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HomeMy WebLinkAbout0009 POND VIEW DRIVE - Health 9 POND VIEW AVENUE, CENTERVILLE A= 278 030 I, //// atcvccE,a nkad, _°� UPC'i2543 No �rico � HASTING3.61N .r Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Foam - Not for Voluntary Assessments r 9 PondView Drive Property Address Peter Mondani Owner Owner's Name information required for every Centerville MA 02632 9-7-12 __�_ page. City/Town State • Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information filling out forms on the computer, �ZN�Fi1�gSs4�i,' use on.lytfie tab 1 Inspector: ``2� �cti key to move your ��Q. JAMES cursor do not = m 3 James D. Sears use the velum -- D. Se _........------ -Q' key. Name of Inspector = r� Capewtde Enierpnses, t_LC �* �p.•r�� ,y Company Name -- �F . I N SO- Off ��•��• 153 Commercial Street '7�r ,11,,,t„+,nX10" Company Address Mashpee _ MA 02649 City/Town Stale Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at.this addes and th tthe information reported below is true, accurate and complete as of the time of the inspection The mspction was performed based on my training and experience in the proper function and maintenanceof on�te sewage disposal systems. I am a DEP approved system inspector pursuant-to Section 16.340:.of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Failc [ " 4:�9 ❑ Needs Further Evaluation by the Local Approving Authority _ a_ _ 9-7-12 �sec=orsS�9—�na�tuF Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "'''"'This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Lott5ins•tin 0 Tills 5pection Form:Subsurr9w a Olsposal System•Page 10 17 C, Sep 11 12 10:34p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owners Name information is required for every Centerville __ MA 02632 9-7-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ms•11f is Title 5 Official Inspection Form:Subsurface Sewage Disposar System•Page 2 of 17 Sep 11 12 10:34p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -_ 9 PondView Drive Property Address Peter Mondani Owner Owner's Name information is Centerville MA 02632 9-7-12 required for every page. Citylrown State Bp Code Dale of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15 ns•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 d 17 Sep 11 12 10:34p p.4 Commonwealth of Massachusetts ECRUMN Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owner's Name information is required for every Centerville __ MA 02632 9-7-12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: " This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6' below invert or available volume is less than 112 day Flow tsins•11110 Tide 5 Official Inspection Form:Subsurface Sawage Disposal System•Pape 4 of 17 Sep 11 12 10:35p p.5 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 PondView Drive Property Address _ Peter Mondani Owner Owner's Name infor nation Is required for every Centerville MA 02632 9-7-12 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue to clogged or obstructed pipe(s). Number of times pumped.- Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. © ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet fro m a prorate water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009 pd. ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails_ The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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"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. lairs-11110 Title 5 Ofrlcial Inspecown Forth:Subsurface Sewage DIsposel System-Page 5 of 17 Sep 11 1210:35p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form -- 9 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 PondViiew Drive Property Address Peter Mondani Owner Owner's Name information is required for every Centerville MA 02632 9-7-12 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® _ ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? . ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Solt Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information` Residential Ftow Conditions: Number of bedrooms (design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 I 15ins-li1110 Title 5 Ofridal inspecdon Form:Subsurface Sewage Disposal System-Page 6 of 17 Sep 11 1210:35p p.7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 PondView Drive Property Address -"- -- Peter Mondani Owner Owner's Name information is Centerville required for every _ MA 02632 9-7-12 page. Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal Precast Tank D Box and Pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?lif yes separate inspection required) ❑ Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2010-21,000Gal Detail: 2011-10,000Gal Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commerciallindustrial Flow Conditions: Type of Establishment Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tsin •11H0 TWO 5 OrrciA h3peaion Form:Subamece sewage Disposal System.•Page 7 or 17 Sep 11 1210:36p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form -- _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 9 and e i w P V Drive Property Address Peter Mondani Owner Owner's Name information is Centerville MA 02632 9-7-12 required for every _ - --- page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System:. ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes,attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•1'Ino Tile SOHicial Inspection Form:Subsurlwo Sewepe Disposal System•Page 8 of 17 Sep 11 12 10:36p p,g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owner's Name information Is Centerville MA 02632 9-7-12 required for every --- ---- •-- page. City/town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 Permit # 86-8 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22" feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal Precast Sludge depth: 2" "Sin •11110 Tile 5 Offa ial Inspection Form:SubsWace Sewage Oisposal System•Page 9 of 17 Sep 11 12 10:36p p.10 Commonwealth of Massachusetts 1132�- Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owner's Name information is required for every Centerville MA 02632 9-7-12 page. 6 rrown state Zip Code Date of Inspection D. System Information (cont-) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or baffle 28" ---- Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and covers at 15", Tank at working level w/inlet Tee, outlet baffle, No sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle - —— Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11110 Tltle 5 Official Inspection Forte SuDsurtaoe Sewage Disposal System.page 10 of 17 Sep 11 1210:37p p.11 ' Commonwealth of Massachusetts --: LW Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owners Name information is Centerville MA 02632 9-7-12 required for every _ page, City/rown state Zip Code Date of Inspection__. D. System Information (cons.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: -- Material of construction; ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: — - Capacity: ----- gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No inns•11110 Title 8 Official Insved ion Form:Subswfaoe Sewage Disposal Sysiem•Page 11 of 17 Sep 11 1210:37p p.12 Commonwealth of Massachusetts - , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 PondView Drive Properly Address Peter Mondani Owner Owners Name iformation is every Centerville required foreve MA 02632 9-7-12 _ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 16"x21"-30" Below grade one line out,wl cover at 6" No sign of over loading or solid carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order. ❑ Yes ❑ No Comments note condi tion dion of pump chamber, condition of and pumps appurtenances, etc.}: Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: tsins•11110 TiM 5 ot5da:Inspetlton Forrtz Subsurface Sewage Disposal System•Pape 12 of 17 Sep 11 1210:37p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. - 9 PondView Drive Property Address Peter Mondani Owner Owner's Name information is Centerville MA 02632 9-7-12 required for every _. page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number. ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is one, 1000 Gal Precast Pit, Pit and cover at 14"below grade, No sign of overloading or solid carry over, pit is dry w/no sign of high stain line Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•i 1l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Sep 11 12 10:38p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form ry -� =I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owner's Name inq credo re Centerville MA 02632 9-7-12 required for every _______.._._. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): 151ns•11/1 D Tale 5 Official lnspectim Fomc Subwdace Sewage Disposal System•Page 14 of 17 Sep 11 12 10:38p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 PondVew Drive _ Properly Address Peter Mondani Owner Owner's Name information is required for every Centerville _ MA 02632 9-7-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below. ® hand-sketch in the area below drawing attached separately 6� R FAR C c 0 L] 13 3a- 15ins•11110 Title 5 offidd Inspecxlon Form:Subsufface Sewage Disposal System•Page 15 of 17 Sep 11 1210:38p p.16 u • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner Owners Name information is Centerville MA 02632 9-7-12 required for every _..._.._........— page, Cityrrown Stale Tip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 11' feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation_ Hand Auger 11 no water Auger hole 4' below bottom of pit_ _ !_ Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11A 0 Title b Offidai Ms pedion Form:Subeurface Sewage pieposal System-Page 18 of 17 Sep 11 12 10:39p p.17 Commonwealth of MassachusettAs Title 5 Official Inspection Form rl Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 9 PondView Drive Property Address Peter Mondani Owner owner's Name information is Centerville required for every _ MA 02632 9-7-12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5im 1 tl10 Tltle 5 Olfcdal krsperxirn Form:SubsuAeos Sewage p Disposal syslem-Page 17 of 17 No. o �V - Fee [ (Jo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0[ppliLation for ;Disposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair h ) Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 9 {06 S>r Owner's Name,Address,and Tel.No_�k63- 1) ��t✓`� Assessor's Map/Parcel N .�o�-� O�d� ��`�)C 1' Q l�iKi cke_sk-�`t`41 CT Installer's Name,Address,and Tel.No.�j O "� - �]7 Designer's Name,Address,and Tel.No. Type of Building: �p Dwelling No.of Bedrooms �f Lot Size (jib A``e' 3 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) R P_ L,e- D 1 s+r- bw \ov" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea S' Date 9 S f�k. Application Approved by fAA J Date 2 Application Disapproved by Date for the following reasons Permit No. ?4 l } - s-p Date Issued °� S / Z— No. )oU Fee /(JU THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION.-TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplication for Disposal *pstem Construction Permit i Application for a Permit to Construct( ) Repair(1r') Upgrade( ) Abandon( ) ❑Complete System Individual Components r I Location Address or Lot No. 9 P6 f v�Q,�/ 'Dr• ' Owner's Name,Address,and Tel.No.A45 3- 2 Assessor's Map/Parcel z 1$ U�O $e-t�r t'\0 v-�ol Q.1► kQ S�y c-'e- l.T 4 f � � Installer's Name,Address,and Tel.No. d -Y_-gg l] Designer's Name,Address,and Tel.No. Co. C.II► ��n�a� h 32� AS Q Type of Building: Dwelling No.of Bedrooms Lot Size 0<<D A�`r'�S sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title p Size of Septic Tank Type of S.A.S. Description of Soil + I Nature of Repairs or Alterations(Answer when applicable) p�� t Si-r � 1 3 I Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in / accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Si Date S f Application Approved by LA Date Application Disapproved by Date for the following reasons Permit No. 01 0 U Date Issued °� S 7, �-- - -.--- -: __ - i-----7------,--- ---------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS a' BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by C o.�`Q- W%t1�K.., G ri�X!P)A s An,. at 9 �eV,o_� ,D( , has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. o h ��{J" C) 3 p p y dated Installer CAIRte= l,.) +, Y1 Y C'�SAS Designer #bedrooms Approved design flow gpd The issuance of this permit shall no be construed as a guarantee that the system will function as designed. Date i ! :-t r Inspector No. Q! '2 Fee 0�>THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct )QlRepair(� Upgrade( ) Abandon( ) System located at PoVA Y 1 y 1 y - , cc-cte C'�/t`��' and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be l;ompleted within three years of the date of this permit. , Date / Approved by i �'�,� � j I )2 RECEW-0 Commonwealth of Massachusetts Executive Office of Environmental Affairs OCT 3 0 1996 De artment of N OF E NST. p, Towne o1=eaT�; �1= Environmental Protection WM m F.Weld Gomm %w.y E�►e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 0"0 ,.,h• PART A CERTIFICATION i Property Address: 9 Pondview Avenue, Centerville, MA Address of Owner: Date of Inspection: Octo+15, 1996 (If different) Name of Inspector: Gordon E. Bunpus Company Name,Address and Telephone Number: Ocean General Contracting, P.O. Box 659, Osterville, MA 02655 (508) 428-5640 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: G Date: October 21, 1996 The System Inspector shall submit.a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: ✓ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no,or not determined(Y,N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street a Boston,Massachusetts 02106 a FAX(617)SWI 49 a Telephone(617)2024M 0 P*&.a an RA.y W r p. 4 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 Cl 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 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 WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure 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. Backup of sewage into facility or system component due to an 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. (revised 8/15/95) 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 D] SYSTEM FAILS (continued) Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the 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 cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 Welhead Protection Area (IWPA) or a mapped Zone II 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 requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 Check if the following have been done: ✓ Pumping information was requested of the owner, occupant, and Board of Health. ✓ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ✓ As built plans have been obtained and examined. Note if they are not available with N/A. ✓ The facility or dwelling was inspected for signs of sewage back-up. ✓ The system does not receive non-sanitary or industrial waste flow. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the Soil Absorption System, have been located on the site. ✓ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ✓ The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. (revised 8/15/95) 4 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 4 Garbage grinder (yes or no): A Laundry connected to system(yes or no): Yes Seasonal use (yes or no): _M Water meter readings, if available: 67432 Last date of occupancy: Presently o- ccunied. COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present (yes or no): Industrial Waste Holding Tank present (yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Pursed two years ago -Per Owner System pumped as part of inspection(yes or no): _ b If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: 10 years. Installed Nov. I Z 1986 ner Town of Barnstable Board of Health. Sewage odors detected when arriving at the site(yes or no): AID (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 18" Material of construction: ✓ concrete _metal _FRP _other (explain) Dimensions: 4'10"X 8'6" - 1000 gallon so2tic tank Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 2'6" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 2 T" Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Baffles are in good LhWe. Liquid level is even with outlet invert. No leakage observed. Recommended pungirag every three,years. GREASE TRAP: bone (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other (explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 TIGHT OR HOLDING TANK: 11bne (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ✓ (locate on site plan) Depth of liquid level above outlet invert: Even Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Box is 24"below grade and is level. Ab evidence¢ leakage or solids carryover. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Located with probe and as built-card om Town gF Barnstable Board gF Health Type: leaching pits, number: 1 - 1000 gal. leach pit with stone leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Soil was da No sign ¢ponding No sign ¢ )hydraulic failure yegetadon was normal CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: None (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.) (revised 8/15/95) 8 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 9 Pondview Avenue, Centerville, MA Owner: E. J. Brown Date of Inspection: October 15, 1996 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include, ties to at least two permanent references, landmarks or benchmarks. Locate all wells within 100'. 9 b y3� 1 a 5 , � o' '0 0 0 DEPTH TO GROUNDWATER: Depth to groundwater: -1 ±feet¢om bottom gf pit to water. Method of determination or approximation: Gre Cod Commission Water Table Contours NM and U.S. Geological TQWog=hic 9W. (revised 8/15/95) 9 ............................ THE COMMONWEALTH OF MASSACHUSETTS r,)I-) BOARD OF HEALTH ........... ...............0 F........ ..................................... Appilration for Uhipoiial Vorko Tontilrurtion ramit Application is hereby made for a Permit to Construct 0�or Repair an Individual Sewage Disposal System at: .11 11n.'A..........L.&A........................ Location-Address or, I No. ..'o..IL ................ ...................................... Owler Address ................................................................................................. ................................................................................................. Installer Address U Type of Building Size Lot----9L-6t_?!I20....Sq. feet Dwelling—No. of Bedrooms.._....................................Expansion Attic Garbage Grinder a Other—Type of Building ............................ No. of persons............................ Showers CafeteriaOther fixtures ....................................................................................................................................................... Design Flow....J.J.47...j(..-3...................gallons per person per day. Total daily flow-___ .........gallons. -9 Septic Tank—Liquid capacity--/ W yv0--gallons Length................ Width.__.........____ Diameter__._____________ Depth.__..__...._.... W4 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.--___-_- f-.FtA.............................. Date_..__ Test Pit No. I----;-_--------minutesperinch Depth of Test Pit. ...13........ Depth to ground water________________________ w Test Pit No. 2................minutes per inch Depth of Test Pit..._._..........._.. Depth to ground water......_____.___......... ...........................................1.................................................................................................................. Description of Soil ...)../..............e,-.r .nAh1.....I.—. -_ , 0 .........kar_.�It­ ......................................... x U ......................................................................................................................................................................................................... W ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ............ ----------------------------------------------*--------------------------------------------------*--------------------------------------------------------------------------------*-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the.State Sanitary Code—The undersigned further agrees not to place the system in operation uilk a ertifi e s bee issued by the board of health. ig (��.............. ...... ned... ........ -------- Application Approved By................ . ..... , ate 6.�........................... -------------- Date Application Disapproved for the fob ing reasons:................................................................................................................ .......................................................................................................................................................I................................................. Date Permit No......Y...4�p—Y....................... Issued_....................................................... Date ----------------------------- No...... Fxs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _._-._._C`U.C-_v1................OF..... 'n-. /V'.gj--- . ppliraa#ion for Disposal Works Tnntrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........................... j. ..C_....... ..._ .......- +f...................... or o. tI)ocation-Address Lot N Y ------- -•----- w Owrr Address Installer Address Type of Building Size Lot..';�`�_n �a...Sq. feet 1-1 Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -_-_____•................... No. of persons............................. Showers ( ) — Cafeteria ( ) Other fixtures ....................................................... Design Flow.... ..................gallons per person per day. Total daily flow_--_.---..3---35a.6 P.4).......gallons. WSeptic Tank—Liquid capacity.ttkl .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 t nk ( ) ~' Percolation Test Results Performed by......._ 4.5r.1:-... ............... Date.......10/;k..y-_�.�:,5. Test Pit No. 1................minutes per inch Depth of Test Pi�t......1'3......... Depth to ground water....?.............. .. rs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ D Description of Soil........ �.. s; .. :._.... c.� ----- w U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------•-----------------------------------........-----------•----------------------------------------------•-••------------..........--•------......--...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation u 1 Certi tell s be issued by the board of health. igned._ `f./1 .._._ ... .>` ate Application Approved By...............Y. Aa , '� z ---------------- e Application Disapproved for the f og reasons:............................................................................... -•--------------------------------•----.....-------------------•-•------------------.......---..........---•-----------•----.._..--------------•-•--------------------------------------------••---•--- Date Permit No..- -------9.......................... Issued...........................................Dat....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF..................................................................................... Trrtifiratr of TuntpliFanrr `r THI I TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by............ 5. .1 -----------•-------------------•---------------:---....--------------------•---.........---...----•---.---------.--------•---. Installer at•------------•------------- ESQ? 11 U! C 1'v b R - --------------- •--••-. ---------- --------•--------•-•-•-----------•----------------------------------------.....---------•-------•------ has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No....... ............. dated_-../.--.? ::. __ .................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUV CTI�N SATISFACTORY. ----� DATE..... �� ....................................................... Inspector....................------------•--•--------•--•--.......------....-----••----...... THE COMMONWEALTH OF MASSACHUSETTS BOARD ��F_ HEALTH No......................... FEE........................ i po 1 Works �nntrnr#ion amit Permission is hereby granted.....__... ..x..._...(12L:��-------------------------------------- to Construct ) or epair,(, Individual Sewagg at No.. t'o ) an Disposal System duD + vJ L 1 -••----------------------•--•-•----.........--•-•-----•-•--••-•.•---•----•--•---------•----••----------•-•--•--•--------•---------•-•••-------•---............. Street as shown on the application for Disposal Works Construction Permit No. --__C.............. Dat ......................................... r r •........................... ..� . - . 1 ' � 4oard of Health DATE............. ................................................................. FORM 1255 A. M. SULKIN, INC., BOSTON 2ZS— TOWN OF BARNSTABLE LOCATION 'l SEWAGE # � 1 .A VILLAGE � � �i✓�� � ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. `� SEPTIC TANK CAPACITY 00 LEACHING FACILITY:(type) size)��_ , NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER �LDOR OWNER A � DATE PERMIT ISSUED: Awl DATE . COMPLIANCE ISSUED:I I VARIANCE GRANTED: Yes No 1 OA"ts ;A 1Z-k" 0 W - _l/SE : S%OELt/.QLG'.�1.E�,4 SS 7oT•4� 'OEs/G�t/ _ 1;,4 GPo .35 t Est - J JIX 1S; , °P C3 FUCHATio r. Pi.TE� SZ, 0 1 PIT A. N�• 6RXTER ~-., SULUVAN No.2a048 INo. Z9133 ; " 4-140 .e l /QNA STC I SPK $!,z �p I 7"E:Sr' 2, GOO O/ST. /A /. /rv✓. GAL. 77 LE<tc G /H✓ �; BOX S Z.�� �2.7.. . LAB Sa�IO y Yt�.eti,+E�7 1A, f � � .rr�,vE '' . . ..�/,9 s2�l, � c,E,erif/Eo '��oT .� �✓l�l. r '• 4�-S ,Scaz ArWAL PL.�.y ,rzE�E,2.E.cic� .�J..S WA Q 4 4 J T�'.4T T�'E' /3 GE.2�/,cY S.yav✓.v i. .:,QE�.c/ G'OM�GYS lvirx/Tye',Si��L✓NE : r B,exr�,e /vyE I've. SETl�/aG,� ,24lJieE�I�Nr_S O 7`y� .C�EGisr�.2r'v.t.4.vo stievEYa.�S ?Niv OF r3A p,)5r.-4 SCa Avv /.S �voT G�s�.2t�iLt c' a- til�� ,a.v . SL7'�!�i✓fj�E.e��/V•.Si��UG I>/'vaT 13�E USEp '