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Home My WebLink About0015 JUNIPER ROAD - Health F15 JUNIPER ROAD, CENTERVILLE A= 210110 Slll �. UPC 12534 No.2_ HASTINGS. MN s Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State Zip Code Date of Inspection 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini . cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 ' Cityrrown State Zip Code (508)477-8877 S14454 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs her Evaluation by the Local Approving Authority -•N 1/26/2011 �� _ Inspector's Signature Date m ;a 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 pr has a design flow of 10,000 gpd or greater, the inspector and the system owner shall sub_init the°t 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. J L/ t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disp al System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The septic system is in porper working order at the present ime. 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): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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). 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•11/10 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 M 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. City/Town State Zip Code Date of Inspection B. 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 protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for 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. 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 '/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State. Zip Code Date of Inspection 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 any of the failure criteria related to Part C is at 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2009:30,000 2010:47,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 1/26/2011 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 ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every 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: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 800 gallons How was quantity pumped determined? Measured Reason for pumping: Check for Groundwater 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 41M 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ❑40 PVC orangeburg ® other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): Depth below grade: P feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass '❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 15 Juniper Rd. Property Address Phyllis Lee Owner Owners Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown 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.): 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 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•''y 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ 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.): Sandy soil.No signs of hydraulic failure.Water level was 12" below invert at time of inspection.No stain line observed higher. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration 1-main and 1-overflow Depth—top of liquid to inlet invert 1' Depth of solids layer 6" Depth of scum layer 3" Dimensions of cesspool both 6'x8' Materials of construction Concrete Block Indication of groundwater inflow ❑ Yes ® No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityfrown 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.): Sandy soil.No signs of hydraulic failure.Main cesspool water level was up to overflow pipe to leaching pit.Overflow cesspool was dry. 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.): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name - information is required for Centerville Ma. 02632 1/26/2011 every 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 ❑ drawing attached separately /i . r - I ' I � I i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every page. Cityrrown 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: bottom of LP 18' feet 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: As-Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 L i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 15 Juniper Rd. Property Address Phyllis Lee Owner Owner's Name information is required for Centerville Ma. 02632 1/26/2011 every 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 i • V DATE:_ '. /� ./_:95 . PROPERTY ADDRESS: �.___ _. . ^ � .. .� .�_5 ^,n.r ire._ ��.:�.�:. oe On the above date, I inspected the septic system at the above address: This system con8lsts of the following: E 5 Z. 14000 y7,z.e�on /znecas.t Perzc.5.-in,y I?J.t Based bn my Ins:w.ctlon, I certify the following conditions: I 7h.is i-f, no.t cc -t,.tZ_e 4 i v e .�ert c y.6:E•_�n„ 2. 7fk,6 4,6 a f,e,va%xe Ay6t._m ;'z:'..t ,6 an. '!*'`2c2^2-t.FQ zk.i.n;, ws-+ • �02�2 �.t �hr. ,2�e.en.t fim_e. 3 . 7h%. 3V6i.em i6 d.zy , .h%u6e n i . ? A SIGNATURr-: Gil Na me:_J P.M_acomber Jr... Company:J. P_MacoMber_ & Son•_Inc Address:_-$e -��-- ---= -- -- Cente�rvill.e Mass : •0.2632' Phone: _548,. 75A3338------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOi�BER & SON, INC. Tank t-CesspoolrLeaohtlelds Pumpsd & Installed Town Sewer Connections P.O_ Box 66�' Centerville, MA 02632-0066 775-3338 775-6412 7 DIS '06AL SYSTEM {ItSPVCt;LQIZ Address Of Proper-�y 15 j-unipe2 Road Na,6.3. Owner ' s name dose fz '?e� P. n Date of Inspection 8/.%9i95 • PART A 01,"CxLIST Check if the following have been done: "/ Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back—up. The site was inspected for signs of breakout. All system components, 4cluding the SAS , have been located on the site nn _J_/ The manholes were uncovered, opened, and the interior of the s was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. _4z"The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance '.of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS:' If residential .� number of bedrooms number of current residents garbage grinder, yes or no - laundry connected to system, yes or no ' N0 seasonal use, yes or no If nonresidential , calculated flow: Water meter readings, if available: �q93- S'�O'O'gg. = Po Last date of occupancy GENERAL INFORMATION Pumpincl records and source of information: ' a-j9- ,� •s� _.A49 System pumped as part of inspection, yes or no if yes, volume pumped r�) Reason for pu pink: , Type of system Septic tank/distribution box/soil absorption system ElSingle cesspool Overflow cesspool—' wl'7_h ave tooa Q,gVk,,u I'alw-`j"0e?'' Privy ,• AfQ Shared system (yes or no) (if yes, attach previous inspection records, if any) _A/0 Other (explain) Approximate age of .all 'components. Date installed, if known. Source of informaion.. __.._.. --.......... ..._-:•. - - _ -._._........... Sewage odors detected when arriving at the site, yes or no i 9 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:JAq?i (locate on site plan) depth below grade:— material of construction: * concrete metal FRP other(explain) MlA ' dimensions:_ N1A- sludge depth distance from top of sludge to bottom of outlet tee or baffle scum thickness distance from top of* scum to top of outlet tee or baffle distance from bottom of scum to bottom of outlet tee or baffle 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, recommendations for repairs, etc. ) DISTRIBUTION BOX:j±L (locate on site plan) depth of .liquid level above outlet invert Comments: .(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) PUMP CHAMBER:--AIM (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and 'appurtenances, . recommen-dations for maintenance or .repairs,etc. ) 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : _ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be 'present, explain: leaching pits and number --1000 a leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recomme dations for maintenance or repairs,etc. ) + Aim g" e LS CESSPOOLS locate on site plan) : number and configuration - ` ' 0,01%4QzLi depth-top of liquid to inlet invert depth of solids layer depth of scum layer- dimensions of cesspool materials of construction 1'e- 1-,PckJ indication of groundwater' inflow (cesspool must be pumped as part of inspection) n16 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, reco endations for mainte ance or repairs,etc.) Ayq 4 /Ld Q Na o97'T P• kie S �7 7�r12i . PRIVY: AlQAJL (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,• recommendations for maintenance or repairs;etc. ) . SUBSURFACE SEWAGE DISPOSAL ,SYSTEM INSPECTION •rORM PART 8 SYSTEM INFORMATION continued SKETCH OF SEWAGE L_SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within lo0 . c DEPTH TO GROUNDWATER depth to groundwater method of dayterjnination or approximation:_ ��s L `� 12 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) _ Backup of sewage into facility? _AIM Discharge or ponding of effluent to the surface. of the ground or surface waters. dX Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1 2 da flow? / y /V`d Required pumping 4 times or more in the last year? number of times pumped Alb Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure., imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? N within 50 feet of a surface water? A10 within 100 feet of a: .surface water supply or tributary to a surface water supply? Ad' within a zone I of a pub-lic well? Al within 50 feet of a bord0ring vegetated wetland or salt marsh- (cesspools and .privies only, not the SAS) ? _- within 50 feet of a private water supply well? -AL 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 anal, for coliform bacteria, volatile organic compounds, ammonia nitrogeii,— and nitrate nitrogen. TOWN OF BOARD OF HEALTH SUBSIRIFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D .- CERTIFICATION yIM -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 15-,TuAjq2e)e 60CL ASSESSORS MAP, BLOCK' AND PARCEL OWNER' s NAME `� Sdo-QL DaVLy PART D - CERTIFICATION NAME OF INSPECTOR -TOS;QA P YY1W-,I m ko A Tk, COMPANY NAME U. R Acdfn6p so" COMPANY ADDRESS GOX 0. Street. Town or City State LIP COMPANY TELEPHONE FAX (.&>,k /-57r CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposil system at this address and that the information reported is true , accurate , and complete as of the time of inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : -L/Zsystem PASSED The inspection which I have conducted has not found any information which indicates that ithe system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED The inspection which I have conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C FAILURE CRITERIA of this inspection form, 46, Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, th')-- owner or"'o-perator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . partd-doc Ccmmcnwecr ,, c; Masscc:7::sers ExecuTNe Qt ice ct Envircnmenlc, ;;��,;,,s Depprtment of Environmentai Protection ' Water Pollution Control Tecnniccl Asswcnce ana Training Secnons VAUL&w F.w.a co.•mor Trudy co:. S•avwy.ECEA Thomas &Powws • Ao"c4mmwwcrw 06/12/95 ATTN: Joseph P. Macomber, Jr. Joseph Macomber and Soul PO Box 66 Centerville, MA 02632- Dear Joseph P. Macomber, Jr. , I am pleased to inform you chat you have actended training, met the experience qual.ificacions, and have passed the Title 5 System Inspector exam, pursuant to 310 CMR 15. 340 . The passing grade for the exam was 39/52 or 75% . This is an official notification that you are a Certified Department of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 . You will receive a System Inspector certificate at a later date. If you have any futher questions, please write to me at the following address: Kimball Simpson D.E. P. Training Center 50 Route 20 Millbury, MA 01527 Thank you very much for your time and consideration in this matter. Sincerely, Kimball T.. Simpson, DEP Training G. :...e-r Director (2 4 0 5) Roues :'0 Millbury, MA . FAX 503-755.9253 • r —!wn• 508-756-77 a l • Water �. Conservation SAVE ME! Tips . . . CHECK FOR LEAKS Water Loss in Gallons Due to Leaks Leak this Loss Per Day Loss Per Month Size 120 3,600 360 10,800 • 693 20,790 1,200 36,000 • 1,920 57,600 3,096- 92,880 .0 41296 .128,980 ® 6,640 199,200. 6,984 200,520 8,424 252,720 9,888 296,640 Aft 11,324 339,720 0 12,720 381,600 14,952 448,560 rW _ TOWN OF BARNSTABLE LOCATICN/l��IGI�� SEWAGE# VILLAGE, ASSESSOR'S MAP LOT :;I,lD--10 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I_ _ V , �� i V V ,� Q � , k �.. o 0 1 �, s � �� .� 1 � � �. �� O - / Fx$.... ...30-.-�JO No.-.. -- ---- THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for 11isposal Workii Tonstrnr#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair M an Individual Sewage Disposal System at: Devlin ................__......_...................................................................... --•••-••••----•-•-•--•••••---...----•••--•--•--•---•--••----•---••----•---••-----•-.........•--... ocatio - dress or Lot No. 15 Juniper .#oac Adenterv111e ------------------------------------------------ ----------------•----•---•---------------•-------------------------------------------------------- W J.P.Macomber Jor;er Address Installer Address Type of Buildiyn� Size Lot............................Sq. feet U Dwellinx"No. of Bedrooms.............3_................__.....__..Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P r 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------_____-___--_..__-. a ••-••--•••••-------------•--------••••••-•-••-------•--------•••----•••.......-------•••-•--•-••----......................................................... 0 Description of Soil---------------- -- -- •-• ••------- ...............••-•-•-••------•-•----------•--•--••------...-----------------••••••-............--•._......._.--•-- x Sand & GraveT U ....••-•-•--•---•---••-••••••--•-••--•-•-••-••--•-•--•----------•---••••----•••--•••-••••••-••---•----•----------------------•-•••---••-------------------•---------•-•-••-.--------------------------- ----------••--------------------------------------------•--- ------------•-----•-••-•-•••-•----••-------•••••-----•-------------------------------•-------•-------•••-••--•••••......•-••-•-•-------- Nature of Repairs or It s— wer en a licable............... _-______ U P �� ga on eac ing Plt - --� ............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ss ed by the oard f health. Signed . ��/'/ . .. '-......................... -2/2.0/91------------ Dare Application Approved By ............. - -- --- - -- -------- --- -,-. ---- . -6.T411_---- Dm Application Disapproved for the following reasons- ----------------------------------------------------------------------------------------------------------------........................ ---------- ---------....................... --------------------------- ------------------------------- ------------------------------------------------------------------------------------------ ------------------------------------ D PermitNo. ......... ---------------------------- Issued ----------_....------------...............----........--are------- Dace No----2L50- Fims...... . .. ...(0....�J0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Disposal Works Tonsh Linn 11nmit t Application is hereby made for a Permit to Construct ( ) or Repair TXX) an Individual Sewage Disposal t System at: Devlin ................_........_....••...........-----•--------•-------------•----•-----•--•----.._... --•-••--------------------•----------•.....••-----•••------•----••-------••------.............---- 15 Juniper ciaa_ .......................................... orLot--......-•-......--••••.................-•----•-----............................................. W J.P.Ma e o mb e r doh:er Address Installer Address d Type of Building Size Lot••-•--------------•---.-----Sq. feet DwellingX No. of Bedrooms.............3............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building .............. No. of ersons....___.......•..•_.._•._.._ Showers — Cafeteria QI —Type g ---------•---- P ( ) ( ) dOther-fixtures .----•--•---------•------------------------------------•-••---••••-•-•---•--•--••-•••••-••......---•----------...........•----------•......--------- W Design Flow............................................gallons per person per day. Total daily flow.....................:_........_____________.gallons. 04 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_______---__.. Depth................ W 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........................................ W Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......................... G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ W •-••••••--•••••••--••-•••••---•------•-•------••----•-•---------•...........................•--••._.......•••••---••...-••••---•-.....--------............... 0 Description of Soil-- U .........._ .�anct � (iY'avel W U Nature of Repairs or Altera i �s—Answer when applicable... __r.._..._...._r_._..___ __. ........................................................ ..--•-------------•••••-•---•••--.......1—�v� ---ga.l..l_on•-•.Lee.c `�ng..P.... -•.....--...-•--= - ......- .................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code=The undersigned further agrees not to place the system in operation until a Certificate of Compliance has eena�ed by the health. Signed .. -.,........ J�........� .::................ v... 2/20/91 ApplicationApproved Bye----------- -------- /-------- -----------`'-----................ ----------------.....------------. .n�...-.�o .�`1.......... Application Disapproved for the following reasons- -----------------------------------------------------------------------------------------------------------1--.-------- .......... .............-------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------•----------- -------------------------------- w, Date PermitNo. -----...?/.. ---a...------------- ----- ---------- Issued ----------------------------------------------............--------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (girth rate of (gutttlatia re THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedi(XX ) by___..-J-..P..Macomber Jr. ------------- Installer at ---..15 Juniper Road Centerville -------------------...............................................--------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ....Y/.-..�� .1..........;-- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ��... �.. �'(' Inspector ------------------------------ ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o TOWN OF BARNSTABLE ................... Disposal Works Tnnstrnrtintt f rrutit • J P Macomber Jr. Permission is hereby granted ' •. ..----•--......_..-•... ................................ ........... to Construct ( ) or Repair (XX)Xan Individual Sewage Disposal System at No...A ..Juniper E.oad Centerville Street �� "'� as shown on the application for Disposal Works Construction Permit No.,_..':...._... Dated.......................................... ............................•�..��..................._.............._..._..__.....___...._. DATE_ 9 -- 9., --------------------------- r . Board of Health FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS ` TOWN"OF BARNSTABLE LOCATION `1 c4ni!, e.- C h SEWAGE # VILLAGE C,c,�T�,,,,�f�j ASSESSOR'S MAP & LOT INSTALLER'S NAME vl,& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITYAtype) el,-F (size) �- --1 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BU16BER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No f� Z 7 io v M 7 00,07F No..._..._ ... `Fs�......�'�.. ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HEALTH _.. ..... ---OF.-- -- Ate/ ........... .................... Apphratiun -for 43i,opnsal Works Tnnitrnrtion Vautit ,Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy t� at Q.16 'a :-'e �Z" .................. -- - -- - c io - 3�s or Lot No. •__•............ ... ....... ...o....-...._ ... ... �_.._..___............... ........__.._._....__*_ __•___... ........__........._.................. W Ow r // Ages ,a �!------ -- ......1 .... 4C" Installer Address �7� Type ,f uilding Size Lot . , __---Sq. feet Dwelling—No. of Bedroo --- ---- --- ---- __0----_-Expansion Attic ( ) Garbage Grinder A). aOther —Type of Buildin a tte- - No. of person .-_s -------------- Showers ( ) — Cafeteria ( ) dOther fixtures ----- ---------- ............ _----••----...._.__.................................... W Design Flow. _.. �`10 ..__. ........................gallons per person per day. Total daily flow...... 0�.:................._..gallons. WSeptic Tank Liquid capacity, ___gallons Length---------------- Width._............. Diameter................. Depth---------------- xDisposal Tre ch—No. .............. Wic h -----__-_-- Total Length-------------------- Total leaching area--------------------sq. ft. -` Seepage Pit No..................... Diameter.ale'_ _- Depth below inl �� ........ Total leaching area__---_._-----_--sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ai- G - w/-/ 77 aPercolation Test Results Performed by-------- -----------------------•-------•-------------•-----•-••....----_. Date-.: ..-----------•------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...-_-_.--_--........... � f3:q Test Pit No. 2................minutes per inch Depth of Test Pit...--_-__--__-_-_-.- Depth to ground water_.._..-..-_-.---_------- ------------------ - --------- t • - - - G Des cripti n of So - `' "�-- - ----"-1 2`• "' - ----- -------j 2 W ..••---.-...... =-f---------------------- •- •---- __ --._:::---_-:__----__------ x -------•--------•---------------------- U Nature of Repairs or Alterations—Answer when applicable.-.--------------------------------------------------------------------------------------------- ---------------------------------------------------------------------•---------------------------------------------•-•-••------------•------•--•--------••--•----------•••------•--------------•---•-- Agreement: The undersigned agrees to install the aforedescribed Individual SKd/f5u�rt e Disposal System in accordance with the provisions of Article NI of the State Sanit r�de— The u.ndersig� -ler agrees not to place the system in operation until a Certificate of Compliance has b eni issued b 1�oar ' health. Sign •------------=•--•---••------- Date Application Approved BY f ---- ..r,�__.aZ'Z 7 Date Application Disapproved-for the following reasons-----------------------------------------------------------------------------------------------------•--••-----•- .......-•-----------------------------------------------------------------------------------------------.-------------------------------------------------------•-----------------------------------•--- Date Permit No......................................................... Issued-••-P•--®---A V 6 Y---_..T'r Date No. ..._ ...`. Fas.-..... ................. THE COMMONWEALTH OF MASSACHUSETTS B.,OARD F HEALTH .. -- ...OF........ - - Appliration -fur Rqvuual Worko Tomitrurtion Vrrniit plication is hereby ade for a Per to Construct ( ) or:Repair ( ) an Individual Sewage Disposal Sy,tilat .__ _____••__---F__ ___ .... ._ .-. _• ... __- - _-___••_ __ •---- -•---- _.._ .... ca - -;pr Lot No. Installer Address U Type wilding Size Lot_ Sq. feet Dwelling—No. of Bedroom _-_.-Expansto Attic ( ) Garbage Grinder per, Other—Type of Buildin No. of persons--- Showers ( ) — Cafeteria ( ) Otherfixtures ----------------- -•---- ----- ---------------------- - ------___--- _- - ------------------------------------ Designw Flow_ ' zllons per person per day. Total Bail flow.._.._ _"----- gallons. ------- ----- - -g P P P Y daily WSeptic Tank Liquid capacity 'O.gallons Len-th---------------- Width_. _-. .... Diameter____-- - - _ Depth-_ __-- x Disposal Tre c —No_ __________ _______ Wu]irl- -^4 Total Length.................... Total-leaching area....................sq.,ft. Seepage Pit No-_----------------- Diameter-_._..l�--�� Depth below inl ____._ Total leaching area------------------sq. it. Z Other Distribution box ( ) Dosing tank ( ) �4 , `" • " ` aPercolation Test Results Performed by----------------------- ...__.._____..___.__.__....__._ Date------------------------------------------ Test Pit No. L_______________minutes per inch Depth of Test Pit.........-___._..... Depth to ground water-..._________-_.-.___- f� Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water------------------------ ............... * a O Descripti of So "" "' `- - { IC U, ---------- ----- - - ------ -------- -------- --- ''`'"---- -------- ---------------------- w. UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------_.......................-------------------- ------------ -• -------- ••--- -- ---------- ------------- Agreement: " The undersigned agrees to install the aforedescribed Individual Se e Disposal System its accordance with the provisions of Article'NI of the State Sani y C e— The undersigi +further agrees not to place the system in operation until a Certificate of Compliance ha issued b ar ealth. Sign -- ------------------• -------------------------------- est " Date Application Approved By- ¢ ✓ (/ M-W— - ------ hate Application'Disapproved for the f olloiving reasons---------------------------------------•---------------•----•---•--_-_-_-• ---•--------------------------------- .............•--._.._._.____.._..__._._.._.._._.._--•------------•-••-•---•-------•----•-• ...............................----------____-----------•-----------•--------_•-____------------------------- Date Permit No--------------------------- ------------------------ Issued. =` --------• Da THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... OF......... ...:# .......................................... Trrtifiratr of Qkumlinrr . T I I TO C RIIF hat Individual Sewage Disposal System constructed ( ) or Repaired ( ) by----- -. E''' r---.................. . -------------- -•-- -------- -- ------•-----------•--------- at........... ---- -- has been installed in accordance with t e provisions A The State Sanitary Code as described in the application for-Disposal Works Construction Permit No... ,�,} ��++�� `M -�--------------• dated "-- _ ': _.. --7------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE :CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �/ f ''L DATE 4 ---�7---- I. ---------------------•------- Inspector ............... 5 THE COMMONWEALTH Of,.MASSACHUSETTS BOARD O HEALTH .. . ...OF.--.. . . r .. FEE.... . ....... •--•....- ali... t �x Y. i� uu 1 urks Cnu r iuff rrmit Permission�i�s hereby gra ted -----•---•- ----j--__ -- -- -----------------•--------------------------•-----_____----•-- •. to Const ( 14 o it (` n Indiv al Sewage D' posal *ystem at No.._ rG?i9+'t� � { G 'zGc� ----Rel" -•-------•--- S et as shown on the application for Disposal Works Construction Per No Dated__ _-2� 7!7__.. f , -------- ------_ / r Boar of Heal t DATE---�_'_I • - ------------- -- --- - ----------_ FORM 1255 HOBBS?;&'WARREN. INC.. PUBLISHERS _ --- LAqiNj ET it uj- r ,_ l�7 ! -------- l c,T l , ' > r 1 JA.,AE ✓ �, ., R!CN.4P.D JAME" =� No 27 7I f �n ;1'U� O'HE.94 Ell o9a � F CERTIFIED PLOT PLAN IN 1,- CERT/=Y TPAT THE =�;;.: r_�i -� 1��> '��' C�'f-I "�Fd�I, R L.S., R. S. -dOVIV ON 791S R AA/ IS LOCATE, /9/ MI'AI/V ST (RTE. 28) ON THE GROUND AS INDICATED AND . WEST DEEM /I S , MASS . CONI=OR/'CIS TO TIYE ZONING LAWS OF J//- r. -;i�t -_ /?�9 5 . DATE: SCALE. D 42-16 / REG. /_lWD SURVEYOR oR. a Y• SHEE 7 2 OF