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HomeMy WebLinkAbout0125 HILLSIDE DRIVE - Health 125 Hillside Dr. , Centerville A= 193-016 i No. 42101/3 URA ESSELTE 10% © O O O Commonwealth of Massachusetts _-- N u Title 5 Official Inspection- Form, _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 125 Hill Side Dr ia Property Address Tony Gallagher Owner Owner's Name information is Centerville Ma 02632 3/5/16 required for every ~ - page. Cityrrown State Zip Code Date of Inspectio Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General4h.fo.rmatlon, filling out forms - - -------- on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return key. Name of Inspector Di Buono*Sewer-and-brain ,y Company Name 8 Johns path Company Address % S Yarmouth Ma 02664 Cityf'rown State — Zip Code 508-364-9587 S103522 Telephone-Number -- License Number- B. Certification 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 the inspection. The inspection was performed based on my'training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CNiR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority >`� ... - 3/7/16. Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system oi� 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. ****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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 a Commonwealth of Massachusetts W Title 5 Official Inspection F®'r ibsurface Sewage Disposal System Form Not for Voluntary Assessments 'IM 125 Hill Side Dr Iripperty Address Tony Gallagher - Owner Owner's Name information is ""enterville Ma 02632 3/5/16 required-for.every '' page _ 41ty/Town State Zip Code Date of Inspection B. Certification (cont.) - complete all of Section D com Inspection Summary: Check A,E3,C,D or E/always y r A) System Passes: .r E"1 have not found any information which indicates that-any°of the4ailure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. = Comments: - The system Cosists of a 1,000 Gallon concrete septic tank. A Pump chamber and 2 500 gallon leaching chambers At time of inspection system showed no obvious signs of failure. 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. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): .r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Off ceal' Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name information is required for every Centerville Ma 02632 3/5/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): „[T.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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). q p P 9 Y p p (s). The system will pass inspection if(with approval of the Board of Health): ❑ broken.pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts' W Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name information is Centerville Ma 02632 3/5/16 required for every I page. City/Town 7State Zip Code Date of Inspection Certification (cont.) 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,prptects the public health, safety and environment: ❑ The system has a septic tank and soil absorptionsysftsm (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 aseptic 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 fecal coliform bacteria indicates absent 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. r' 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "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 Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official lnspcti®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 125 Hill Side Dr - Property Address Tony Gallagher Owner information is Owners Name " required for every Centerville Ma 02632 3/5/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year MOT 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 an performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ❑ The system falls. 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 Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone ll,of a public water supply well If you have answered" es"to any y 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For Subsurface Sewage Disposal System Form Not for Voluntary Assessments 125 Hill Side Dr M Property Address Tony Gallagher Owner Owner's Name information is required for every Centerville Ma 02632 3/5/16 page. rv._ CityrpVn State Zip Code Date of Inspection ,L C. Checklist 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: ® ❑ Existing information. For example, a plan at the Board of Health. Determined in the field if an of the failure criteria related10 Pa C i a® ❑ ( y rt s t issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D:-System Information Residential Flow Conditions: 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For - _ Subsurface Sewage Usposal System Form - Not for Voluntary Assessments. cw 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name •- information is Centerville Ma 02632 3/5/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system Cosists of-a 1,000 Gallon concrete septic tank. A Pump chamber and 2 500 gallon leaching chambers. At time of inspection system showed no obvious-signs of failure-. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ® Yes ❑ No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): . Detail: 198'GPD Sump pump? ❑ Yes ® No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203). Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): _ Grease.trap present? ❑ Yes El No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts .. W Title 5 Official' Inspection F®r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 125.Hill Side Dr Property Address _ Tony-Gal lag her Owner Owner's Name information is required for every. Centerville Ma_ 02632 3/5/16 page. _ Cityrrown State Zip Code Date of Inspection D. System Information (cont:) Last date of occupancy/use: Date -- __ -- Other-(describe-below): General Information Pumping Records: Source of information: Last pumped 8/10/15 . Was system pumped as part of the inspection? - ❑ Yes ® 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts,. `Title 5 Official Ins �ci� ®�°r� . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w„ 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name. _ information is required for every Centerville Ma 02632 3/5/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 20 Years -- --Were sewage odors detected when arriving at the site? - -❑ Yes ❑ No -Building Sewer(locate on site plan): .. Depth below grade: 3feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: .-feet Comments (on condition of joints, venting, evidence of leakage, etc.): No signs of leaking Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 Gallon If tank is metal;Jist age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection For _ a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments = M 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name information is Centerville Ma 02632 3/5/16 required for every page. City/Town State Zip Code Date of Inspection " .e2�r, D. System Information (cont.) Septic Tank Cont. - - Distance from-top of sludge to bottom of outlet tee or baffle-`- Scum thickness - - 3� �- 42'.- Distance from top of scum to top of outlet tee-or baffle Distance from bottom-of scum to bottom of outlet tee or-baffle --1°_Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass - ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness I Distance from top of scum to top of outlet tee or baffle I Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts 'Title 5 Official Inspection orn1 Subsurface Sewage Disposal System Form- Not•for Voluntary Assessments 125 Hill Side Dr - Property Address Tony Gallagher Owner Owner's Name information is required for every Centerville Ma 02632 3/5/16 page. CityFrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank(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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? "' ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17 Commonwealth of Massachusetts Title .5 Official Inspection For Subsurface Sewage Disposal System Form -Not fo'r Voluntary Assessments ` 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name information is required for every Centerville Ma 02632 3/5116 Pity/Town- State Zip.Code _ Date of Inspection_ D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): ._.._- --_" Depth of liquid level above outlet invert Dbox is,leveLand at normal operating level 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.): - No signs of carry over Pump Chamber(locate on site plan): Pumps in working order: ® Yes ❑ Nci* Alarms in working order: ® Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is functioning properly I I • i * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): I If SAS not located, explain why: f f I t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 'official Inspection For Subsurface Sewage Disposal System-Form -Not for Voluntary Assessments 125 Hill Side Dr M Property Address Tony Gallagher Owner Owner's Name - information is Centerville Ma 02632 3/5/16 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type _ leaching pits number: ❑ -leaching chambers number:, 500 GI _.❑ ___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.): No ponding no breakout Cesspools (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 ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System:.Form - Not for Voluntary Assessments" 125 Hill Side Dr 4M Property Address Tony Gallagher Owner -- Owner's Name information is required for every Centerville Ma 02632 3/5/16 page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) - Comments (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): No ponding no break out, : . t Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i I i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System.Form - Not for Voluntary'Assessments ,M 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name information is required for every Centerville Ma 02632 3/5/16 page. City/Town State Zip Code Date of Inspection D. System information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below.. ❑ hand-sketch in the area below �I drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 .f " TOWN OF BARNI STkBLE ! LOCATION �� S\C�� SEWAGE # " ASSESSOR'S.MAP &LOT-; INSTALLER'S.NAME&PHONE NO. . J .. ....: .e-g�, (•,f ...L71 �1�'f SEPTIC TANK CAPACITY l�yQ `� , �..� Q N,, J LEACIING"FACILITY: (type)-2 NO. OF BEDROOMS �'vv BUILDER OR OWNER --c _ PERMITDATE: t tX I� 1 gT- COMPLIANCE,DATE: Separation Distance Between the: .Maximum Adjusted Groundwater Table and Bottom of.Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) �L) Q t Feet i Edge of Wetland and Leaching Facility (If any wetlands exist: , within 300 et of leaching fa ' ' ` J— Feet Furnished by y_ Commonwealth of Massachusetts W Title 5 -Official Inspecti n, or Subsurface Sewage Disposal System Forrim -Not for Voluntary Assessments wM 125 Hill Side Dr Property Address Tony Gallagher Owner Owner's Name information is required for every Centerville Ma 02632 3/5/16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑'Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells .-Estimated depth to high ground water: 10+ ftfeet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: - Property sits high on a hill with a vernal pool behind the house at a much lower level. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Commonwealth of.ftssachusetts ' Title 5 Offici I Inspection r Subsurface Sewage Disposal System Form - Not for Voluntary_Assessments- 125 Hill Side Dr Property Address ,.Tony Gallagher, Owner Owner's Name,. information is required for every Centerville Ma 02632 3/5/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file - I i i i f i i r i I l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Certified Mail#7012 1010 0000 2850 8203 �� rati Town of Barnstable Regulatory Services BARNSfABLE, MAM yip 1639. "`°�A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 December 17, 2013 John Gallagher Po Box 427 Centerville, MA 02632 NOTICE TO ABATE VIOLATIONS OF,105 CMR 410.000, STATE SANITARY CODE II —MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE, TITLE 5. The property owned by you located at 125 Hillside Drive Centerville, MA was inspected on December.17, 2013 by Timothy O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a rental registration. The following violations of the State Sanitary Code were observed: 105 CMR 410.450 —Means of Egress. A room was observed being used as a bedroom within basement of home without proper second means of egress as required by 780 CMR 3603.10.4.1of the Mass State Building Code. You are directed to correct the violations.listed above within twenty-four (24) hours of your receipt of this notice by ceasing and desisting the use of said room within the basement as a bedroom and removing mattresses. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation.V ER OF HE BOARD OF HEALTH (:�47 Xns A. McKean, R.S., CHO Director of Public Health Town of Barnstable Kelly Keane, Occupant: QAOrder letters\Housing violations\Rental ordinance\125 hillside 9-7-12 i TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date ' >' Time: In Out Owner Tenant Address l 75 I 1. �- Address I s Y q Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities L 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities L W-1)Cut 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Ap �Llvcr 10�9c� Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here e Certified Mail#7008 3230 0002 5178 0547 oFTMf lati Town of Barnstable Regulatory Services BA"STABL, p MAe& Thomas F. Geiler, Director Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 - Office: 508-862-4644 Fax: 508-790-6304 September 7, 2012 John Gallagher �=x- 1 l• 125 Hillside Drive e 0 Centerville, MA 02632 U NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION, THE STATE ENVIRONMENTAL CODE, TITLE 5. The property owned by you located at 125 Hillside Drive Centerville, MA was inspected on September 7, 2012 by Timothy O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of a rental registration. The following violations of the State Sanitary Code were observed: 105 CMR 410.450—Means of Egress. A room was observed being used as a bedroom within basement of home without proper second means of egress as required by 780 CMR 3603.10.4.1 of the Mass State Building Code. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this notice by ceasing and desisting the use of said room within the basement as a bedroom and removing mattresses. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an'order shall constitute a separate violation. PER ORDER O THE BOARD OF HEALTH Thomas . McKean, R.S., CHO Director of Public Health Town of Barnstable QAOrder letters\Housing violations\Rental ordinance\125 hillside 9-7-12 TOWN OF BARNSTABLE L � i � -- LGCATIGN � -- r SEWAGE # 2 'irl",LAGE P& ��\��{� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. CrT �.t� b����� SEPTIC TANK CAPACITY C iu6t� LEACHING FACILITY: (type) MDo ;rA c' gg M / NO.OF BEDROOMS C ro L) BUILDER OR OWNER 9� PERMITDATE: /Q n qlp _COMPLIANCE DATE:, I C Separation Distance Between the: p ' ® Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ,v 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 1100 et of leac ''ng fa ' Feet Furnished by t y tb C �� U No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: / Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS �\ ZIPPYication for Mitpozal *potem Con5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(, SAbandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.IR'sl S f ck Owner's Name,Address and Tel.No. Assessor's Map/Parcel clell-hi-vt 1 le cfi�,V�-Y �+ C, `I �� �/ 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5 w t� =.h,.�.t,�r,Cs cape ea ,5f Skve, Het c-,5 2 o NPkA.� Q0 UNtk -7 Mc�- oa601 6 k y�M�vkt,• toot r,'l Type of Building: Dwelling No.of Bedrooms _ 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 (-r"L Type of S.A.S. off. bc Y W`pc" Description of Soil Nature of Repairs or Alterations(Answer when applicable) a--e— ?Lw` 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 Bo off Signed n Date 1o(1;U' % Application Approved by �_-/j I Date Application Disapproved for the following reasons Permit No. Date Issued rf"'i7i'(" "T'.....v-.,.��..y. �r,,.,.,�.�tr, ,,.. 4...ti,a 7C.�v..Sw'A..s,. .:�4rt'v^.. :r-. .�.. :r.• •.J•CMY' ., fi , ­016 101�. 5OFee THE COMMONWEALTH OF MASSACHUSETTS f Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migpogar *pgtem Congtruction Permit Application for a,,Permit to Construct( )Re air( )U grade( �Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 1 S i A Owner's Name,Address and Tel.No. Assessor's Map/Parcel C vt 't A y C, C �� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Gcee CU 13_y. 5kve H,-�c 1 Q c`y l t 'F,-� M r,- 0 a 601 Xc , t_0 r Type of Building: ' i Dwelling No.of Bedrooms _ 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 /,6 n U Type of S.A.S. -a SZ� C-�_ bC Y W eL Description of Soil { Nature of Repairs or Alterations(Answer when applicable) - e ?�Co� Date last inspected: A reement• -'"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 Bo of He Signed Al A m t, Date Application Approved by Date Application Disapproved for the following reasons l r Permit No. .i 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( )b at o?: (11 SI C l c '� �� a b n constructed in accordance with the provisions of Title 5 and the for Dis osal S stem Construction Permit No. dated " ' Installer SG���`'*��� �� Cef: Designer � � The issuance of this permit shall not be construed as a guarantee that the system. ' 1 func ' n as design id. Date Inspector �+ ! ---- ------------------_------- No. Fee- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi!5pogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade Abandon( ) System located at 1,2 C— H I .SI 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 s e 4qcompleted within three years of the date of t i pe it. j� /y / Date: Approved by �, �/ o / i ' I TOWN OF BARNSTABLE LOCATION 711 � �` SEWAGE # — 2 VILLAGE p,�}ssy\r`C� ASSESSOR'S MAP 8c LOTZ—J6 INSTALLER'S NAME&PHONE NO.s-�� "Cr'IIL.c SEPTIC TANK CAPACITY VQ 6 LEACHING FACILITY: (type SM a—aiJ, NO.OF BEDROOMS C"('Uv BUILDER OR OWNER PERMITDATE:��! q b COMPLIANCE DATE: — Separation Distance Between the: A 1 LQ Maximum Adjusted Groundwater Table and Bottom of Leaching Facility I v T 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 et of leac ng fa ' ' /Y Feet ' Furnished by , �w Zvi J ° All oc ' ' ASSESSORS MAP NO: 93 D3 No...�.�:��r�..� PARCEL N0: Fms...lZo...'.-........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF tHEALTH f�.UW1.....................OF- 41b-I4�...... Appliratiou for Uhipoii l 10orkii Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal System at NN// Lo tion-Address b / l o I S¢. . m... ...........� ...••••"--------•-•-••-••'•-•'.._.._.....••... r t� lul.�..................-•-- Owner Address ---•---------.•-- --------- -------- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons.......................... Showers ( ) — Cafeteria ( ) P4 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 -•---------------------•-•----•-----------•-------------------------------------•-----------------...........---'-....--•-•----------•-•--•--..............-- ODescription of Soil.....................................................................................= -----------•------••----•--•-----•----------•----------------------------•------ x U ---•...--------•--•............................•---•-•---------....--•-•--•---------------------------•------------------------------------------------------......---------------•••------------------. ------------------------------------------------------------------------------------ ------ - ------ ------------------------ ---- ------ ---- --------- ------- Nature of R air or Alterati ns—Answer when a licable.-.1A5.. .. U �p PP - �e�'IeYaAd=..w�-fi n `� r � -------------------•-----------•----••-•----•----.....---- --------•----••-------------- .._......_..---- eement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. . . L .10 71 Date Application Approved By............. .... .--- Date Application Disapproved for the following reasons--------------------------------------------------------------------------------•------------................... ••------------------------------------------------------------------------------------------------------•---•-•-----------............................................................................ Date PermitNo._......�._.7= -�.................... Issued....................................................... Date No. a=• �1 f F>�$... ..:.I...:............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................O F................>:...... ............................................................. Applira#ion for Diapnsal Workfi Tnnitrurthin .erntit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: Il F .. Location-Address or Lot No. Owner Address -------- Installer Address U Type of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ....:....................... No. of persons............................ Showers ( ) — Cafeteria ( ) a' 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-----------------_...... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•------------------------------------------............................................................................................................. ® Description of Soil........................................................................................................................................................................ U W -••--------------------••---.._..-•-------------•--------•-•--------•---•---------------••-----•-•-----•--------•----•----------------•---------------------------------------------------------------•- UNature of Repairs or Alterations—Answer when applicable_�____- ------- - - ................... .. _{ e r. ---- --------•---•------- ----....•---• .... .......... kAgreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT:..L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed...`...=...s.............` (q• �` -----------------------=----•-••--••------ ------------------•-•-- Application Approved By._...------'. ._..��..a,.c�•�,•��.---.-�........................... ...................Date.............. Date Application Disapproved for the following reasons----------------------------------•-----------------------•--------------------------------............-•-------- -------------------------------------•----•--•-•••--••---•------------•---------------...._.........-------------------------•------------•------------------------------•-----•--•-----•••--------•---- Date PermitNo....... .................... Issued....................................................... Date 3 THE COMMONWEALTH OF MASSACHUSETTS/ BOARD OF HEALTH .........!................................OF....... .................. ....................................................... Tatif irate of Toutpliane THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (7 ) by..............................1, ........... �..---....---------------- Installer at................ ------ -----• .._..- r' I--------_------------------------------------------- has been installed in accordance with the provisions of TITLE. 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---ems-..?__-__�.z/.......... da.ted--..._.---_------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCZION SATISFACTORY. DATE..................��. - -_..� ................................... Inspector------------------ ....... -----------••..................------........-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No...... .-7--_ / FEE........................ hoop oal Work,5 �nrn rnr uan ernti Permission is hereby granted........... _6.•----- I''-----------•-------------------------------------------------------------------------- to Construct ( ) or Repair ( k} an Individual Sewage Disposal System atNo.........../-4�------/Y. ......................................... .............................................................. Street 7 as shown on the application for Disposal Works Construction Permit NO---67.Zz/ Dated.......................................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS No...... :. �" #�, FEs....... .�......... I • THE COMMON IEALTH OF MASSACHUSETTS BOAI�D OF HEALTH �Ot.iy............. OF...-.......-. cY.�c1�.5 e ._................. Appliratinn for Uiiltutial Workfi Tomtrnrtion ranfit Application is hereby made for a Permit to Construct >5r or Repair ( ) an Individual Sewage Disposal System at:,�,� ..� .v '1° s ode D;,, G, L .v�ird� � �� ��(c�vor� -'�.e��� ...- Location Address ♦ or Lot No. %_!T1.:!Z.Y_.r.les��_!.�/g t'E.'r...�tJ_�a.......... � Qi�,r.�.......--��P rl�l. ✓!_.l!�...•^ Owner �/�I � �ff� �—y ��^Address ��A W •................` C rA%....... /A dli!.L... 6.[? ./.��_ L/�/sa Installer JAddress Type of Building �., Size Lot.__� $4__7......Sq. feet U Dwelling—No. of Bedrooms___771-11 o_________________________E pansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of pe, sons__......_............._.__.. Showers ( ) — Cafeteria ( ) Q' Other fixtures ----- ---------------------------- P ------------------------------------------------------------•-•---...-------------------------- w Design Flow...............................� __gallons per person per day. Total daily flow................;7-7-Q................gallons. P4 Septic Tank—Liquid*capacity' _gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—No. ............ f__ Width_-i-_____--______-_ Total Length_. Total leaching area....................sq. ft. Seepage Pit No._Ji�?-070____ Di meter----- Depth below inlet.................... Total leaching area..................sq. ft. '-' Percolation Test Res t� Performed tank ( )Other Distribution box erformedby.......................................................................... Date......................................... 111'-1-92-Test Pit No. 1_,___._.t,mmutes per inch Depth of Test Pit____________________ Depth to ground water------------------------ rx, -Jg-8S?Test Pit No. 2..._...'�._�minutes per inch Depth of Test Pit........` ......... Depth to ground water-----!_1/m---U1..7; Pi ----------------------...................................................................................................................................... 0 Description of Soil........ �R�---------------------------- x U --•-------••---------------------------------------•--•----------------------------•-------•---------------•-----------........-....................................................................... w VNature 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:T L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of iealth. Signed_r'f-!7!_� ...... y -m •------- Date�� Application Approved BY _A_` ----------------------------------------- Date Application Disapproved for the following reasons------------------•------------------------.--------•--•---------•--------------------------------------..----•- .............-........................................................................................................................................................................................... Date PermitNo--------------------------------------------------------- Issued-------------------------------------------------------- Date i — QQ No. -4�. ' 143l tom, FEE.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T. a_41 ...................OF........... g-.f.--�St ...._--.-.----_---_---- Ali ration for UhiV aal Workii Tumarurtirrn Fautit Application is hereby made for a Permit to Construct (-;:�) or Repair ( ) an Individual Sewage Disposal System at, -LGf�� �L^ .. � L t dress r Lot N _! ..5..........- r Add��,s� ,.a ................A A... .................... ........... ......------------------ Installer Address �� Type of Building .ram Size Lot_f0Y.7_______Sq. feet Dwelling—No. of Bedrooms._.__ ....................................Expansion Attic ( ) Garbage Grinder ( ) p-I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Ga Other fixtures ---------------------------------- . W Design Flow.............................5S_=_..gallons per person per day. Total daily flow............... 3-G.................gallons. WSeptic Tank—Liquid capacity4rzvV.gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___--__----_-------sq. ft. Seepage Pit No---1t.&x V:..... Diameter-___ '_Q. '. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (KI Dosing tank ( ) Percolation Test Results Performed by------------------------------------- ------------------ •.................. Date........................................ �JA a � xl'est Pit No. 1......._��_......minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, j�/n Test Pit No. 2.........Z__niinutes per inch Depth of Test Pit------- !....... Depth to ground water____/�4e__ r Description of Soil..... x c, -: w ------------•-- -------------------------------------------................................--..........------------ .._....----•••---------------•••••---•...----•-•--•------------------------••---•-- 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 TITLE,-L p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signedf�,,l�:- P y Date Application Approved By.......... �..alc� E�+7 ----------------------------------------------- ---- ------------- Date Application Disapproved for the following reasons-.....................................------------------------------------------------------------........--•--- ...................-..................................................................................................................................................................................... Date PermitNo. ------------------------....... Issued-------................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trr ifirtar of Tuutphaurr THIS IS TO TIFY, That.-the Individual Se - structed or Repaired by ..................... •--...... ( ) ( ) ._.. ._...... - a e Disg al System con ' +�,. '� /�St ........... /�/rlaller at /�y C----- --------------------------•-----------------..... has been installed in accordance with the provisions of TIT r o e tate Sanitary Code as described in the application for Disposal Works Construction Permit No------ =_.��� ...... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHAtI. NOT BE CONSTRUE® AS GUARANTEE THAT THE SYSTEMMlddlt FU TION SATISFACTORY. DATE.....�� lP. . ................................................ Inspector........-- ------ ---------•--......----•-•..................................... THE COMMONWEALTH OF M SSACHUSETTS BOARD OF HEALTH No... ..'...... FEE.........,+ ........ Billpos t1 urk Anil Gila r utit Permission 's ereby granted................; to Construct or Repair ( 6) an In� al Sewage Dispos System Street as shown on the applica 'on for Disposal Works ConstrZp rmit No___________ _ ___ Dated------------------------------------------ ,- Board of Health DATE....•--- ---.... .... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 6%W6 L- FA�ntL�( - f3EORooM I ; No GA¢13AGE CaR�t►1DE2 I\ ^I,L ( F%-ow �i`SEPTIG -rAwJK A. 1 0%5Po5AL P1T V5E IvoO GAL, 5%DcWALL AP-r-ls - ,Jcs.F / l / r � � n`° ,I 11 BOTTOM AREA- �0 5F• � // // ! �/� / F ! :. .., 5o S.F x I• o A. •p -T OT A 1-. E 51 GN o 42- -TOTAL >A I►-Y F%-DV4 - 33O G.Po PaZCOL.ATION RATE : 1 IN ?-MINI 09-Lr=55'�_ / et lob ! _ AID i � Q� ip wd 1H OF M4 �P`�N OF Mgs Of RJC .HARD ALAN �. A. W. ;` I 101 / It / /, v BAXTER A _ JONEs I?$ Na 24o4e . 25100 o I I 1 piT / �`�� g3 T� P Na pJ dad sv� v 7 I51(o ��-a2 ToP FNDFIoo.o ; SUB-sOIIi . pix �6?T I o0o INY TAN. LEAcu INV.- INV Val I'r�u I Il.51 •1% SLOPE ' ,ox 7�hj 6Tv h16 `` QQ , li GEwrIFIGr-i PL®'T PL-A.W. PR.d-FILG Lo4A- I0SJ 6t5j ,TR21ji'LIZ iI �51 10" 56ALE SCALI_ l 'i yA-TKE l 163 74• o (✓Ua��z d(SOS brj P L-A W R E 61ZE N GE i I CE RT1FY 'THAT 'THE 40VS6 511oWN D ` N6.REoW GOMPL` :5> WITO"THE SIoi:L1N Ln-r r>. Awe 56T2�.GK R-6Q�►R. MENT•> fl,F.,'.CNE ,(� . -TvYdN OI✓ Tr34atA,)A-sLbANV LoGAT D WITHI T V�-ooD PL 04 I DAT i✓ ��I� ' s3AXTEcze IJYE INC• ' REG I ST E.Q6U 1.A►�o 5 u r-Y EYci�S jl "rids PL&KI IS NOrr Id AN o67E2VILLS- • ems. ; I; 1►4,5T-R,uMENT 5V2Ve'f �--THe oF�S5 6u0ULSI No-c p�c 'ugE.D-To pe-TeRl^I►�� L.oT l,-IN1E�J ,4PPLIGAI-IT- _� , . �2�,�. _�Iu..jAltt� L-0 C A T ION SEWAGE PERMIT, NO. �. Jt�S 19 3 ` 014 VILLAGE _(ra.1 4 , INSTA LLE 'S NA i ADDRESS d U I L D E R OR Y rVM cJ ig DATE PERMIT. 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