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HomeMy WebLinkAbout0613 OLD STAGE ROAD - Health 613 Old Stage Rd. (Centerville) E No. 42101/3 ORA ,�aY 10% , 0 o a a a U TOWN OF BARN TABLE �`vC;e►TIt�N �� SEWAGE # VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 i LEACHING FACILITY: (type) 1� (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE:' Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 Le ching Facility(If any w ands exist within 300 fee f 1 hi cility) Feet Furnished b f lie , �� 0ATE ,9/12/01--------- - PROPERTY AOORESS;613, Old Stage Road ---- - 'Centerville,Mass_------ ------------------------ On tho aboye data, I Inapooted the oeptfo uyiteM at the aboye address This iyatom conslata of the (ollowlnst 1 . 1 -1000 gallon septic tank, . 2 . 1 -Distribution box. RECEIVED 3 . 1 -1000 gallon precast leaching pit. sexed on my Inepecllon, I certify the followlns oond t1or0T 0 9 2001 4 . This is a title five septic system. ( 78 Code ) 5. The.-septic system is in proper working order TOWN OFBARNSTABLE HEALTH DEPT. at the present time. 6 . Waste water is 64" below the invert pipe of the leaching pit. SIQKATVRe rr a m e ! S Q a k cr-..U---_-- Company; Jo , .,ph_P _ Necowb!r-b Son , Inc , Addreaa ; Box 66------ __0vnce^rY1IleLAG- 026J2-0066 Phone - S08 115- 7>>8_- THIS CCATIFICATION GOES NOT CONSTITUTE A OVARANTY OR WARRANTY a JOSEPN P, MAOOMBER & SON, INO, T+nkiOr��pooltl.��chll�ld� Pvmptd 4 In+tilltd Town S+wfr Conniotlontl P.O. Box 66 C1nlirYllle, MA 02632-0066 rrs.))�o rrs 6�1z �Y• r COMMONWEALTH OF M.A,SSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 613 Old Stage Road en ervi e,Mass. Owner's Name: Brian Stewart Owner's Address: 46 Meadow Lane e . 02668 Date of Inspection: 9 1 2/01 Name of Inspector: (please print) Joseph P.Macomber Jr. Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 Centerville,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 rraining and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to S,tion 15.340 of Title 5(310 CMR 15.000). The system: Y Passes _ Conditionally Passes Needs Further Evaluation by the Local Approving Authority _ Fails y� g Inspector's Signature: usC Date: The system inspector shall 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 v "'This report only describes conditions at the time of inspection and under the conditions of use time. This inspection does not address how the system will perform in the future.under the sameor"different y conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l l OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 613 Old Stage Road en ervi e, ass. Owner: Brian Stewart Date of Inspection: 9/12/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A=SystemPasses- �L I have not found an information hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 31(T 15,304 exist. Any failwe criteria not evaluated are indicated below. Comments: The septic System is in proper working order at the present time. 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. Answer yes, no or not determined(Y,N,ND) in the 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. ND explain: 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: 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 `y Page 3 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 613 Old Stage Road Centerville,Mass. Owner: Brian Stewart Date of Inspection: 9/1 2/01 C. Further Evaluation is Required by the Board of Health: tic, 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. I. 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 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: a 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. 40 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 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: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 613 Old Stage Road en ervi e, ass. Owner:Brian Stewart 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 __jZDischarge 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 1.4-p->if v _ Liquid depth in4ssspeel is less than 6"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 I . YV 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 1 of a public well. mportion of a cesspool or privy is within 50 feet of a private water supply well. y 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.] (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 _ �1-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 li 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 4 Page 5 of 1 1 a OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 613 Old Stage Road Owner: Brian Stewart Date of Inspection: Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No/ !/ umping information was provided by the owner, occupant, or Board of Health y ere any of the system components pumped out in the previous two weeks? as 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,Ukuding the SAS, located on site? _ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition �f the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth o c p q p g p fs um . 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 nVExistLng information. For example, a plan at the Board of Health. 7_ 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)) I 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 613 Old Stage Road Cen ervi e, ass. Owner: Brian Stewart Date of Inspection: 9 12 01 RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): OA [if yes separate inspection required] Laundry system inspected(yeA or no): �' Seasonal use: (yes or no): iit) /J Water meter readings, if available(last 2 years usage(gpd)): — , A Sump.pump(yes or no):iL ,.fDc{�- � ��y, Last date of occupancy:,, COMMERCIAL/INDUSTRIAL 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):.eX Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): _ GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or .40 If yes, volume pumped: e) gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool P 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 ;d Attach a copy of the DEP approval Other(describe): Approxi ate age of all components,date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):yj 6 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: 613 Old Stage Road Centerville,Mass. Owner: Brian Stewart Date of Inspection: 9/12/01 BUILDING SEWER (locate on site plan) Depth below grade: l Materials of construction:Mast iron Z40 PVC .11 Ether(explain): �ql Distance from private water supply well or suction line:,j/) Comments(on condition of joints, venting, evidence of leakage,etc.): Joints appear tight.No evidence of leakage_ThP system ; s vented through the house vents. SEPTIC TANK: (locate on site plan)A"'5K�5 >i Depth below grade: Material of construction: concrete/metal,fiberglassP/ polyethylene �ther(explain) If tank is metal list age: U Is age confirmed by a Certificate of Compliance(yes or no):,0 (attach a copy of certificate) Dimensions: Sludge depth: Distance from top 9f dge to bottom of outlet tee or baffle:1,,e� Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee pr baffle: How were dimensions determined: A.�// 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 P-,;,Pry?--A ears.lnlet &outlet tees are in place_Th tank is str„ct„rai ly so,-ind sound and shots no evidence of leakage.The liquid level at the outlet invert is 51 " GREASE TRABC(locate on site plan) Depth below grader Material of construction-,&o concrete l metal fiberglass t�P_poIyethyIene,{!other (explain): 'dM Dimensions: I/� Scum thickness: &d _ Distance from top of scum to top of outlet tee or baffle: A41 Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 1614 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 nct present- 7 Page 8 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 Old Stage Road en ervi e, ass. Owner: Brian Stewart Date of Inspection: 9 12 01 TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: A4 Material of construction:AZ concrete meta l r1.,_fiberglass/polyethylene yff other(explain): Dimensions: 424 Capacity: PR allons Design Flow: JM gallons/day Alarm present(yes or no): Alarm level:_A Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): Tight or holding tan sure not present. DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 7 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.No evidence of solids carry c)vpr No evidence of leakage into or out ot the box. PUMP CHAMBEM / (locate on site plan) Pumps in working order(yes or no): W-H Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump chamber is not present. 8 Page 9 of I I Y OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 613 Old Stage Road en ervi e, s. Owner: Brian Stewart Date of Inspection: 1 SOIL ABSORPTION SYSTEM (SAS): zocate on site plan excavation not required) 1-1000 gallon precast leaching pit. 6tX10 ' If SAS not located explain why: Located Ty1/lpe/ - leaching pits, number: k leaching chambers, number leaching galleries,number: leaching trenches, number, length: _ leaching fields,number, dimensions: , !overflow cesspool, number: > innovative/alternative system Type/name of technology/TiCt� P')l/P t� L 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 pond ing.Soi s are dry.vegetation is 11UTILICX1. CESSPOOLSvRA?_ (cesspool must be pumped as part of inspect ion)(locate on site plan) Number and configuration: Q Depth—top of liquid to inlet invert: tll� Depth of solids layer: Depth of scum layer: Dimensions of cesspool: __ Jl 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.): Cesspools are not present. 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.): Privy is not present. 9 Page 10 of 1 I y OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 Old Stage Road Cen ervi e,Mass. Owner: Brian S ewart Date of Inspection: 9 12 01 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. 1 3 --r-4,\ lie- i 22 i 10 r 3► Page I I of 1 I r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 613 Old Stage Road Centerville,Mass. Owner: Brian Stewart Date of Inspection: 9 12 01 SITE EXAM Slope Surface water Check cellar Shallow wells I Estimated depth to ground water,9 feet Please indicate (check)all methods used to determine the high ground water elevation: A/Abrained fr stem design plans on record - if checked,date of design plan reviewed: �Oheckved ed site(abutttng proper bservation hole within I50 feet of SAS) wtt loca oaz o ealth-explain: Checked with local excavators, insta lers-(art h documentation) \Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used; Garity & Miller Model 12/16/94 Used; USGS )bservation Well Data For June 1992 Used; USGS; 92-0001 Plate # 2 Top of Ground Leaching Pit 'eet Groundwater:yltFeet Below Bottom of Pit Therefore, the vertical separation distance between the bottom i of the leaching pit and the adjusted groundwater table is 91 feet. Il m:nrn,—nrr.--rri.sr—mr•nm'v-�•rrt rnrm'r::�•rro+rrl�se*+nrtn ncrn-v*+e�rt� � .. TOWN OF Barnstable IlUARU OF HEALTH SUIISUItFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I•.•rr��r•.-:•r—r.rr. rnmr.+n-rrann rair+esrrrn-m�-rs��:rr+err annsr� si ersw�7 "Mn V ..err*-•r-n, •'..A -TYPO OR PRINT CI.EARLY- PROPERTY INSPECTED 613 Old Stage Road Centerville,Mass. STREET ADDRESS ' ASSESSORS MAP, BLOCK AND PARCEL # n1G0 lq 1 _ P�arcP 1 Lp OWNER' s NAME Brian Stewart PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J-P•Macomber & Son Ines: ' COMPANY ADDRESS Box 66 Centerville,Mass.02632 Street Tow„ or City State LIP COMPANY TELEPHONE ( 508) 775 - 3338 FAX ( 508 ) 790 _ 1578 R CERTIFICATION STATEMENT I certif that I have Y 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 recommendations regarding upgrade , maintenance , and repair are co with my training and experience in the nslstent proper function and maintenance of on- site sewage disposal systems . Chec ne System PASSED The inspection which I 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 which I have con acted has found that the system fails to Protect the j)ublic health and the environment in accordance with Title 5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date ., � e copy of this t.ificationmust be provided to the OWNER, the BUYER On where applicable and the BOARD OF HEALTIi. * If the inspection FAILED, the owner or"operator shall u he within one year of the date of the inspection, unless allowed dort required eyetem otherwise as provided in 3.10 CFJR 16 . 305 . partd .doc i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION W � � d h A� t OW I�M 5y0 v TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner's Name: BRIAN STEWART , Owner's Address: 46 MEADOW LANE 02660 Date of Inspection: 8/23/01 k Name of Inspector: (please print) r,;, JOHN GRACI Company Name: SEPTIC INSPECTIONS Mailing Address: P.O:'BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 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(3.10 CMR 15.000). The system: X Passes _ Conditionally Passes _ Needs Further aluation by the Local Approving Authority _ Fails Inspector's Signature: Date: 8/23/01 The system inspector shall submit a her of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. I 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 SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. ****This report only describes conditions at the time of inspection and under the conditions of use at that liwe.This inspection does not address how the system will perform in the future under the same or different conditions of use. Titlo 5 Incnrrlinn For", r,/I"nnnn I Wage 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. n/a 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: n/a n/a 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 . t _ obstruction is removed . _ distribution box is leveled or replaced ND explain: n/a n/a 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 Boat&.df Health): _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 613 OLD STAGE RD CENTERVILLE, MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 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 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 wli_ich will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. i _ 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 n/a "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/a #f, z Page 4 of I 1 , t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 1..r Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner: BRIAN STEWART , Date of Inspection: 8/23/01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each ofthe following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. _ X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (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 forma _ (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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet ofa tributary to a surface drinking water supply s: _ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply.well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered 0yes" in Section D above the large system has failed: 'The owner 01:operator of any large sy®tem comidered a §ignilieant 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. n Page 5ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No X _ Pumping information was'provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period`? X Have large volumes of water been introduced to the system recently or as part of this inspection X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out'? X _ Were all system components,excluding the SAS, located on site'? X _ 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 9 X _ 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: 8 f Yes no X _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any bf the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] a I 5 'Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 t : FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use:(yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a t Design flow(based on 310 CMR,15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the`Title'5 system(yes or no): NO Water meter readings, if available:.n/a Last date of occupancy/use: n/a t OTHER(describe): n/a GENERAL INFORMATION Pumping Records j Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a Reason for pumping: n/a TYPE OF SYSTEM X 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): n/a , s� Approximate age of all components,date installed(if known)and source of information: 1992 Were sewage odors detected when arriving at the site(yes or no): NO Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 BUILDING SEWER(locate on site plan) Depth below grade: 12" Materials of construction:_cast iron X40 PVC_other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints,-venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade: 6" Material of construction: Xconcrete_metal fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7" W 4'40"" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP:_(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):!' n/a •Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 OLD STAGE RD.CENTERVILLE,MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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 IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. PUMP CHAMBER: _(locate on site plan) Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a R Y Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632. Owner: BRIAN STEWART Date of Inspection: 8/23/01 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required) If SAS not located explain why: . n/a Type 1000 GAL 6' X 6' leaching pits, number: 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: n/a n/a ,innovative/alternative system Type/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEAR TO BE FUNCTIONING PROPERLY.THERE HAS NOT BEEN MORE THAN 2' OF WATER IN IT. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number.and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): n/a --Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 OLD STAGE RD CENTERVILLE,MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 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. C o /} 6 AA K Ac y° A c �p N9 e BCab� CAa cg 33 CC 2 3 1- f 10 Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 613 OLD STAGE RD CENTERVILLE, MA 02632 Owner: BRIAN STEWART Date of Inspection: 8/23/01 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 10+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,installers-(attach documentation) YES Accessed USGSdatahase-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS-10+FEET ' TOWN OF BARNNSTABLE / Z '► r� i V S E W AG E # `! LUCt1TION �� VILLAGE s SILL N ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. l'jJ/l �� ��� 27 9 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) / ^—(size) NO. OF BEDROOMS PRIVATE WELL 0 ,' PUBLIC WIATER BUILDER OR OWNER 4rA-Y,-) DATE PERMIT ISSUED: 5 6 b DATE COUPL'IANCE ISSUED: VARIANCE GRANTED: Yes No LR a GG�� G No....70_:=.ado Fles..... ........... THE COMMONWEALTH OF MASSACHUSETTS AMOVED BOAR® OF HEALTH ft C==vataDepantmTQWN OF BARNSTABLE Signed Date spusai Works Tnnitrnrtiun ami# Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Disposal System at: 13 ©tee 57-4 - - � ��^�.�. -A r "��.--•--� ...............•------•-•--....--•--•-----or-Lot No. ................' .......�._.1 _�1 . --•-.................. ---.............----................................ caner ��,,}}''��' Addr U Installer Address UType of Building Size Lot.................... .....Sq. feet �-, Dwelling—No. of Bedrooms................ .........................'Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitygallons 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 ( ) 0-4 Percolation Test Results Performed by................................................................---•----- Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 .-•-•--------------------------------•-------------•---•---------•--------••--------.....---._...........------------------------------• ... 0 Description of Soil.................................................................................................---.......------------•---------------•-------------- W U ---------------------------------------•-••----------------------•----------••---•---...-----•----------••--------------------------------------•--•-------•-•---------- --•------ -..... •----- --------- W U Nature,of Repairs or Alteration—A wer when ap$licable....____�!,! l I�.I�-�L_........�__....... ...J ��.—�-` Agreement: 11 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 been issued b the board of health. �j�� Signed ...... v /. J/Z-G Z f ------ ApplicationApproved By ............. .. ------------------------------------------------------------------------------- Date Application Disapproved for the following reasons- ...................................................-------------------------------------------------------------- ------------------- ..... .. .. ............ . Dare Permit No. ---------7.--off.........0�.;k.)--......................... Issued -- ------------------- -- Dace No.---. =-� FimB............3.. V VVV THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` TOWN OF BARNSTABLE parks Tomitrur'fi n ramit Application is hereby made for a Permit to Construct ( ) or Repair (k) an Individual Sewage Disposal System at pL `c- .......... l 3....................... ............ ......------- ------------------------•----------•. -----•--••------....................----- /f I� •Location rgs��T or Lot No. •- .............-----------..���.........�.j..� 5 ----------- -------- ............................... ` a fawner /J �Addres a / ..2�L.. �� {_K/. k .pJZ .......... `Irk___ ' ` h.............................................. Installer Address UType of Building Size Lot............................Sq. feet I—I Dwelling—No. of Bedrooms.............. _________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d 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........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 W ----•-----••----------------------••--••-•---••----•----••-•----•--•-•-----•-•-•----•---------------......................................................... Description of Soil........................................................................................................................................................................ x W -••--------•--•-•••-----•-------•-••-•--...•-•-•---••••---•-•-••-•-------••••-•••---••--------•-•----•--•-•--------•-•---------•••-•••---••-----•-----••••..................•-----•-••••••...._...-•••- W x --d?-� - U Nature of Repairs or Alterations--An$wer when applicable--.....-;/l -�1- ---------Z1��---��L L 1�'1// - y 't/w/J !'�/ 7�n 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 been issued b, the board of health. Signed ...............v"� ..-:....--....-- --------..-..-..-------------:----...------- -.. -z- Dat Application Approved _: �� PP PP B Y C .-.... CQ'----------- Da-te Application Disapproved for the following reasons- ----------- ----------------- - ----------------------------- ...-.-..-.....-------- ...----------------------- ---------------------------------------------...............----------- ........... . ...........................---- -....--....---- -----------..------------....----------- --- -- -- ----- -------- ------------- -- ------ c�Permit No. ---------{ a-..'.. C ........................ Issued ....................................................... Dare ............ Due THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifirate of C oraptianre THIS IS TO CERTIFY 1hat the Individual Sewage Disposal System constructed ( ) or Repaired ( �) by --------------- ,� '.--...�1/ ---------- -- ............................................................. ^, Installer � at ---------- -- -3... ............ I / tf-L� - GI..................................... 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. ..........�,�.--..2---------------d------_-- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------5.- - /tx. .�--- -- -------------------- -- --- ---- ----- ------ -------- Inspector ----- ---------.t.--------................•.....................-----........................ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Disposal/ urkn �untrutiun rrndt Permission is hereby granted............M6_ U --•----- -�1-... e5- ----------------------------------------------------------------•--- to Construct ( ) or Repair -an Individual Sewage Disposal System at No........n.j__?i__..�1•L r' ---�----- - --------•--.---- _-...... Street q 7,G/ as shown on the application for Disposal Works Construction Permit No./d� d___ Dated_.____...../___.__...� Z-.--•--- ......................••-•--•. _-'�--------------•-•••----••••----••- � -- --•------•-----•-- DATE- `' ----------••----••••-•--•------ U Board of Health FORM 36508 HOBBS h WARREN.INC..PUBLISHERS