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HomeMy WebLinkAbout0217 KNOTTY PINE LANE - Health 17 Knotty Pine Lane Centerville A= 152 —041 I i i 1L* F -1 s-,a'1,,�- Floor Plan Existing Deck ulkheo 10' 14' Shower —--- CT CT vootrM T opening MBR Kitchen Dinette Garage 2 , 24' S Existing Hone Living Room 9, BR 2 BR 3 Li S cetlDa�- F 44' NEAL A. PRATT Chuck Higgins Residence DATE: 6,16.10 PAGE 1 OF 1 B /DE SCALE: None 42 CH ROAD 42 CHASE ROAD 217 Knotty Pine LN E. SANDWICH MA. 02537 BY: NAP PHONE: (508) 888-3206 Centerville, MA A3 Mi � J 5 la M 9 a =n P t � e jEL A A€r:­ � .O' s ® L=39,27' MBLU 191®40 217 KNOTTY PINE LA Lir CENTEj?WUF, MA ® A EX � PROPOSED DbUET L ING ADDITION 25.03' y EX TAW DECK °vvV @ LF Sri 11,9 0, SEPTIC SYSTEM PLOTTED FROM INFORMATION PROWDED BY OWNER. CER 7'IFIEI) PLOT PLAN sews RESHXNCE I CERTIFY THAT THE IMPROVEMENTS SHOWN OF 217 KNOTTY PINE LAAfE HAVE BEEN LOCATED WITH AN INSTRUMENT ��`� Ass�a CEN7W MA SURVEY. ROBB y DATE OCT. 6,,2009 DRA N.E S SCALE) =30 im ift Epp 51 N SYK g v� EASTBOUND 10_ 7_0 9 ci ��° LAND SURVEYING, INC. ROBB SYKES, P.LS DATE P.O BOX 442 , , FORESTDALE, MA 026" f ,per COMMONWEALTR OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS - DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM FART A CERTIFICATION Property Address: (� P;RF Lam_ Owner's Name: l2�kEy-\ 1& q, 15p_�-\T , eS Owner's Address: 51 tl A I r Date of Inspection: �z ir,,c' Name of Inspector.(please print) W i I 1 i am E_ .Rob i nson Sr. CompanyName: William E. Robinson Septic Service Mailiag Address: P O Box 1 089 Centerville, MA Telephone Number.. (5081 775-877-6_ ` CERTIFICATION STATEMENT I certify that 1 have personalty 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 t7S 'on 15340 of Title 5(310 ChIR 15.000)- The system: gasses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Faits Inspector's Sigtiature: Date: r} The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Health Vr DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the repott 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 approriing authority. Notes and Comments 4**This report only describes conditions at the time of inspection and under the conditions of use at that time_This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2ofil r m OFFICIAL INSPECTION FORM—NO*f FOR VOLUNTARY ASSESSMENTS r f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: a lC` 04-k`t At Yam. �D_,,t� 1 1 i t ILOwner.A 1QXCLV��G'L Date or inspection; �f Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste Passes: I have not found any information which indicates that any of the failure criteria described in 3la be 15.303 or in 3 10 CUR 15.344 exist A_ ny failure criteria not evaluated are indicated low_ C� Comments: B. System Conditionally Passes: ^ ! `� � .`. One or more system components as descnJJJ'bed m the"Conditional Pass"section need to be replaced or repaired_The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the explain_ -for the following statements_if"not determined"please The septic tank is metal and aver 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exftltration 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 Certificate of Compliance indicating that the.tank is less.than 24 years old is available. ND explain: V bservation of sewage backup or break out or high static tearer level in the distribution box etas to two or obstructed pipes)or due to a broken settled or uneven disuibtttion box_System vARl pass inspection if(with. approval of Board of Health)- broken pipe(s)are replaced . obstruction is retn9ved , disonbution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken Pass inspection or o n if w' bsutrted P (With approval of the Board of Health): P�(s)•The system will broken pipes)are replaced obs0vctian is srttsoved _t ,• ND explain: Page.of I i OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address- Owner,, s"cL Se ET-A-3-�k%6 Q.5 Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions-exist which require further evaluation by the Board of He it 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 15.3030)(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 surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the-public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has'a septic.tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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 coliforni bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria.are triggered.A copy of the analysis must be attached to this form_ 3. Uther: 3 Page 4 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: °�l� ��'"`� '` Q �'� La Owner. Nexc Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"Yes"or"no"to each of the following for all inspections_ Yes No _ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or > dogged 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 G'below invert or available volume is less than%day flow Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private w-Atrr supply well with no acceptable water quality analysis.IThis system passes if the well water analysis,. performed at a b£P certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free-from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy or the analysis trust be attached to this form.) (Yes/No)The system fails.I have determined that one or more of.the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. S E. Large Systems: . To be considered a large syste the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no ' _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E dw-system is considered a significant threat,or amwcrcd "yes"in Section D above the large system has failed.The o%mcr or optrator of any large system considered a u significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ' CHECKLIST Property Address: 1 t Owner. �� Date of Inspection: 3� &2 42P, tJ 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 7 ✓ ` Were as built plans of the system obtained and examined?(if they were not available note as NIA) ✓ 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? e 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? i The size and location of the Soil Absorption System(SAS)on the site has been determined based on: .. Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)j 5 Page 6 of 1 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:�l Owner: �� „� Date of Inspection: 3 FLOW CONDITIONS RESIDENTIAL. --� Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): . P� l� Number of current residents: r Does residence have a garbage grinder(yes or no):!UG DLs`Y Is laundry on a separate sewage system(yes or no):?�� [if yes separate inspection required] Laundry system inspected(yes or no ):v Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): o1CQ'S— 1, 00o Sump pump(yes or no):. t ©D? ©Utz Last date,of occupancy: COMMERCIAIJINDUSTRIAL /\ i Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings;if available: - Last date of occupancyluse:= OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):A4> If yes,volume pumped: �atlons—How was quantity pumped determined? Reason for pumping: TY�KOF SYSTEM ` Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate ag-,of all components,date installed(if known)and source of information: F�riR `I' tcr/tt, Were sewage odors detected when arriving at the site(yes or no): %1 6 I'agc 7 of t I OFFICIAL INSPECTION FOR114—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: Vtv1.QJo _ 0»acr1 `�C`J.,CES Date of Inspection:_ 1 r- BUILDING SEWER(locate on site plan) Depth below grade: 1•! +,' / Materials of construction:_cast iron - 40 PVC_other(exl>lau►}: Distance from private water supply well or suction yule: Comments(on condition of joints.venting,evidence of leakage-,ctc.): SEPTIC TANK:t!(locate on site plan) Depth below grade: r Material of construction: --cluncrete_metal fiberglass_polycolylene ' _oUtcr(explain) If Lank is metal list age:_ Is age conGnned•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: fCca_- Sludge dcptl►: go _ Distance from top of sludge to button,of outlet Ice or baffle: �• Scum thickness: /" Distance from top of stun'to top of outlet tee or baffle: (gyp" Distance from bottom of scum to bouon►of out(et ice or baffle: I low'vcrc dimensions determined: e�:fle.i" C'C�t•� _ 3oa:e snt�s�t�ys�r1.�/ Comments(on pumping(eeommendatwns,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): lt{- �.,.1 �lde Fries •4y4clt- - e•rl � I�tt S jj�r�C3 �►r+F y11tc G lLc s. iVt3 a , Zs!3 /a4a GREASE TRAP. -IV c lie on site plan) Dcpth below grade:_ Material of construction:_concrete_metal_fiberglass___jnolyethylcne other (explain): Dimensions: Scum thickness: Distance from top of scull,to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet ice or baffle: Date of last pumping: Continents(on pumping tccomincudations,u'let and outlet ice or baffle eunditioa,structural integrity,liquid levels as related to oullet invert,evidence of leakage,etc): 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) RcrtyAddress:oZt`7 ^� �Aal�; j ier: jMe4(0 y1 ('ac F t or Inspection: CAL/ r11T or HOLDING TANK:M41ank trust be pumped at time of inspection)(locate on site plan) ith below grade: ;crial of construction: concrete rectal fiberglass__jtulycUtylcne otl►cr(explaut): tensions: iacity: _ gallons ,ign Flow: galionsiday no present(yes or no): .rm level: Alann in working ordcr(ycs or no):— le of last pumping: mrncnts(condition of alarm and float switclics,ctc-): STIUBUTION BOX: Z(if resent must be o toned locate on site plan) P } )( P ) 'pill or liquid level above otitict invert: -nuncn(s(note if box is lcvcl and distribution to outicts equal,any evidence of solids'carryover,any evidence of ikagc into or out of box,ctc.): '1�' �s•�. as ,�c� .���.� �s E.�rs/ r-��r>t�t�� Car:. - ,�° �vW �.r��. J111P CHAMBER:�(/ocate on site plan) imps in working ordcr(ycs or no): lames in working ordcr(ycs or no):— onunenis(note eondilion of pump chainbcr,condition of pumps and appuncnanccs,cic.): Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:GQI-) Owner: des Date of Inspection: 3f a 7l;ta SOIL ABSORPTION SYSTEM(SAS). (locate on site plan,excavation not required) If SAS not located explain why: Typ leaching pits,number. / fA1t"-� 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.): y I /n4 1 �e�)r+ LA.sa( R I�• • Vi�'<'� V V ����j �f..TV 6AAP 'VU SI C�t C fh y 6�ram li L Js�c {:w /'r:4� CESSPOOLS: N j cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:N� (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM PART C SYSTEM INFORMATION(continued) Property Address:, Owner• ` c rr cz cat t�fPs Date of Inspection! " SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet Locate where public water supply enters the building. a 3 TAN s 4•:�= 3 , 3 ' 10 Page 11 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:at �7 P)C\k \t I wL Owner. A1O-xCLL6LCC'k— !; t>nACOlk d.e-S Date.of Inspection: /c3De: SITE EXAX Slope ✓✓ Surface water '— Check cellar -- Shallow wells Estimated depth to ground water ��� feet Please.indicate(check)all methods used to determine the high ground water elevation: /Obtained from system design plans on record If checked,date of design plan reviewed: Observed site(abutting property/observation hole within ISO 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: Rt -5,, yael a s ems/ 11 a t • 4 dv ! 3D THE COMMONWEALTH OF MASSACHUSETTS -BOAR® HE ill - 0� 0 ` ................. "-.......OF.............% . 2�-7 ApAration for Uispwial Work nnitrnrtinn amit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Sys 'L _ , ` — � - .- . .. L tion-Addres or Lot o. O ne ' Add -• ...:................... .. ----•--• ��'`__....... .....------........--------- Installer Address � Type of Building � Size Lot...........................S q. feet Dwelling—No. of Bedrooms............................................Expansion�ttic (/j/f Garbage Grindera Other—Type of Building ____________________________ No. of persons___.___ ._...._...._.. Showers ( /) — Cafeteria ( ) Other fixtures -----•-------------•----------------.....-----_----- d _ 9;5 ................---------- W Design Flow...............�.5....._.._..___...gallons per person per day. Total daily flow----- _ ..............gallons. WSeptic Tank—Liquid capacity/ttr-"gallons Length................ Width_............... Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.............. ....sq. ft. Seepage Pit No--------------------- Di meter.................... Depth below inlet.................... Total leaching area.�1-�__..sq. ft. Z Other Distribution box ( � Dosing ) Percolation Test Results Performed by-----t2............... .. ...... ......... .................. Date..... Test Pit No. 1.152___.minutes per inch Depth of Te t Pit___________ ______ Depth to ground water........................ Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Description of Soil......Q_-__�.__..........( .V -------------------- .------------------•-----------...----C.'- ---�......--- 4.�. ; . ___.__...___---------------- ---- s 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 LIT::L 5 of the State Sanitary Code—The undersigned further agrees no to place the system in operation until a Certificate of Compliance has been issued b the oar of ealth. �C . �' -� ✓L/ � Signe .C_A -- . . .................•••--•----•-•-- Date Application Approved By... �./[�i ...... /L ------- D e Application Disapproved for the following reasons:................................................................................................................ --------------------••----•-----------------------••--------....---------....--------.......---•--••-------------------•.....-----------------•-•••------------------------------------------•---------- Date PermitNo........................................................ Issued....................................................... Date r 2,4 LOCATION SEWAGE PERMIT NO. �lt/�/c -r%1rf �?/=;519 VILLAGE 0 7- INSTA LLER'S NAME & ADDRESS GUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �oL1S/LL r � q I iw> __ 4JV THE COMMONWEALTH OF MASSACHUSETTS .......... "".......OF........... /T �. .....+ .... .Appfiraftou for Uigpootal orks onstrur#ion ramit is Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal .4.... t �, < �� . ... • ................. ---......•. L tion Addresr ,y ,{�,+,'� J�j7 or Lott No. ' .... f ,�`.�:.` .. �d/ ilt!a1' _ L-•�l°�✓,?:✓,J�t�ti/. �.�', �:�.�.��.........T...� j Addre s ^` � `/ ' Installer Address Type of Building Size Lot...........................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion ttic (/Oa Garbage Grinder (41)nj Other—Type of Building --------- ............. No. of perso ................Showers ( j) — Cafeteria ( ) Other fixtures .-----------F------------------•------..... ------------------ Desi n Flow................. `� allons per person per day. Total dail flow.... r`..3� g •- - •-• g P P P Y• Y� -- W Septic Tank—Liquid capacity aw—e0gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-----------------_-- Di meter.................... Depth below inlet.................... Total leaching area.7-6.6....sq. ft. Z Other Distribution box ( Dosing tank ) Percolation Test Results Performed by.....F .�....... .... ........................._. Date._..__._ Test Pit No. 1. .. ....minutes per inch Depth of Te( Pit.................. Depth to ground ........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--- --------- -- - ---------..-----------•-------..-.-------------.----.----..-------.--•---••--•-----.-.------•-•-----••-•-•--------•----- O Description of Soil......t� Z '� ', 5�C - --•--•---- -----------------------------------••-•-•---- W ------------------------------------- -r f ----- UNature 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:ITIS 5 of the State Sanitary Code—The undersigned further a rees not to place the system in operation until a Certificate of Compliance has been issued by the,board of ealth. ... .............V.............. .....Z/....... ..4F/ Al A,? s Date Application Approved By-- f ______, , 'G� / ....................... ... Application Disapproved for the following reasons--------------------------•------...-----•------------...-----------------------------------------------......... ........--•---•....................•-•-....--------•--------......----•-•--•----------------------------••----••---•-----••--•----•---•------•-•--••----------•-----•------------------•----•-••-•..... Date PermitNo...................-------------------------------------- Issued.---------------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARS HEA iTH ......"`...........O F...... . ... � 5.... ..... ............................. Trx#if irttfr of Moutpliaaatre THtO CERTIFY, That thg Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.... 4 C.......... ------•-•---•-•-------•-----------------------------•-•-•-----•---•-••------------ Insta er r � at------------ A-......... R.+t U--4.....X.,­....'E, -*I -•---•----------------------•----------•--•-------•-----•--- has been installed in accordance with th rovisions of TITL' 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit Nre _?_7Sr--------------------- dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHAMNOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION S TISF4�CJJTORY. / DATE............................... 5 11.-•----_-----...... Inspector.... !' G - THE COMMONWEALTH OF MASSACHUSETTS BOARD ,.WF HEAILTH ��C" lJ�-z oF... r,� ....a �.............................. ... Fw................... ;R?Rio o�tt1 �rk� �oat,�#rion .rr�i� I~ Permission is hereby granted-- - r�..c �� � to Construct) or Repair ( ) ndlvidual Sewage Disposal System at No......... ..*A ..4.......V...... treet �V as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... ' ........................... Health DATE................�Z z ............................... FORM 1255 HOBBS &.WARREN. INC.. PUBLISHERS I _ FZ=0N4 Tiry I E!! I, r t •f 1L 1 1` k ` j - 1M K /� r {1giSRa .p - x f , 5 . :.x� 1., � i' K ���_J• V. � � b . - it k ; e ,b t&°� TV* (ETA ) , LEGEND. ,r � EXISTING SPOT ELEVATIQN o OxQ CERTIFIED PLOT PLAN EXISTING CONTOUR .,.,.. 0 .�,,,;_ /<'n/D 7 FINISHED SPOT ELEVATION $� _ G�r—NT�-Ae— 4 5 INISHED CONTOUR O7-7 'APPROYE:D BQARD OF HEART 1N D E A GENT i 8CIALEt / /l= U r DATESi LD KEDGE ENGINEERING C42 lN: CLIENTS s. 1. CERTIFY THAT THE PROPOSE .. r EGISTERE, REGISThRRID J+qG NQ /. BUILDING SHOWN ON THIS PLAN CIVIL LAND`—, CONFORMS TO THE ZONING .LAW$ DR.S � '-ems� E ,. R r, ��� QF GAR:N$T �LE, MASS. , 712`MAIN ST HYANNISI%1MAS3. k SNEET:.�.OR' ,�.,.... DATE EG. LAND SURVEYOR IVOTW //r E17MCR TJ,I�E SEPTIC.rAMK OR s '1GtI/NG Aplr,Am4r MORE r,f /2"d.R�L0PV GRAAN 14 ?4��DIAM INTER Co/yG'A' TF Cov.�. ' AMALI BE !lROL K7 T® 61�'AGE.CAW.EXTRA_PV&'oY qC' P l CONGR!'Tfi` � J5►EAYY CI15T/RON GOI/2'R Sg/ALL BE-USED erg cow I p MiIV. 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