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0040 OLD STAGE ROAD - Health
40 Old Stage Road, Centerville T to �' ��• . - ' ���,�� J�QEaaF000UPC 12543 S � No. 53LOR co HASTINGS. MN IL r. A `' DATE:�/5/01 ----- PROPERTY ADDRESS; M-Old Stage RQ,�c�•_____ Centerville_Mass.__---_ —_ 0263_?---------------- On the above date, I Inspected the eeptlo system at the above address. This system conslsts of the following; 1 . 1 -1000 -gallon septic tank. 2. 1 -Distribution box. 3 . 1 -1000 allonda3edopi myl�i ,s ;FRFPiT`-�el?Atr the following oondltlon3I' 4 . This is a title five septic system. ( 78 Code ) 0 -ill 5. The septic system is in proper working order at the present time. 6 . The leaching pit is presently dry. SIGNATURE:./ ---•�=� if� Company; Jos..2h_F _ Hacombor_b Son , Inc , Addrem_ Box-66 Centeryi11e L Ha__02692-0066 Phone ,--- 54B_775_ THIS CERTIFICATION OOES NOT CONSTITUTE A OVARANTY OR WARRANTY J6SEPH P. MACOMBER & SON, INC- Tsnks•C�ispoola•l.iichll�lds Pumped L Initillod Town Sswor Connsotlont P.O. Box 6775,JJJ tiry lif, M 102632.0066 RECEf 'E® 0 9 zoo, TOWN LTH DEPT. T BLE r • L _I -\ COMMONWEALTH 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 PART A CERTIFICATION Property Address: 40 Old Stage Road Centerville,Mass. Owner's Name:Steven Metzger Owner's Address:l 805 Ridge Road North Haven CT 06473 Date of Inspection:Z f S 101 Name of Inspector: please print) Joseph P.Macomber Jr. Company Name: J •P•Macom er & Son Inc. Mailing Address: Box 66 Cen ervi e,Mass. 02632 Telephone Number: 508-775-3338 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes �— Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: ADate: The system inspector shall s mit 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 or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments 1 ****This report only describes conditions at the time of inspection and under the conditions of use at that tip me. This inspection does not address how the system will perform in the future under the same or different conditions of use. s Title 5 Inspection Form 6/15/2000 page I t "Paee 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Old Stage Road Centerville,Mass. Owner: Steven Metzger Date of Inspection: 2/5/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _gZL7) 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: - ZIM& B. System Conditionally Passes: -AA_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. �Q The septic tank is metal and over 20 years old* or the septic tank'(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: �j Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _,L)L The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 r � Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Old Stage Road Centerville.Mass. Owner: Steven Metzger Date of Inspection: 2/5?01 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 envirorunent. 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: NO Cesspool or privy is within 50 feet of a surface water Alp 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: NO 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. a The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. 4).& The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. VO The Svstem has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: �n�la 3 r Page 4 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 40 Old Stage Road en ervi e,Mass. Owner: Steven Mpt4apr Date of Inspection: 2 5 1 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 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool — —Z Static liquid level in the distri ution box above outlet invert due to an overloaded or clogged SAS or cesspool f- 14 �f C Orly 7 _ Liquid depth in.�es ,! is less than 6"below invert or available volume is less than h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped--b-. _ V/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. _ y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) A/Q (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large 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. 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 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. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 40 Old Stage Road (_' ntervi 11e.,MasR Owner: ,Steven Metzner Date of Inspection: 2 f S 01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _qPumping information was provided by the owner, occupant, or Board of Health ZWere 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 pan 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? 4z— Was the site inspected for signs of break out ? Were all system components,Oluding the SAS, located on site? -- Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum ? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example, a plan at the Board of Health. �_ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(3)(b)] 5 7 � 'Page 6 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 Old Stage Road en ervi e,Mass. Owner: Steven Metzger Date of Inspection: 5 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): =ly � Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system (yes or no): &P [if yes separate inspection required] Laundry system inspected (yes or no): Seasonal use: (yes or no):*-f Water meter readings, if available(last 2 years usage(gpd)): / � Sump pump(yes or no): AD D'- Last date of occupancy: COMM ERCIAULNDUSTR.IAL Type of establishment: Design flow(based on 310 CMR 15.203): ,Q�gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present (yes or no):d2 Non-sanitary waste discharged to the Title 5 system (yes or no):,dk Water meter readings, if available: ,rJd Last date of occupancy/use: ,r';4 OTHER(describe): GENERAL INFORMATION Pumping Records �� Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons-- How was quantity pumped determined? 104 Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool .Ud 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 V Other(describe): App ximate age of all co onents,date installed (if known)and source of information: �T1 lLZtl.�� Were sewage odors detected when arriving at the site(yes or no):/M 6 r • Page 7 of 1 I OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Old Stage Road Centerville,Mass. Owner: Steven Metzger Date of Inspection: 2/5/01 BUILDING SEWER (locate on site plan) y Depth below grade: Materials of construction: cast iron 40 PVC yQother(explain): nlR Distance from private water supply well or suction line: 01A Comments(on condition ofjoints, venting, evidence of leakage,etc.): Joints appear tight,No evidence of leakage.System is vented lGoo 94V.,'Xl5 through the house vent. SEPTIC TANK: lzoocate on site plan) Depth below grader Material of construction: ✓concrete 1,10 metal tine fiberglass,yUpolyethylene AV other(explain) Z/� If Lank is metal list age:.!t�o Is age confirmed by a Certificate of Compliance(yes or no):nr4 (attach a copy of certificate) Dimensions: P6".��,e� `X1iG.�' s'�7j Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:/a� _ Scum thickness: Distance from top of scum to top of outlet tee or baffle:�L Distance from bonom of scum to bottom of outlet t�ee$r baffle: Ho,A 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.): ,Pump the septic tank every 2-1 years IL Pt & outlet toss are 'in -place.The tank is structural ly sniind and shows nQ -Qvidenee of leakage. GREASE TRAP,i (locate on site plan) Depth below grade: 4,0 Material of constructionw,4 concreted&metal&,±fiberglassjlg olyethylene/other (explain): 14A Dimensions: 414 Scum thickness: ,f)_4 Distance from top of scum to top of outlet tee or baffle: ,r/,4 Distance from bonom of scum to bottom of outlet tee or baffle: 00 Date of last pumping: A�W 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 is not a rPcant 7 Page 8 of 1 I ' OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Old Stage Road Centerville,Mass. Owner:Steven Metzger Date of Inspection: 2 f 5/o 1 TIGHT or HOLDING TANK:,t,&e. (tank must be pumped at time of inspect ion)(locate on site plan) Depth below grade: AM Material of construction: concrete&(d_metal A�A fiberglass A&I polyethylene _other(explain): AA Dimensions: 4JA Capacity: NA gallons Desien Flow: gallons/day Alarm present(yes or no): Alarm level: �/L Alarm in working order(yes or no): Date of last pumping: A)A Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present DISTRIBUTION BOX: Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 40 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.): Distribution box has one lateral Nn tzNddence of solds carr-�? over-No evi dpnre of 1 eakagA into-nr out of the hQX. PUMP CHAMBER:4,6j (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump chamber is not resent 8 Paae 9 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Old Stage Road Centervi e,Mass. Owner:Steven Metzger Date of Inspection: 2/5/01 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number: v6 leaching chambers, number:Q _A)Qleaching galleries,number:C leaching trenches,number, length: _ leaching fields,number,dimensions: A.24 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.): Loamy sand to boney sand to fine sand.No signs of hydraulic failure or ponding-Soils are dry. Vegetation is normall CESSPOOLS/I.�u�(cesspool must be pumped as part of inspect ion)(Ibcate on site plan) Number and configuration: L7 Depth—top of liquid to inlet invert: Depth of solids layer: .,14 Depth of scum laver: _ Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): d Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Cesspools are not present. PRIVY:.tfucit (locate on site plan) Materials of construction: lt)i,? Dimensions: AIV Depth of solids: Comments(note condition of soil;signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present. 9 z y r ^ Page 10 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Old Stage Road Centerville,Mass. Owner: Steven Metzner Date of Inspection: 2 f 5/n 1 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. ri mad •u o•L ''E 0 0 t3•� r �:� tro'�geat�x0.1 Ae .zo uo IttctTUU9,4ap ;0. pot(goul a912Apunozb 04 ggdap uaiymaNnouo os Hyd3Q AJ 4�d pauopuBgl3 Mou eav sToo'dssao - 17- -- .puvs UV910 'rT o xo© odssao q om4 UT p9TTTdj0 T Page I 1 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ProperT Address: 40 Old Stage Road Centervi e,Mass. Owner: Steven Metzger Date of Inspection: 2/5/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Pleases indicate (check) all methods used to determine the high ground water elevation: lv/ btained from system design plans on record - If checked,date of design plan reviewed: ite a uttutg prope bservation hole within 150 feet of SAS) ith local Boar o Health-explain: p� A S �6il.�i f3h�ecked with local excavators, installers (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used water con o i G ma_n_ Gahrety & Miller Model 2/16/94 II r1.f}T^A•'I"I^Tr 11rTl...'PT'TTRitT.TRI'.T•tT�fT11RATTffT.1V�11�l�III.T �_ ' TOWN OF Barnstable BOARD OF HEALTH 0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D .- CERTIFICATION +,•T••.••.• —�.1 I I.�—TT1.T.a•TII•R.7'.I.TT 4T1flTTrl•.r t'1 r1N7'R't IIRIr—TRRR'AI fA'�.111�'A'..T7 R.I.IITATR1�ir^T1TTI�R.�..•I•r "-.�. ._. -TYPO OR PRINT CI.EARL1'- PI10PERT Y INSPECTED STREET ADDRESS 40 Old Stage Road Centerville Mass . ASSESSORS MAP , BLOCK AND PARCEL # OWNER' s NAME Steven Metzner PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Son InC`. ' COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State CIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of -inspection . The inspection was performed and any r ecominendationss regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec one ; System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public healLh or, Lhe environment as defined in 310 CMR 16 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form , System FAILED* The inspection which I have co acted has found that the system fails to Protect the pilblic 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 . e Inspector Signature Date copy of this ce if1cation must be provided to the OWNER, the BUYEROne Where applicable ) and the BOARD OF HUAL7'II. * If the inspection FAILED, the owner or"' perator shall upgrade within one year of the date of the inspection , unless allowed ort required he m otherwise as provided in 310 CFIn 16 . 305 . partd . doc Commonwealth of Massachusetts 8 Executive Office of Environmental Affairs Department of REcEvEV Environmental Prot My WWlua F.Weid 1 1997 �Trudy Core aO""1O/ TOWNOFBAIIIIABLE a.ae.q An" Paw C*UUcd Q HEALTH OEPL B.Struhs LL 0ownor �,`, corrvni�.lorw t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSP PART A CERTIFICATION PropertyAddreew 40 Old Stage Road Centerville ,MA Addreeaotowaer. 11 Silver Hill Road Data of Inspection:4/1 6/9 7 (It different) Weston,Mass . 02632 Name of Inspector.J o s e ph P.Macomber Jr. Company Name,Address and Tele hone Number. J. P.Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT 1 oartLO that I have personally inspected the sewage disposal system at this address and that the information reported below is true,aomrats AM Complete as of the time of inspection. The,inspection was performed based on my training and experience in the proper function and matataaaace of on-site sewage disposal systems. The system: / Pasaes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Falls Inspector's Slgnatw. �i//� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days,of completing this insPoal a. If the system is a shared system or has a design slow of 10,000 gPd or greater,the inspector and the system owner shall submit the report to the sPPrapriate regional office of the Department of Enviroaaeatal Protactica. The original should be seat to the system owner wd copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Chock A. B, C, or D: AJ SYSTEM P ES: I haw not found any information which indicates that the system violates any of the failure criteria ss deaned is 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B J SYSTEM ONDITIONALLY PASSES: • Gas or more system Compoaeats used to be replaced or repaired. The system,upon complstion of the replaoament or repair, passes '""Won* Iadieate des,nonot determined(Y,N,or ND). Describe basis of determination in all instances. if'na determined-,apwn why not) /V The septic tank is metal,cranked,structurnlly unsound,shows substantial iniiltration or ex8ltration,.or tank failure is imminent. The system will Pass inspection if the exist septic tank is replaced with a nfo�gP J� rming sspUc teak as approved by the Board of Hsalth. (revised 11/03/95) I One Winter Street a Boston,Massachusetts 02106 a FAX(617)5WI049 a Telephone(617)292.5500 t�IrNHrd on RocKied rapw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddrees: 40 Old Stage Road Centerville ,Mass . owner. Richard Sher Date of Imapeotiom: 4/1 6/9 7 B)SYSTVd CONDITIONALLY PASSES(continued) 4&/f, Bewage backup or breakout or boh static water level obearved in the distribution box L due to broken or obstructed pipo(s) or due to a broken,settled or uneven distribution boz. Ths system win pane inipectloa if(with approval of the Board of Health): brokam pipe(a)are replaced . obstr,uebm is removed distrmution box is levelled or replaced .(JU' The gstam required pumping more tban four timer a year due to broham or obstructed pipe(s). The gstam will pass inspection if(with approval of the Board of Health): broken pipe(s)w replaced obstructkm is rwuoved C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTEU A'�P Conditions exist which require Au4bar evaluation by the Board of Health in order to determine if the kystam is Luling to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WLLL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A,24 Cesspool or privy is within 60 feet of a surface water &)6 Caapool or privy is,within 60 feetbf a bordering vegetated wetland or a salt marah. 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMLTIES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a wptk tank and soil absorption system and is within 100 fief to a surface water supply or tributary to a surface water supply. The system has a wptk tank and soil absorption gstam and is within a Zone I of a public watar supply w%L The system has a septic tank and soil absorption system and is within 60 Let of a private water suppbr well. &0 The system has a septic tank and sob absorption system Lad is lws than 100 fact but 60 feet or more from a private wits supply-4 unleea a wall water analysis for conform bacteria and volatils organic compounds indiutea that the wall is tree from pollution from that facility and the psewmos of ammonia altrogsm and nitrate nitrogen is equal to or lane than 6 ppm. 3) OTHER /1C1� (revised 11/03/95) 3 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) b Property Address: 40 Old Stage Road Centerville,Mass . Owner. Richard Sher Data of Inspection:4/16/9 7 DJ SYSTEM FAILS: , �)� • ivv I haw determined that the system violates one or more of the following failurs criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. 4/1) Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of sIDuent to the surface of the ground or surface waters due to an overloaded or clogged SAS or owapool. AA)e Static liquid level in the 4strbution box above outlet invert duo to an overloaded or clogged SAS or cesspool. I a,aa�► H r Liquid depth in cesepeet is Isar than 6'below invert or available volume is lees than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbs of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a oaspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is Is"than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analysed to be acceptable,attach copy of well water analysis for coldbrm bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: �Q The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant throat to public beaith and safety and the environment because one or more of the following conditions exist: d,2L' the system is within 400 foot of a rodeos drinking water supply the system is within 200 feet of a tributary to a surface dri:ildng water supply the system is located in a nitrogen sensitive area(Interim Wallhaad Protection Area(IWPA)or a mapped Zone 13 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program rvquiremoats of 314 CMR 6.00 and 6.00. Plorw consult the local regional office of the Department for further information., (revised 11/03/95) 3 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECIa.IST pr,pertyA,ddr,,s: 40 Old Stage Road Centerville ,Mass . Ownet. Richard Sher Date of Inspection: 4/16/9 7 ' Chock it the have been dons: p a�Information was requested of the 2wgg.occupant,and Board of Health. one of the system componants have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumse of water have not been introduced talc the system recentby or as part of this inspection. 2AAs built plans have boon obtained and examined. Now if they am not avaikable with N/A. Z71 fatality or dwelling was inspected for signs of sewage backup. L The systam does not receive non or industrial waste flow The site was inspected for signs of breakout. system components,.e�ateluding the Sots Absorption System, have been located on the site. ZTba wptie tank maaholea ware uncgvered,opened,and the interior of the septic tank was inspected for condition of hem es or tees,matarial of construction,dim;nsions,depth of liquid,depth of sludge,depth of scum '1►a airs and lecst, a of the Soil Absorption System on the site has been,determined based on,ecisting information or ap ted by noa•intrusivo methods. The facility owner(and ooaipants,if dkSerwt from owner)were provided with information on the proper maintenance of Sub. Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addrvas: 40 Old Stage Road Centerville ,Mass . owner. Richard Sher Date of Inspeotiou: 4/16/97 FLOW CONDITIONS RESIDENTIAL- Design Design flow n+/� ��1 • Number of bedrooms: Number of current reaidsnta:0 Garbage erindar(.vw or no):,M Laundry coanactod to or no):,� ee Seasonal use(yee or noo) �.�^ Water meter reading, if available: b= ld e , . Iv-16 - 1 Doe - Last date of oocupaacy:�� COMMERCIAL ND S 7`po of establishment: Doeip Dow: AIA galloy/day Grease trap presaat: (yes or no).&�f Industrial Waste Holding Tank present: (yes or ao),g.�4 Non4a.nitary waste discharged to the Title 5 system: (yes or no)4 Water motor readings, if available: Last data of occupancy: OTHER(Describe) .424 Last data of oocupancy: A14 GENERAL INFORMATION PUMPING PCOjtDS urce f into do L., .z Systam pumped as part of inspection: (yw or no) It yes,volume pumped ors Reason for pumping: TYPE YSTEM 8eptie taak/ aoil absorption system Singia oeaspool , Overflow co"pool Privy Shared system(yes or no) (if yes,attach previous inspection reoords, if any) 07 Other(explain) APPROXIMATE AGE of all components,data iartalled(if known)and source of information: All' I1i7 Sewage odors detected when arriving at the site: (yes or no) (revised 11/o3/95) 6 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: 40 Old Stage Road Centerville,Mass . Owner: Richard Sher Date of Inspection: 4/16/97 SEPTIC TAN K:,L oe llyCf' (locate on site plan) AnQconcrete Depth below grade:_Material of constructi _metal _FRP_other(explain) Dimensions: # zp—leu 66' 7" Sludge depth: _` 4 ri Distance from top of��sl�dge to bottom of outlet tee or baffl , Scum thickness:- it _ it Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle.j,zdey Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle depth of Iioyid level in relation outlet invert, structural rity, evidence of leakage, etc.) PUMP tank-every 2-3 ears • nlet & outlet tees __'dZe in place : Liquid level at-outlet invert,is 9 t; e se- is tank , a. c- i i.t:+.,,dal 1 d' Gnijnrj Nn ci gnG of •1-PAkagP GREASE TRAP..,Vd4l& (locate on site plan) Depth below grade; Material of cons(ninion•; .*oncrete _metal _FRP_other(explain) ,dA Dimensions* Scum thickness:. Distance from top vt scum to top of outlet tee or baffle:4Ai Distance from bottom of srts- to honom of outlet tee or bahlerw Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, ett.i Grease trap is no presen s (revised I/15/9$) 6 L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddresa: 40 Old Stage Road Centerville,Mass . Owner. Richard Sher Date of Inspection: 4/1 6/97 TIGHT OR HOLDING TAN&&Ve (locate an site plan) • Depth below grade: AA h(atsrial of conwvct _metal_Flip othsr(explaia) Dimensions• A)A CapacityImllon- Design flow: Alarm level: comments: (oondition of inlet tea,condition of alarm and float switches,etc.) Tightor Holing Tanks are not resent. DISTRIBUTION BOX:JL'j)pj)C, (locate an site plan) Depth of liquid level above outlet invert:J_ Cammsats: (note if levol and distribution is equal,evidence of solids carryover,evidence of lealmp into or out of box,etc.) Distribution box is not presen . PUMP CHAMBER:.&Q,UC- G]ocaa on sito plan) Pumpe in working order:(yes or no)-Z& Commmu: (nots condition of pump chamber,condition of pumps and appurtenances,etc.) Pump chamber is not present. (revised 11/03/95) q "; •'': I • l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(ooatlawd) 40 Old Stage Road Centerville ,Mass . Owner. Richard Sher Date of Iasp.otlow 4/16/9 7 SOIL AWORPTION SYF= OW _k/_ Oocau cm site plan,if poa& ;aeration not required,but my be appradz atsd by aaa-latruaive methods) • If not determined to be pre6=4 e:plaia: Type- of P4 assarbar. 6"hias ahambere,camber. 6"hini P DdrW number. 6"hin treacbes, aambes,leagth: 6achiaj Salds,number, overflow m-pool,number" Cc—-:(nou condition of eoil,sips of hy&sulla allure,!oval of pondin4 condition of vegetation,etc.) MpHium to fine sand:No signs of hydraulic failure or pon ing: All wogetat; on ; a normal , CwSPOOL9r/'&f'e Qoeu on site Plan) Nambar and coafiguration D.pta-top of liquid to inlet iayrt: Depth cf solids layer Depth ad scum layer. Dimcmioas of osaspooi Materials Of ooastruetioa: Indication of POundwatw. indow(csespool mast be Pumped sa of lasPktioo)_ Commsat-(act.oonditioa of eoil,Sip+of kvdmulie(ai)ur.,level of pondia&Condition of reg t.tloa,eta.) Cess7000 s are not presen . PRIVYid,bV — aoc:u on ails Plea) ILA1,6fi-L Cfo0n9trUCdoa: NA Dlma-gtos. NA Depth of ealids NA • Cammeats:(nou condition Of eat,4PA Of hydraulic UBUN,level of poadlA&condition of veputka, per; .... ; c not present (revlsed 11/03/95)• i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks. or benchmarks locate all wells within 100' Centerville Osterville Marstons Mills Water Company 428-6691 --,,;—Filled in two block cesspool.0 with clean sand. l.7- , Cess.p.00ls are now abandoned.. W)l � r DEPTH TO GROUNDWATER depth to groundwater r thod of determin ion or approximat�oln: �ilj__Z-Xtems, in rids"- oca ion. I •rrnl'+.-nt•1�r-.Tra�ram•ns.wl�nnr.nanlrr•T+Tnn►I�rRRnT Arnt7tA!'e�nsT �'Pr��r-...-•,r-, TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •-. CERTIFICATION `� �•••rnR••.-: -T.lif.�..:T.'1J.tt•.+w'rt.Tnr7tr+rna+rlef•r.�-S7rtV7RTt>�-T� f7 ewn ..-•trrr•t--�.-. -TYPE OA P9114T C1.EAR6Y- 1 PIOPERTY INSPECTED STREET ADDRESS 40 Old Stage Road Centerville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # 208-041 OWNER' s NAME Richard Shbr PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & Svtf 'Inc. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE �08 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal 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 P consistent with my training and experience in the proper function and maintenance of on- site sewage di sposal istesai systems . Check one: aXXXXX$XI, Sys teui PASSED The inspection which 1 have conducted has not found any information which indicates that the 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 whictl I have con toted 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 . Inspector Signature Date 4/16/97 One copy of this rtification must be provided to the OWNER the BUYER ( where applicable) and the BOARD OF HEALTH. ' * If the inspection FAILED, the owner or"'Operator shall upgrade ' the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd .doc r THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the w Issued b The Department Environmental General Laws. y ep of E o tal Protection. June 8. 1995 Acting Director of the ' ' ton of Water Pollution Control f No..-••..1 A�l Fps...:.. ®�....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ...Town....._......OF.......Ba-rns.t ab.1 e Appliratiun -fur Uiipuiitt1 Works Tonotrurtiun Vrrni t Application is hereby made for a Permit to Construct ( )-'or Repair ( X) an Individual Sewage Disposal System at: Old___St_a_ge...Rd_,.,•__Centeryitle--•--_•_••__-___••_ AVIS_ 208/41?, .o8 - ---•--------------------------•----.------ Location-Address or Lot AVo. l�ndre Bella........................................•-••••-•-•-•--•---.-•-•- •45.9...S outh..S t.........Hy...nni s----- W Owner Address ` W Paul Owner ...32 Wianr;o A. ...Q. txvil Ile.................. Installer Address 08 Q Type of Building Size Lot..... ....................Sq. feet U Dwelling-X No. of Bedrooms....2--------------------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ---------------------------- No. of persons-------2------------------- Showers (1 ) — Cafeteria ( ) a' Other fixtures -2---wat-e-x:...c.J.:a.s.e-t�9......2...I.ay.s......2..-tuba,-.-.kit_chen...sink............. Q W Design Flow...........................5.0............gallons per person per day. Total daily flow---------1-4-0-------------------------..gallons. WSeptic Tank m Liquid capacity 1 OO(?gallons Length---------------- Width..---........... Diameter................ Depth.......--..--... x Disposal Trench—No--------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit NoLP_1--q9.9.... Diameter----6-'-_......... Depth below inlet-66................. Total leaching area---25Q------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.....no,t...raquire-d................................. Date.................------------.--..-.-_-- ,� Test Pit No. 1----------------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--.-..-..-.----.-._-___. s� ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------ x W U Nature of Repairs or Alterations—Answer when applicable-e-p. .a.aing--.e-xi-s.t_ing...a_e_S.sp.o.Ctl...w/ab.ove sys-tem.... n__ run--,out__.t_o.._service__ 1....bath__6----kitchen ----------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in _,op eration until a Certificate of Compliance has been issued by the bo rd o healt Signed....... ................- --•------- --------------------------------- / ate Application Approved By.. - �J`......-••---•--•............ .......................................... ------..........----D..at e-------------- Date Application Disapproved for the f ollou3ing reasons:............................................................................: .................................. r 6 .......,.....................•-_...........-_..--........----...-•-_-•--......._.........._..-..............-------_-_.......-.....---•-.----_-.-----.-..-...-_-_---.--_-.------------------.------------- / Date PermitNo..- (�•�•---••-••••-•---••-•-•••-•••..... Issued..................... ---------------••••• -••-•---••- Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA No......................... ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ..... ....Town. ----OF.......Bsrnetable. ..........:....... , pphratiutt -fur ii,ipuuttl Worko Tottarurtiutt Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: Old Stage Rd._a___Centerville__. _ AVZS 208�4 •-� Location-Address 4 or Lot No. Bella.....------ 4. -._ .Qyh__.5 • + y' t:�s............= Owner Address -Paul T. Lebel ...32---Vianno..Ave..,...0.s.t.er_v_i_1la................ Installer Address Q Type of Building Size Lot......i0$--------------Sq. feet U Dwelling-x No. of Bedrooms----2-------------------------------------Expansion Attic ( ) Garbage Grin er( ) per, Other—Type of Building ------------------------ -- No. of persons-------2------------------ Showers (1 ) — Cafeteria ( ) Other fixtures .2_--water... .1-Qset_V_,_---2_Ia-Y.S. ----2..-tubs,....kitchen---sink---------------- Q W Design Flow--------------------------30............gallons per person per day. Total daily flow---------100___..__--_-_-.---------.---gallons. WSeptic Tank S Liquid capacity-1 OOOgallons Length................ Width------.--------- Diameter---------------- Depth-----_--------- x Disposal Trench—No- -------------------- Width-------------------- Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit NoOp_1 000-__ Diameter___6_1............ Depth below.inlet_ 1.............. Total leaching area---2Q......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.----not---Mglii_x'Q_d---------------------------------- Date____-_____--_-_-----_--.------__---.-_.. Test Pit No. 1................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__.-.._____--_-----.---. W --•---•------------------------------------ -------•-----................................................................................................ GDescription of Soil------------------------------------------------------------------------------------------------------------------------- ----------------------------- --------------- x U ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------ W V Nature of Repairs or Alterations—Answer when applicable;r!PPI c.ing-__exi-S.t.11.ng:__aess ool_--W f ab-ove system on run out to service 1 bath 8& kitchen ---------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 .......... -- i�= - /--------------- ---•-- --•- f - ' Date ApplicationApproved BY-------------------------------------------------------------------------------------------------- Date Application Disapproved for the following reasons:.--------------------------------------------------------------------------------------------------------------- ...........................................S ='-........................................---------•------------------ ..... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD,,,OF ,•HEAALTH ........................................'OF..................................................................................... ,. . TInlifirate of 101k1lut;1hatta THISIIS;-TO ifERTIF,Y,;That the'hndividuar Sewage Disposal.System constructed ( ) or Repaired ( ) by ..... --•----------------------- -------------------------•--••-••••----•-----------------....•--•---------------•-•----•--•-------- Installer at---------------------------------------------- has been installed in accordance with the provisions of Article NI of The State Sanitary Code as described in the a application for Disposal Works Construction Permit No------------------------------------------ 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 y f ..........................................OF......................-------------------- ---................---.......------..... No......................... FEE........................ . � u.�tt1 urk,� �utt,�trttrtiutt rrutit Permission,-is hereby granted -='._ '; ----••--------...Zx 2 _42---- ;•;---• -,>-;•-•--•----------•------------------------ to Construct ( ) or Repair (. ) an Individual Sewage Disposal System at No ---- ---- i . . Street f as shown on the application for Disposal Works Construction Permit No--------------------- Dated---------.------------•............_....... -----•---------•----------------------------------- --•-----------------•------••-----------••----------- Board of Health DATE.................-............................................ -----------•----- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS LO%CAT ION� SEWAGE PERMIT NO. �*o D- / VILLAGE INSMA LLER'S NAME & ADDRESS B UI'LDE R OR OWNER DATE PERMIT ISSUED 0ATE COMPLIANCE ISSUED ���s a _.. yy,.ary�r ..�. ,. a ae TOWN OF BARNSTABLE 1,0CATION re, , .SEWAGE I VILLAGE e,eX)4-rLJj jf. ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(cype) (sLze) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: RIANCE GRANTED: Yes No �� �� �9 Q ;�. i9R'Ckl �� � `-1 ,♦ � t11� � M, ,���. i i