-lyjo �r
Owner:
Date of Inspection: p
D. System Failure Criteria applicable to all systems:
You must indicate-yes"or"no"to each of the following for all • _ . . . ... .._
_mspecoions:
Yes Nq�
V_,_!'Backup of sewage into facility or system component due to overloaded or clogged SAS or 5�e or ponding of effluent to the sarfaoe of the ground or surface cesspool
SAS or cesspool hem due to an overloaded or
/� tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
iquid depth in cesspool is less than 6"below invert
— Requir+ed pumping more than 4 times in the last or available volume is less thaa'r4 day flow .
✓'of times pumped ear N-OT to clogged or obsrructW pis).Number
portion of the SAS,cesspool or privy is below high ground water elevation
Z Any poffiolm of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
4,1117water supply.
Portion of a�Y Po cesspool or privy is within a Zone 1 of a public well.
Portion of a cesspool or privy is within 50 feet of a private water supply
A�portion of a cesspool or privy is less than 100 feet but well.
supply well with no acceptable waterer than 50 feet from a private water
sty analysis' [This system passes if the weu 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 facfiliy and ids pence of ammonia
nitrogen and nitrate nitrogen is equal to or left thae S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/NO)The system 144 I have determined that one Or
more of described in 310 CMR 15.303,therefore the stem fails.The the above failure criteria exist e
Health to determine w �' system owner should contact the hat will of
be necessary to correct the failure. ��
E. Large Systems:
To be considered a large system the system most serve a facility with a design flow of 10,000
gpd. god to 15,000
You must indicate either"Yes„or"no"to each of the following:
following criteria apply to large systems in addition to the criteria above)
yes no
jsystem is within 400 feet of a surthce ddnldng water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is locatednitrogen
Sensitive area anterim Wellhead Protection Area-IWPA)or a mapped
Zone H of a water supply well
If you have answered"yes"to any question in Section E the system is considered a significant
threa
"Yes"in Section D above the large system has failed,The owner or operator of any Jars or answered
significant threat under'Section E or failed under Section D shall u 9C sY M considered a
15.304.The system owner should contact the appropriate regional ofc, of the Departm0,�ce with 310 CMR
A
Page 5of11
' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
_ CHECKLIST-
Properta.-*
/),4
Owner.
Date of
Check if the following have been done.You most indicate ee or"no"as to each of the foIIowin
— — g information was provided by the owner,Occupant,or Board of Health
W of the system components pumped out in the previous two wed
Hasreceived normal flows in the previous two week
Peal
_. Have 14avent
olumes of water been to the system recentlyorasportofthisinspectionWere place of the system obtained and ammince(H they were not available note as N/A)
Was the t3or dwelling mspected for signs of sewage back up
Was the site inspected for signs of break out
Were all system componemik owluding the Sk%located on site
Were the septic tank manholes uncovered,opera,and the interior of the tank inspected for the condition
of% es of tees,material ofconstructio
n,dimensions,depth of liquid;depth of sludge and depth of scum
Was the bcdq owner(and occupants lf(hffcrM
maintenance of sewage from owner)provided with information on the proper
The she and location of the Sal Absorption System(SAS)on the site has been determined based on:
Yes n�
i/ t
infwn�atim For e�le,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to pert C is at issue approximation of distance
is unaccept d de)P 10 CMR 15.302(3)(b)]
w
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION _.
Pn)perty Address: 4e
e H
Owner: OW_701—
m u
Date of Inspection: / n
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms
DESIGN flow based on 310 ChM 15:203 for_. ..... (actual). e example: 110 gpd x#of bedrooms):
Number of current resident: c-
Does residence have a garbage Bander(yes or no):i"
Is laundry on a scpaiate sewage system(Yes or no): [if es
I.aund<y system inspected es or no): [ y ate inspection regmv4
Seasonal use:(yes or no:
Water meter readings,if avarlabk(Iasi 2 years usage(am):
Sump pump(yes or no):
Last due odoccupancy; Weei�� �5
COMMERCUL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): rnd
Basis of design flow(Sests/persons/sq@,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank pmsent(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings if available-
Last date of oc cupancyAw-
OTHER(describe):
Pump GENERAL INFORMATION
Source of infoxmatioa �.
Was system pumped as part of the' (yes or no):_
Ir yeS,volume Pumped:_gallons-How was quantity pumped determined?
Reason for pumping:
TVPfOF SYSTEM
V Septic tank,distribution box, soil absorption system
—Single CCRXxd
overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the ccurent operation and mau terms contract(to be
obtaimed from system owner)
_Tight tank —Attach a copy of the DE P approval
_Other(describe):
Approximate age of all Mdate installed(if known)and source of inf on
C0 We,y S, •S 8 /S ��- �0�7/
Were sewage odors detected when arriving at the site(yes or no):L(/�
Page 7 of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contmiedj
Pro1ertyjAddmv, � e�r�s'i'vOwner. OHDate of Ion:
BUILDING SEWER(locate(p site plan)
Depth below grade:
Materials of construction: castiron =� pVOC (��);
Distance bout private water supply well or section line; -
Commeru(on conation of joints,venting.evidence of leakage,etc.):
SEPTIC TANK;; (i site
oc��on plan)
Depth below grade:
Material of construcj =�ncrete metal—ems—polyethylene
0d=(`ex01ain)
If tank is
certificate list age:_ Isalp confirmed by Certificate of ComPliaace(yes or no): (attach a copy of
Dimensions: x z5
Sludge depth
Distance fFom top of sludge to bottom of outlet tee or baffle: 07
Scum thickness:---L_
Distance from top of scam to top of outlet tee or baffle:
How
Distanoe from bottom of scum to outlet tee�gr bale:
were dimendow determined: o
Comments(am PUMpmg.recommendW
as reed to outlet' e�i�det and outlet tee or bale condition, h
//� W M� f�=t,!j ��tY, quid levels
Gz N �N111111111
GREASE TRAP:_ ocate on site plan)
Depth below grade:_
Material of construction:_concrete_metal
(explain): —fibezglass—Po$'elbylene__other Dimensions:
Scum thickness:
Distance from top of scam to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bale:
Date of last pumping
Comments(an pcmiping reco
as related to outlet invert,evi�� Outlet tee or baffle condition, 1W�,,li levels
!i
Page 8 of 11 to
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION co( ntinued)
Property Address: y.,
Owner. ��O Ova � D.1 pl�L,
Date of Inspection;
TIGHT or HOLDING TANK: must be pumped at time of mspection)(locate on site
per)
Depth below grade:
Material of construction concrete metal
fiberglass--pobvtbYlene other(explain):
Dimensions:
Capacity: gallons
Design Flow: salloyday
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.):
DISTR®DTION BOX: ( present must be opened)(locate on site
Pam)
Depth of liquid level above outlet invert v"-7 cn
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage' or out of etc.):
PUMP CAE:"(1 on site plan)
Punqx in working order(yes or no):
Alarms in working order(yes or no):
Commends(note condition of Pump chamber,condition of
pumps and appurtenances,etc.):
f
1 ` Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continue
Property Address:
c,77,,Z-�e ,4 fD C r-2—
Owner. l0 11OLf
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number: �00
leaching chambers,member:
leaching galleries,nim4ber.
leaching trenches,number,length:
leaching field,number,dimensions:
overflow cesspool,number
innovadvelalternative system Typethame of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): /j H cil
D i Fes,' vt
CESSPOOLS:�oesspool must be pumped as Pert of inspec.'tionxlocate on site plan)
Number and confignmtion:
Depth—top of liquid to inlet invert:
Depth of solids byw
Depth of scum layer:
Dimensions of cesspool:
Materials of conwmwtion:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic bflme,level of ponding,condition of vegetation,etc.):
PRIVY&(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of(lording,condition of vegetation,etc.):
Page 10 of 11 �.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART C
SYSTEM INFORMATION(contiwa4
Property Address: �T /T E�f�'�N'►u,�
_ e n, vr, ie
Owner.A�c o O
Date of hqmtim-
SXETC181 OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system incluftg ties to at least two permanent ret'ereoce landmarks or
benchmaft Loots aD wells within 100 feet.Locus when public wales supply enters the b Wdng. _
0
c) - r
F
r
• 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: 14,71 u
Date of Inspection:
9&1-
SM EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water �i� feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If chocked,data of design plan reviewed:
Obsezved site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Heahh-explain:
Checked with local excavators,installers-(attach documentation)
To Accessed USGS aatabese-exn:
You m descnber yc7 established the�gb ground water elevation:
7-0 i° off' de-
X/0() r 9—rd9 E4 Vt J
TOWN 07 BARNSTABLE
LOCATION ,��/ //Elir73,,02kZ SEWAGE # 97- ell
VILLAGE �'-Fhn5-2-01,4= ASSESSOR'S MAP & LOT /9- 2-77
INSTALLER'S NAME&PHONE NO.Jose,04 At
SEPTIC TANK CAPACITY Po d O /
LEACHING FACII.1'I'Y: (type) 2 SDOGa� size) 21 X /32"
NO.OF BEDROOMS 3
BUILDER OR OWNER -,Cy .. aA-cam/'
PERMITDATE: 8-/3- 97 COMPLIANCE DATE: —/S- F7
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 Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leacIfing facility) Feet
Furnished by c �
�,s�i�s�lasr Or �,
�.
� .r
_ �
�� a a
`. z- /
r
i
_ _� ���
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Di.5pool *pztem Cow5truction Vertu
Application for a Permit to Construct(()'Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. g�/ f/�/,YyJ 5 i✓b!!�v! Dn Owner's Name,Address and Tel.No.
et:Hf �"✓////3 /-(latGiS/ ��13C/SS�r'
Assessor'sMap/Parcel /91 ,9zf
� �7 r-
Installer's Name,Address,and Tel.No. (a,7.7— 0!5/ICJ' Designer's Name,Address and Tel.No.
✓os epy O c 8a er,.S
Type of Building:
Dwelling No.of Bedrooms 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 .Y/OlIZ'
Nature of Repairs or Alterations(Answer when applicable)
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 Board of Health.
Signed Date — /°1,—97
Application Approved by Date
Application Disapproved for the(Allowinoreasons
Permit No. 7 — Date Issued
Fee
No.
5 Entered in computer:
' THE COMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppiication for Mtzpaal *patent c_on!6tructton Permit
Application for a Permit to Construct(fair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
/r
Location Address or Lot No. gel H&_/,4Sl A00f On Owner's Name,Address and Tel.No.
C,0m_-eVi1/,-_ /,C,wr4y N,�usS�r
Assessor'sMap/Parcel h/�r/y9gryl/Is9 -40
/?1 2 31 C�hrr-t r fir- 1 -
Installer's Name,Address,and Tel.No. e4,7,7- O C Designer's Name,Address and Tel.No.
Joseph De /341-ec S
$/6,0A*1 We,17-A/ MW,-_f rosy
j
Type of Building:
Dwelling No.of Bedrooms 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
Nature of Repairs or Alterations(A swer when applicable) i /= .51 Z_/0G HGG' l
doo - 00
Date last inspected: J'
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 Board of Health.
Signed 1'Imz� .Z,6 Date '- /1-27
Application Approved by Date -FL- tom_ 9'7
Application Disapproved for thelgllowin2leasons
Permit No. 7 - Date Issued
————————————————--—————————————————————,
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( Repaired ( )Upgraded( )
Abandoned( )by ✓asr ,n�i �e l�,�rH�r
at $y Ha -r Lii w7 Ur, l��Hfi-i-1/i///: has-been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9'7-�'Z :? dated
Installer ✓etlIfRl, U-e Designer J v6i 44 4/?Z4 -0j
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date _ _ y `l Inspector
———y———L—————————————————————————————————
[
No. % - "'7'17 Fee L -C-9
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ligpoar *p! tem Construction Permit
Permission is hereby granted to Construct( 4-}Repair( )Upgrade( )Abandon( )
System located at R 5' y�=lss�S ��rei Uy r�iyla Ti= V"
i
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 off the date of this permit.
Date: Approved by �E-V�
NOTICE! This form is to be used for the repair of f>filed septic
systems only
-CEAH A TI N OIr SKLICli ANIi AUl C AC t;i ll1s"ML
"MKS C--0—hWitUMON PE MI I fig 1111OUT DESIGNED—PLANS-)
hereby teftlCy that the appilcation Cot disposal works
construction permit signed by me dated $ -- /�Z 7 _, concealing file
property located at /�_s�is�� �� �i=it/FHY���_ meets all of file
following crilerin:
e---f�ere ere no wetiands withih 30o feet of the ptopo§ed septie§ystetr
Mere are no private*ells Withid 150 reef of the ptdpOed Optic 4ystenV
*---11te observed grottltd*alet table is 14 feet dt gteatet 6e1oW the bottom of the leaching facility
4 'There is no incte9se 1h no*laid/or ch9itge ih h9e htopmed
"ere are no vAtiance9 recldested of heeded.
SIGNED:
LICPWSED SEPTIC SVSUM INS'17ALLPA,IN 11ip 1-oWN or, t3AMS,I-A"Lt NUM13r.-A
[Attach n sketch pion of the ptopesed system.Also If the licehsed installet posesses a t alined plot pltitl,
this plan§Mould be subhtitted].
q:health roller:ceit
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• J =/ 93 - 3.7
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street, Boston,Ma. 02108 .T�l Grad
D.E.P. Title
V Septic Inspector
Y
P.O. Box 2119
Teaticket,MA 02536
WILLIAM F.WELD (508) 5
Governor )� I
ARGEO PAUL CELLUCCI � +.
Lt.Governor 09
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ORT A
CERTIFICATION m AI,G, Eli WA
U 1 3 19
Property Address: 84 Helmsman Dr.Centerville Address of Owner: 70%0pe 97 �+
Date of Inspection:8/6197 (If different) yai.Typ'TAB(f N
Name of Inspector:John Graci Hausser
I am a DEP approved system inspector pursuant to Section 15.340 of Title%.(310 CMR 15.000) A ,`
Company Name,Address and Telephone Number:
s
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-site sewage disposal systems. The system:
_ Passes This inspection is based on criteria defined in Title V
— Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Fu her.Evaluation 8 the Local Approving Authority performinq at the time of the inspection.My inspection does
Y PP 9 ty not imply any warranty or quarantee of the Iongevity orthe
X Fails septic system and any of its components useful life.
Inspector's Signature: /� Date:8111197
The System Inspector shall s bmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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.
INSPECTION SUMMARY:
Check.A, B,C, or D:
A) SYSTEM PASSES:
_I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
BJ SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
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 conforming septic tank
as approved by the Board of Health.
(revised 04m197)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Helmsman Dr.Centerville
Owner: Hausser
Date of Inspection:8/6/97
_ Sew.aae backup or.breakout.or. hiah.static water level observed.in.the distrihution box is due to a broken.
or obstructed pipe(s)or due to broken, settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations.
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled 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
Cl 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) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
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 APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
x I have determined that the system violates one or more of the following failure criteria as defined 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 No
_X_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
_x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
X_ — SAS is in hydraulic failure.
(revised 0427/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 84 Helmsman Dr.Centerville
Owner: Hausser
Date of Inspection:8/6197
D] SYSTEM FAILS(continued)
Yes No
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
— Numbers of times pumped
x Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
—x. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
__C Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
_ X 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 84 Helmsman Dr.Centerville
Owner: Hausser
Date of Inspection:9M7
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_x_ — Pumping information was requested of the owner,occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the 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.
X As built plans have been obtained and examined. Note if they are not available with NIA.
X — The facility or dwelling was inspected for signs of sewage back-up.
X — The system does not receive non-sanitary or industrial waste flow.
--X_ — The site was inspected for signs of breakout.
X All system components, excluding the Soil Absorption System,have been located on the site.
X 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.
X _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
X Existing information. Ex. Plan at B.O.H.
X Determined in the field('If any failure criteria related to Part C is at issue,approximation of distance is
unacceptable))15.302(3)(b))
(revised 0427f87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 84 Helmsman Dr.Centerville
Owner: Hausser
Date of Inspection:8/6J97
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•p•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 4
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
n/a
Sump Pump(yes or no): No
Last date of occupancy: nfa
COMMERCIAL/INDUSTRIAL:
Type of establishment: n/a
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system: (yes or no) No
Water meter readings, if available: We
Last date of occupancy: n/a
OTHER: (Describe) n/a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped in the spring of 1997 by AB Canco
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: rda
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components,date installed(if known)and source information:
1987
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04/27/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 84 Helmsman Dr.Centerville
Owner: Hausser
Date of Inspection:8ro/97
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 8"
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age to . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L8'8'H5'7'IN4'to'
Sludge depth:2"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness:1"
Distance from top of scum to top of outlet tee or baffle:UP TO MIDDLE OF PIPE
Distance form bottom of scum to bottom of outlet tee or baffle:rya
How dimensions were determined: Measured
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: We
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: n/a
Scum thickness:n/a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle:n/a
Date of last pumping,va
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
n/a
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 14•
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?—
Diameter: 4"
rn/amments:(conditions of joints,venting, evidence of leakage,etc.)
(revised 04/27197)
�j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 84 Helmsman Dr.Centerville
Owner: . Hausser
Date of Inspection:816/97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: We
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: rya
Capacity: nla gallons
Design flow: n/a gallons/day
Alarm level:_n1a Alarm In working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches, etc.)
n/a
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: rda
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.)
nla
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
We
(revised 04127/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 84 Helmsman Dr.Centerville
Owner: Hausser
Date of Inspection:M/97
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n/a
Type:
leaching pits, number: 1,000 gallon leach pit
leaching chambers,number:n/a
leaching galleries, number: n/a
leaching trenches,number, length: n/a
leaching fields,number, dimensions:n/a
overflow cesspool,number:n/a
Alternate system: n/a Name of Technology:_n/a
Comments:(note condition.of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
The leach pit is past the effective depth of leaching.The sas is in hydraulic failure.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a
inflow(cesspool must be pumped as part of inspection)
n/a
Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
nle
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n/a
(revised 04/27/87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 84 Helmsman Or.Centerville
Owner: Hausser
Date of Inspection: 8/6/97
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
FNAI
IQ
0 A i
�I 2
A� ILL
At S5
k %
0 e.
(revised(am1e7) page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Address: 64 Helmsman Dr.Centerville
Owner: Hausser
Dale of Inspection, 13/M7
Depth to Groundwater 12+ Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised 04/27/97) Pay 10 of 10
TOWN OF BARNSTABLE
LOCATION &1ofs'WIv�r Jr, SEWAGE # _17- 5//7
VILLAGE ASSESSOR'S MAP& LOT/EY .?-77
INSTALLER'S NAME&PHONE NO. .f osrp�i �� �prroS y�J- 03y9
SEPTIC.TANK CAPACITY l o OO /
LEACHING.FACILITY: (type) 2 2,f X /3'2"
NO.OF BEDROOMS 3
BUILDER OR OWNER
PERMTTDATE: R-/3 17 COMPLIANCE DATE: —/S" 97
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
i on site..or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands.exist
within.:300 feet of leac 'ng facility)) Feet
Furnished by
E�F��y1JvJJfplj Or
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r
i
LQ? AT IOM S ACE PERMIT YO
VILLAGE
- - C (-
Al I N S T A LLER'S NAME & ADDRESS
LF
Ol
I U I L D E R 0 ®WNER
DATE PERMIT ISSU € D
DATE COMPL ! ANCE ISSUED---�Z � ��
,,
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N ...................... Fnz..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® PF HEALTH
� .....................
Appliration for Disposal Vorkii Tnnitrurtion Prrutit
Application is hereb. made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Sync . ..... ......_&......... --•--------- .. mac... ..................................
/�Locatio Address or t
wner Address,
. .:.. -1 ------------•
� Installer � Address �•/ ���y
UType of Building Size Lot. ..... ... ..............Sq. feet
Dwelling—No. of Bedrooms............. ........ ..... .........Expansion Attic Garbage Grinder (W
P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Othe fixtures ......................................................
W Design Flow........_. ...............................gallons per person per day. Total daily flow-------f3.O.......................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..........0- _._ . . . .. ...... . .....................
Test Pit No. 1................minutes per inch Depth Test Pit................... epth to ground water------------------------
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 Description of Soil.......f,.- -......_ .... _ ...
x .....14.
• •-- . ..............................................................
0
iJi1O'I1tX? `- man
ature of Repairs or Alterations—Answer when applicable.. NI��...................................................
�+US
U = PP
Agreement. UjQ1 j WCs' -!E3;:�S T ZE-7PA %,� t&)5-Cr9z-c eEt) I M S-TY21 CC Ax--cC,a T'e P,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation n -1 a Certific4te of has beej* ued.by the board_of healt
Signed----•--- ....... - ....
/ D e
Appi tion Approved By-- .--•- -•-• �.......................... ............................... 3 f$ ..............
Date
Application Disapproved for the following reasons-------------------------------•------....--•-------•---------••----------------•--•-•••--•-•------•-.....----
....................•-----....------......---•-----------•-------•---•----------------.....----------•----------•------------•--•---------•............................................................
J _ Date
PermitNo..... .....f- 0-------------------- Issued.......................................................
Date
No ._. ...... Fus.... a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
d .'.fir !""!!�✓" OF... /.� w ,,..r✓�......................
,XVp iraa#ion for Disposal Works Tontrnrtion Prrmft
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at
J>Locatio Addressd r Lo
/=- ....................... ............'.. rf:«. 19 ' .1M1`.....'
��caner
,.X.rc S. �}c'✓d' y yam"" r��=•� ' = -----•-••-•-•--------------•-- ............. . ...... ..�!"'✓,, �'i --._..",_....---•-----•-•......
Installer Address /
Type of Building Size Loh.t_i'y.. o
Sq. feet
Dwelling—No. of Bedrooms...........::.......................Expansion Attic ,({, Garbage Grinder ,
`4 Other—TYP e of Building ............................ No. ofP ersons............................ Showers Cafeteria
a ( ) — ( )
0 Other fixtures ...---•-------------- --------------------------------------------------------••--------------._....------------ - .......---•
Design i - t go sP Pn e.. day. Total �. ........................
gallons.
Septic Tank—Liqudca aci _...........gallons Length Width ... Diameter...-----•--..___ Depth----------------
W Disposal Trench—No. .................... Width....................Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tankf )
0-4 Percolation Test Results Performed b --•------ 1 ('
a Y - -�' .�--V-.... ;,,,,�:�° Date_j:��-�•...`.e .-----'"---•�••-•-----
Test Pit No. I................minutes per inch Depth o Test Pit.............�.%ep"th to ground water.__.............._...__.
P4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---••----------------
------------
D Description,of Soil...... Ct gf ; --------•------•-•••---------••------------
e l --ace
w _
x �
U Nature of Re airs or Alterations—Answer when ap 1lcable
. ......................... Z.7 .....1.10......
................................
...........
Agreement: kp(R j WG, c:M f64 +F (N --'-rOp1Cr ccra> f--?'a
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation Ati) a Ctificate o Compliance has been issued by the board of healt .
`.
" Signed..----- `--.6''1"v
r Date
APplition Approved By.... ;• .:.-•..................................... ��� Vy ------••••----
a e
APpliea.tion Disapproved for the following reasons:................................................................................................................
.................-.......................................................................................................................................................................................
Date
Permit No.--- - Issued-------------------
------•-------- --•---------------•-------.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF. HEALTH
.........OF...... .........................
Trrtifiratr of (fontph aurae
T'I IS TO CERTIFY, hat the Individual-Sewage Disposal System constructed ( or Repaired ( )
by........ 4--- •-t� " - - -- �..- .. .................................... ................_....._
_ ,r� / taller
at ------••------•----•-•--..........
has tlbeen installed in accordance with the provisions of TIT'LZ 5 of The State Sanitary Code as e cribed in the
application for Disposal Works Construction Permit No.....
_.._:/_�:,z5 .... dated . _1 4 C6.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILLJE4NCTION SATISFACTORY.
DATE.. .. 2�•-��........................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS ALC QA)%;V C C,�•
BOARD OF HEALTH Niyl (zo,- • °��' -a -
No -_.... FEE........................
Disposal Works Tons#rnr#iun amit k:-fu6 iN.;-,R, twwsl"
Permission is hereby granted........................ . 6 TZ
p -,�.1
to 4 or. e r Individual Sewage Disposal S stem .` ��')NCa3 Wft-c.
at No.Construct an
as shown on the application for Disposal Works Construction Permit No r_,_:I G? _ Dated:_ /, ?..............
c^g ; .......
DATE. /�a( _ t Board of Health
__
•----- -- ----------------------------------•--•
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BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville,Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLWAN,P.E.-Vice President-Engineering
May 6 , 1986
Town of Barnstable
Board of Health
367 Main ST
Hyannis, MA .02601
Re : Lot 8 - Helmsman DR - Centerville
Builder : J. K . ' Smith
Dear Board :
In accordance with. the terms of the permit, I have
inspected the installed septic system at Lot 8 . The
system has been installed as per the approved plan.
Very truly yours ,
Peter Sullivan, P . E.
Baxter & Nye, Inc.
PS/fmj
IV% OF
PETERG�
SULLIVAN
No. 29733
"ST�R�o �Q
FFs$�011, t 4'0����
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS