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0290 RIVERVIEW LANE - Health
290 Riverview Lane Centerville A=228 - !160 UPC 12534 2-153LOR rlWNtlr TOWN OF BARNSTABLE LOCATION � �,WL>Vet--S P31CJIQ SEWAGE# iUJ.3 VILLAGE C�3 (,�t�, ASSESSOR'S MAP&PARCEL w-0 INSTALLER'S NAME&PHONE NO. MP LA SEPTIC TANK CAPACITY tk:)0 � . LEACHING FACILITY:(type) WCA-peAl 1 size) NO.OF BEDROOMS OWNER d _ C lA 115011r� PERMIT DATE:T2,&4U43 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 Leaching Facility(If any wetlands exist within 300 feet of eaching ility Feet fI FURNISHED B t4•1-12�� .0. z 'a7 d ©bne�ui4T� I No.y'G< 3 Fee AQo THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplication for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgraded Abandon( ) ❑Complete System T Individual Components Location Address or Lo No. O er's N e, ddr s, Tel. Assessor's Map/Parcel 9&V 229 NXC-j41,® 22,9 //oEiQj1/,f U1 ZA✓ 71'4-' '34 -5e 2 Installer's Name, dress,and el.No. Designer's Nam Address,and Tel No. , �� , Zi M(C. � �-m-CT 19 v 22 ,YVV 6 / � C /,i.� w , ,F o cv�� Type of Building: �d 8--s -f�/y Dwelling No.of Bedrooms .3 Lot Size If sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 33 gpd Design flow provided .3 gpd Plan Date 3'2S—/.3 Number of sheets Revision Date Title _52�44/ nWr AaeA� Size of Septic Tank /,G'Od G.�'/S��VG Type of S.A.S. AQ63 6 ,IIC / i /✓C� Description of Soil © -f�A LDO�n1 A/�30 d�®•may sum 3D`'�3Z°�D�.e��� S,I Al Nature of Repairs or Alterations(Answer when applicable) j�/STAz� /✓fir/ S:y.S� , �•r/sTj� 1,��-�� ,�/T ,�'�/L�yo 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 Real l e Date G Application Approved by Date0 Application Disapproved by Date for the following reasons Permit No. IQ C5 I Date Issued 6 7-13 nA No.CJtJJ-3 Fee A:C/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION T WAN OF BARNSTABLE, MASSACHUSETTS Yes Rpplitation for Misposal *pstrm Construction Permit Application for a Permit to Construct Repair( U adet Abandon Complete System Individual Components PP ( ) P ( ) PSG' CIS ( ) ❑ P Y �I P Location Address or Lot No. rj�/ O er's Na , dress,an Tel.No. ZV0 /f'/Y��2V/ C Irt 1 hw 4��', r9LxVG 1�soN Assessor's Map/Parcel /n9 Z 2 3 MY ^/'G O Z Iq/!/tI'///e W Lam✓ 77Y_ �-3� .5f 2 144 Ir�s�taller's Name, d ess,and el.No. Designer's Name,Addre s,and Tel No. r1 tC 4., a b ?4-$3��3� J 00// /�1so , ��►'�� I?ZZ try /70 ctol�EiP�iE�O wy, f,y��ovTy Type of Building: sd 8 Slo y� Dwelling No.of Bedrooms .3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 2 �[ r- Design Flow(min.required) 33 � gpd Design flow provided 3 / J gpd Plan Date .3,2-5--/-3 Number of sheets / Revision Date Title SEA✓ SyST 41AG:I OC COS /7 /ZA) �DL D CQSOii/ Size of Septic Tank Type of S.A.S. AQC3 Description of Soil /Z� �OA/1I /Z":�D dLOA/y1 f/ s��1,lD 3(� /3z "�D�¢�S� _� �AX,O Nature of Repairs or Alterations(Answer when applicable) 7- 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 Bo rd of eal Si e Date ` ,�� /3 Application Approved by Date Y Application Disapproved by Date for the following reasons Permit No. G I � j Date Issued �o THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by �0 64"/J <7-'- at Zc{c:) R-Cc,e{/U Ott c� �-�r(,�- (-�Y4ly,4 Lk- has been constructed in accordance i with the provisions/of Title 55 and the for Disposal System Construction Permit No� 3 dated / 3 Installer LLO. 'Jy d P Designer J "D, #bedrooms Approved design flow -Jc3® gpd The issuance of this perrnin hall no'be onstrued as a guarantee that the system ill�fim t as d signed Date ✓X; /_3 Inspector - ------------------------------------------------------------ - No. 'l 3 —/0 Fee /00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction i9ermit Permission is hereby granted to Construct( ) Repair(✓) Upgrade( ) Abandon( ) System located at Z�l D R k- ,cr-LKJ-C� wL 4fcvt e✓u,(Lf. 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:Constructiory must be mpleted within three years of the date of this ermit. Date �� Approved bb �— I Town of Barnstable Regulatory Services ,g rY Thomas F. Geiler,Director BAWWABM = Public Health Division MAM �``� Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: 1f)04, 2 24/,3 Sewage Permit#ZO/3-`41/ Assessor's Map/Parcel M, Z Z 10,140 Installer&Designer Certification Form Designer: .T ,DoyL.E- 4��14r2z -s Installer: /V, /oi Address: /7,6 4,Y Address: rj�>ePg VO)ZZ 44 On - Z /3 /yl/ 61- ln/ UT6 was issued a permit to install a (date) (installer) septic system at 29D based on a design drawn by (address) • dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State& Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required)was inspected and the soils were found satisfactory. �twOF � �P (Installer's Signature) o�V� SONdt P. OOYLE,11 N N0.33589 (Des' n 's Signature) (Affi f '�' Here) SUR�� a ,ASE RETURN TO BARNSTABLE PUBLIC HEALTH CERTIFICATE Off COMPLIANCE_WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- LL�1�.I PaU3' Pu.:.K�.L:IY14114 La ~aN Lau 1v l—E i U-9 Be HyN A7L of it 'ITS,a®:aiv a 14®Tai'ai ` i a'a i y:loulec iGInumueSi icii i iuiii duuu iviui.uuC Town of Barnstable Barnstable Regulatory Services Department AFAnMftQV ' MAS& � • Public Health Division I I �• fD p`� ub 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2843 2065 April 1, 2013 . Ms Helen C Bolderson 290 Riverview Lane Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, Title 5 • The septic sy stem located at 290 Riverview Lane, Centerville, MA was last inspected on 3/0212013, by Mike Hudson a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails", under the guidelines of the 1995 TITLE 5 (310. CMR, 15.00) due to the following: • System is in hydraulic failure. You are ordered to repair/replace the septic system with sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF TH OARD OF HEALTH s McKean, Agent of the Board of Health • i 1 Q:\SEPTIC\Letters Septic Inspection Failures or Future Eval\290 Riverview Ln cent Mar 2013.doc Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=16126 eY 11 � CAt3a .1 I as .t - tab d4 Logged In As: Parcel Detail Tuesday, March 12 2013 Parcel Lookup Parcel Info Developer Parcel ID 228-160 I Lot LOTS 23, 32&33 Location F290 RIVERVIEW LANE �, Pri Frontage I150 __ I Sec Road Sec Frontage I Village CENTERVILLE mm� I Fire District�C-O-MM Town sewer exists at this address NO I Road Index 1376 Asbuilt Septic Scan: Interactive 228160_1 Maps Owner Info Owner BOLDERSON, HELEN C � Co Owner Streetl 1290 RIVERVIEW LN Street2 City jCENTERVILLE I State IMA zip 02632 Country Land Info Acres0.41 __ Use Single Fam MDL-01 I zoning(RC Nghbd�0107 � Topography[Level � I Road Paved Utilities Public Water,Gas,Septic �I Location F Construction Info Building 1 of 1 Year 1981 Roof[°Gable/Hi Ext Wood Shin Built Fi____�� I Struct! p le I Wall g Living 1412 ' Roof Asph/F GIs/Cmp ( AG None I Area Cover Type i Int; Bed Style Ranch I Wall IDrywall I 3 Bedrooms I - Rooms Int Model Resldentlal v _ I Floor or Hardwood Bath Rooms 12 Full+ 1 H I ! Vk4T Ave -` Heat �� —"— Total Grade Average Plus I Type Hot Water —I Rooms 16 Rooms I Heat Found p �' GARS Stories 11 Story I Fuel Gas I ation i'ypical �I Gross 3568 m� I Area Permit Histor y http://issgl2/intranet/propdata/Parce]Detail.aspx?ID=16126 3/12/2013 L_ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ;M 290 Riverview Lane Property Address Helen Bolderson Owner Owner's Name information is required for every Centerville MA 02632 03/02/13 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:out forms A. General iMformation filling out forms on the computer, use onlymove your 1. Inspector: key to move your cursor-do not Mike Hudson use the return Name of Inspector key. Septic-wiz Environmental Services �y Company Name 31 Midway Dr Company Address Centerville MA 02632 Cityt town State Zip Code 508-367-5669 DEP SI#4254 Telephone Number License.Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function.and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5.(310 CHAR 15.000).The system: ❑. Passes ❑ Conditionally Passes ® Fails El Needs Further Evaluation by the Local Approving Authority EJ r `E 03/06/13 "=� ' Inspector' Sign (Ur Date " Cis. The system inspector shall submit a copy of this inspection report to the Appeoving AutB�rity ffloard of Health or DER)within 30 days of completing this inspection. If the systems a shared-syste or has.a design flow of 10,000 gpd or greater, the inspector and the system owAer shall sctbmit Ga report to the appropriate regional office of the DEP. The original should be sent to the s7,,stem"Towner 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. t5ins•11/1.0 Title 1InspecUon Form:Subsurface Sewage Disposal System•.Page 1 of 1.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owner's Name information is required for every Centerville MA 02632 03/02/13 page. CltylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 re the Board of Health P pair, as approved by ..will. ass. p Check the box for"yes", "no"or"not determined" (Y,.N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not).is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *.A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): .t5ins-11/10 Title 5 official.lnspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owners Name information is required for every Centerville MA 02632 03/02/13 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will .pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below.): The system required.pumping more than 4 times.a year due to broken or obstructed pipe(s).. The system will_pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C,) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further_evaluation by.the Board of.Health.in order to determine if the system is failing to protect public health, safety or the environment. 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 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 290 Riverview Lane Property Address Helen Bolderson Owner Owners_Name. information is Centerville required for every MA 02632 03/02/13 page. CityTrown 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. El 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 ® El Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 0 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/day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 290 Riverview Lane Property Address Helen Bolderson Owner Owners Name information is required for every Centerville MA 02632 03/02/13 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No 11 ® Required pumping more than 4 times in the last year NO due to clogged.or obstructed pipe(s). Number of times pumped: Q Any portion of the SAS, cesspool or privy is below high ground water elevation. 0 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. Q ® Any portion of a cesspool or-privy is within 50 feet of a,private water supply well. .0 ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.,[This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Jess than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ® The-system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of.the above.failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) .Large Systems: To be.considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. .For large systems, you-must indicate either"yes"or"no"to each of the following,in.addition to the questions in Section D. Yes No ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply .Q ❑ 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M s 290 Riverview Lane Property Address Helen Bolderson Owner Owner's Name information is required for every Centerville MA 02632 03/02/13 page. Cltyrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was.provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the,previous two week period? ❑ Have large volumes of water been introduced to the.system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components., excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction., dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the.facility owner(and occupants if different from owner) provided with information on the,proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a_plan at the Board of Health. ❑ Determined in the field(if-any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System information -Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 .t5ins-11/1.0 Title 5 Dfficial.Inspection Form:Subsurface Sewage-Disposal System-.Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM s ey''r 290 Riverview Lane Property Address Helen Bolderson Owner Owner's.Name information is required for every Centerville MA 02632 03/02/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 3 bedroom ranch Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑, Yes _® No Water meter readings, if available(last 2 years usage(gpd)): 2011 -74 GPD 2012 -71 GPD Detail: Sump pump? ❑ Yes .® No Last date of occupancy: occupied for sale Date Commercialfindustriial Flow Conditiom Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day.(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes _❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: .t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System.•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owner's Name. information is required for every Centerville MA 02632 03/02/13 page. City/Town 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: Homeowner Was system pumped as part of the inspection? ® Yes ❑ No If yes,volume pumped: 1000 gallons gallons How was quantity pumped determined? pumping contractor Reason for pumping: SAS"hydraulic failure tank over loaded Type of System: .® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no.) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe.): t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage.Disposal System-.Page 8 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owners Marne information is required for every Centerville MA 02632 03/02/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known)and source of information: 32 years, installed 1981 'via permit and engineering p'an Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 33" feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints., venting,evidence of leakage, etc.): joints ok, vented thru the roof, no leaks Septic Tank(locate on site plan): Depth below grade: 26' feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain.) If tank is metal, list age: N/A years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate.) ❑ Yes ® No Dimensions: 4'10"Wx8'6"Lx5'8"H - 1000 gallon Sludge depth: N/A t5ins•11/1.0 Title 5 Official In spection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owners Name information is required for every Centerville MA 02632 03/02/13 page. Clty/To in State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? visual inspection after pumping Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet concrete baffles appear in.good condition,tank appearsstructurally sound and is not leaking, due to overloaded SAS tank required pupming, recommend replace with new system due to age. Grease Trap(locate on site.plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑pol eth lene y y 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•11/1.0 Title 5 Official Inspection Form:Subsurface Sewage DisposalSystem-Page 1.0 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G'M , 290 Riverview Lane Property Address Helen Bolderson Owner Owners Name information is required for every Centerville MA 02632 03/02/13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: 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 45ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owner's Name. information is required for every Centerville MA 02632 03/02/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert outlet invert underwater 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.): replace d-box with new system Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑. No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.,): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: L5ins-11110 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 290 Riverview Lane Property Address Helen Bolderson Owner Owners Name information is required for every Centerville MA 02632 03/02/13 page. City/Town State Zip Code Date of Inspection D. System Information (coot) Type: ® leaching pits number: (1)6' radius w/ 1'stone around ❑ 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.): .Med sands, SAS in complete hydraulic.failure, no ponding, damp soil or abnormally lush vegetation, bottom SAS 120" below grade. 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•1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner OWner's Name. information is required for every Centerville MA 02632 03/02/13 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..): t5ins-11110 Title 5 Official Inspection Form_Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Riverview Lane Property Address Helen-Bolderson Owner Owner's Name, information is Centerville MA 02632 03/02/13 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two,permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ® drawing,attached separately t5ins•11/1.0 Title 5 Official Inspection Porn:Subsurface Sewage Disposal System•Page 15 of 1.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 290 Riverview Lane Property Address Helen Bolderson Owner Owners Name, information is MA 02632 03/02/13 required for every Centerville page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ®, Shallow wells 144"' Estimated depth to high ground water: 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: Reviewed engineering plan and soil test ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: Reviewed USGS topo and water resource maps • You must describe how you established the high ground water elevation: Reviewed engineering plan by RJ O'Hearn, RLS, RS from 3/19/81 indicating med sands and.no ground water encountered to a depth of 144"below grade. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 16 of.17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 290 Riverview Lane Property Address Helen Bolderson Owner Owner's Name. information is MA 02632 03/02/13 required for every Centerville page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ED Inspection Summary:A, B, C, D, or E checked • inspection Summary D (System Failure Criteria Applicable to All Systems'completed ® System Information—Estimated depth to high groundwater • Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/1.0 Title 5 Official Inspection.Form:Subsurface Sewage Disposal.System•Page 17 of 17 Y r 3 290 Riverview Lane Centerville, MA 02632 1000 gallon A B leach pit w/ 1' washed stone (1981) 1000 gallon septic tank z O Al - 52' B1 - 18' 1 D-Box A2 - 74' B2 - 16" A3 - 86' B3 - 26' 3 Jrd 3 2li` C Town of Barnstable P /"3 # Department of Regulatory Services a�xnarner� i Public Health Division Date • � i639 200 Main Street,Hyannis MA 02601 ArEU AAA'I A s . Date Scheduled �/ G _ Time_ f $ Fee Pd. Soil Suitability Assessment for Sew a a Disposal Performed By: J�Dfi�'tl ®y�-C Witnessed By: �} LOCATION& GENERAL INFORMATION Location Address �� /t/,BQL�Ek.5- / 90 �lt/��!/�E�,�1 G Owner's Name y Address G'AA,7,z-xVIZ-LF Assessor's Map/Parcel: AA/0 2 MR 2 93 / o Engineer's Name Cf j�DyL E /4 S-SD G- NEW CONSTRUCTION REPAIR !/ Telephone# Land Use /06�ly4c- SI'p,m e X0 Surface Stones /14'>� d�SE-.PtV.o)' Distances from: Open Water Body ft Possible Wet Area .3�Q ft Drinking Water Well ft I� Drainage Way 2Po ft Property Lineft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) /L�, DS- ✓�D,Dv No, 14d I /Bj 71 f S',6 O - r C> w 1_ . Parent material(geologic) eMA 5 Depth to Bedrock t-°' Depth to Groundwater. Standing Water in Hole: /yQ Weeping from Pit Fflce Estimated Seasonal High Groundwater E� /�'J/L ER /rlgf' DETERAHNATION FOR SEASONAL HIGH WATER TABLE Prt Method Used: � Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft." Index Welt# Reading Date: Index Well level Adj,factor,,.,,m,4 Adj,Groundwater Level, n PERCOLATION TEST bate 3-Z!-/3 Thne i/:3o A Observation Hole# -7;0 Time at 9" u " Depth of Perc Z 50 Time at 6" Start Pre-soak Time @ f' 2 S U Time(9"4") End Pre-soak Rate Min./Inch fO%S.l e4-'4'o ff L�SS.Tf//i•l� Zvi jN� Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTI0PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# 750-/ Depth from Soil Horizon Soil Texture .Sdil Color Soil Other R) Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsistencL%Graven v y/2 u DEEP OBSERVATION HOLE LOG Hole#Z�" 2— Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsis en %Gravel) /3 3/ 3/' 32 Zs y,� 7 /3 o GL I t DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. F i t - Flood Insurance Rate Mg: / Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? IYA•-� __ If not,what is the depth of naturally occurring pervious material? Certification I certify that on �,�9✓� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required training,expertise and experience described in 3 10 CMR 15.017. Signature Date g 20�3 Q:WEVnC\PERCFORM.DOC j Town of.Barmtable. P# l list ' Department of Regulkt Services Pub licHealth Division Date.' -200'Main Street,Hyannis MA 02601 • �,�lEpMJtt� : ' Date_Scheduled � G �Titrie Fee Pd. W. Soil Suitability Assessment for Sewage Disposal _. Performed By: f©y'� y4 P—S Y Witnessed By: � � � _rLOCATION&GENERAL INFORMAsTION Location Address 2 Owners^Name <�:�D1 DFQ SD�90 �erv��evrE� Ai�lE ' zpq Address LL Assessor's Map/Parcel:Ma A4/d 2 2 S . �/�� ��p D`. L /¢3-So G. P Engmeer's-Name . r NEW CONSTRUCTION REPAIR, l/ Telephone# Land-Use.5/e�r�iC� '�� ' ��//IE/t/Gg%�V Slopes(9b): Surface Stones.NOS MS�e-,ev-:, 22 J Distances from: Open Water Body ft Possible Wet Area ✓dQ ft Drinking Water Wellft Drainage Way goo ft Property Line Q ft. Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pere tests,locate wetlands in proximity to holes) /2 7, ^t 71�4 � o N _ 4. D ZL" � R Parent material(geologic) eaV 5 ST "' Depth to Bedrock ' :Depth to Groundwater. Standing Water in Hole: D A'e' y -c P g . .. Weeping from Pit Face Estimated Seasonal High Groundwater Fl—6 ., /0 A54 C0446:*/�R/j 1—, /A 90,4 DETERMWATION FOR SEASONAL HIGH WATER TABL F' Method Used: Depth Observed standing in obs.hole: __ __ In, Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index,Well Level Adj,factor,,,,,m,4 Adj,Groundwater Level,,,e PERCOLATION.TES.T Date 3-21.13 Thne 1 3D A Observation Hole# �/ Time at 9" Depth of Perc 2 'Sd r Time at 6" Start Pre-soak Time @ I 2 S Tide(9"•6") !�. End Pre-soak 11,3 �; Rate Min./Inch �D%Sf L .4At�DL�SS.r)gWA/_ 21A/, .-. Site Suitability Assessment: Site Passed"i' Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed•on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC r DEEP.OBSERVATIONHOLE LOG Hol el '���/ Depth from Soil Horizon Soil Texture-' Soil Color Soil Other Surface(in.) (USDA) "?(1Vlunsell Mottling (Stnucture;Stones,Boulders. orI istencv:%Gravel) 2 a 19 zmm /2,` 3 a � B S � ��, ,� AlY k 131;4:u co/a,e..s . DEEP OBSERVATION�H,,OtE'LOG HolO#2;0 2— Depth from Soil Horizon .'Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones,Boulders. onsistency,%Gravel) PIZ Al DEEP OBSERVATION HOLE LOG Hole:# Depth from Soil Horizon Soil Texture. Soil Color Soil Other Surface(in.) (USDA) (Muosell) Mottling (Structure,Stones,Boulders. istency.%Gravel) y DEEP OBSERVATION HOLE,LOG Hole Depth from Soil:Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell Mottling iStrueture,Stones;Boulders, on iptency%Gls4lUI) ---- - - - —Flood-Insurante Rate Map: Above 500 year flood boundary No— Yes .W Within 560 year boundary No' Yes Within 100 yeas flood boundary No, Yes Depth of Naturally.Occurrina,Pervious Material Does at least.four feet of naturally occurring pervious material exist in all areas ob'or throughout the area proposed for the soil absor<'ti" system? If not,what is the depth of naturally occurring pervious materials Certification I certify that on ZZ95 (date)I have passe&the soil evaluator examination approved by the Departinent of Environmental Protection and that the above analysis was performe'd by me consistent with tkrequired training;expertise and experience described,in 3,,10 CMR,15.017., Signature_ ,� 'G Date�3-20"2(/-3 Q:\.SEVnCIPERCFORM.DOC LOCATION SEWAGE PERMIT NO. VILLAGE /GG I N/yS�/T A L L E R'/'S\J -NAME �i7J ADDRESS DDRE S S I U It 0 E R OR OWNER/ F DATE PERMIT ISSUED 3 , DATE COMPLIANCE ISSUED ' r i, a THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Il--......OF..... ✓s7/Z/CITT/�jJL/ ......................... Appliratiou.f nr Uh4posFal Works Ton,itrurtiun ramit Application is hereby made for a Permit to Construct (,.Y) or Repair ( ) an Individual Sewage_Da osal System at: ..... .. L ation Address r Lot No. ........................................ :s;:r. •- ------------------------••-••••-•---••-•--...... .1._._g.P. !E_ dr.........................•) -e9EA[.nli,.� '1 Owner Address ,Wa li ..... .........-•--•-•--...... Installer Address Q Type of Building Size Lot./ ...Sq. feet .............Ex Expansion Attic Garbage Grinder 0) Dwelling—No. of Bedrooms.............................. . p ( ) g ,� aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures F D2---- --------•------------------------------------ ..--------•----.---------.---------- Design Flow____.._.__:._ ....................gallons per LSQtl er day. Total daily flow____.._....._....43 ...3__ gallons. WSeptic Tank—Liquid capacity ® gallons Length__......:_6.. Width._4 l� Diameter-_.____--___•-_. Depth... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No ...Diameter.._..11�.fT Depth below inlet.... FT... Total leaching area..7_-G.__._7...sq. ft. Z Other Distribution box (,X) Dosingtank '-' Percolation Test Results Performed by-7 .__ l✓ `t'�:..� C.................. Date ..11_$.!........... a Test Pit No. 1.._L.Z....minutes per inch Depth of Test Pit.....l __ Depth to ground water------------------- --- Gr4 Test Pit No. 2__ _z_._minutesper inch Depth of Test Pit--- ram.y... Depth to ground water........................ x ------------------•••••................... S � .......te O Description of Soil.... 4111 d 42 w Z ---- -y y Ce_e ... ------------- ---------------------------------------------------•--------------------...--•-- 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 TLITHLI, 5 of the State Sanitary Code— The u igned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued by e bo of health. Signe ----- -- -------- - - . --. . .............................. .... 4ateA .. ........--•...............APPlication Approved BY ... . ..... � j Application Disapproved for the following reasons-------------------------------•---------------------------------------------•---------...------•---------------- ••-----------------------------------•---....._....-------------•----•--...-------=---••••-••------....••---------------••------•------ -•----------------•--------------------------------•------...••. Date PermitNo......................................................... Issued_....................................................... Date A a No.....` �..�, Fps.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD !OE HEALTH .��---.....OF.......l i .!Z.n/I../�..7C�_......................... Appliration for Disposal Works Tonotrur#iun Prrutit Application is hereby made for a Permit to Construct ( )6 or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. rx .........................................- .......---..............•....................... .............--•--•---...•---------•.......--•-•-................-•-•---•-••-.................--•- Owner Address W - Address ...... ...0 `J Sq. feet Installer ', Address Type of BuildingSize Lot..//._._f/___._____ U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria Other fixtures ...........•---•--•-•--••---•--- G b " �5 P72UO :----------•-•--.-•-- - W Design Flow..............� U.._, ............gallons per.person er day. Total daily flow................. ............gallons. p: Septic Tank—Liquid capacity.l���/gallons Length.. �:62._ Width.,_,`_:��!Diameter................ Depth..... Disposal Trench—No..................... Width.................... Total Length................ leaching area....................sq. ft. Seepage Pit No-----------/....... Diameter-__._4�_FT'Depth below inlet..... r? Total'`leaching„area...?-- ._7...sq. ft. Z Other Distribution box ( X) Dosing tank ��T ti� . Percolation Test Results Performed by.. :._ _. /..............�._�^'�.._............._ Date_ .%,l .�.............. Test Pit No. 1...G Z....minutes per inch Depth of Test Pit...... Depth to ground water......--`............. LL, Test Pit No. 2..G. :...minutes per inch Depth of Test`Pit.... Depth to ground water........................ O Description of Soil.........------------...:: ..... •�/ » ri --- -----------vT3toi`.... Zy ��� ��-------..._G c i }, W ---••m-r.n••-•-.. ` �Z--.......�/...- .�.�------.G�� '' � �(�.a s.a./ `. •--••----...---- .............. ..•-----••--•• ..................../Y� --- UNature of Repairs or Alterations—Answer when applicable................................................................................................ -------------------•--•------•----•-----------------------------------.....--------------------------------------------------------------------------------------------•-•-------..---• • Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with provisions of TITLE the p 5 of the State Sanitary Code—The u rsigned.further agrees not to place the system in operation until a Certificate of Compliance has been ued by,� e bo of health. Sign - /,„ � s ,mow.- ...................... . >y� Da r Application Approved By..... �a----. . . ....� a. ............................. Application Disapproved for the following reasons-------=---------•--------------.....-------------•-- ---------•-----.......................................... ....-•••----•--•---••._.....---••--•-•---••--•--...-•--•--•--•----•-•-•--.....•-•-•--------------------•..---------------•--------------------------------------•---------------------------•••-•----•--- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 2r if irtt#r of Taut litI r THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( L)lor Repaired ( ) by..................................................................................................................................................................................................... Installer at � �d C /l•� .�C 1 -1• > + ................ '-V4.16.ele..................................................................... has been installed in accordance with the provisions of TIT—";` 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.(,;;,). ------t3z?-------_--••-•• dated_.-.._.____.................................... THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. 5_f 5-iP. Inspector....: '. .................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . ,/s . .... ....OF. y9�2> s ................ N .�3' .:..:.. ..... FEE.... _ d ..... Disposal Works T-Funstrudinn rrutit, Permission is hereby granted.......................................................................................... =: ... to Construct (L_� or Repair ( ) an Individual Sewage Disposal System at No.. 4:.�Q .1 11i A.-v I e * s fi '`/� G 4.----------•-------------------------------------------•-•-•--- treeE" as shown on the application for Disposal Works Construction Permit Na....................• Dated.......................................... . �" ir �-�_-.-- - -�_.. ....j .............::......•.......•...............» o ealth DATE .2---------------------.............. FORM 1255 HOSES a WARREN. INC., PUBLISHERS s.