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HomeMy WebLinkAbout0065 SHORT BEACH ROAD - Health 65 SHORT BEACH RD., CENTERVILI A= 206105 i i III_ t 14'qECYCIfp'p UPC 12534 No.2' 3LOR � � HASTINGS, MN I i f r t h j-K COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION `0 Property Address: 65 SHORT BEACH RD. CENTERVILLE ` co Name of Owner THEORDORE PRZYBYLA to �-9� � � Address of Owner: 29 GENTRY WAY N.SITUATE R.I.02857 Date of Inspection: 4126/99 'l , Name of Inspector:(Please Print)JOHN GRACI 'r99 1 am a DEP approved system inspector pursuant to Section 15.340 of T/tfe 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a t 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: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further E lu tion By the Local Approving Authority performing at the time of the Inspection.My Inspection does _ Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:5/9/99 The System Inspector shal submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 65 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: n/a 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. n& The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is 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 complying septic tank as approved by the Board of Health. n(a 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 n1a 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 revised 9/2198 Page 2 of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 66 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance nLa_ (approximation not valid). 3) OTHER Wa revised 9/2198 Page 3 of 11 L` - r 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 65 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nta. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 66 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4126/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)j X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. i revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 65 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-440 g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 44Q Number of current residents:Q. Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): Mo If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NO Last date of occupancy: nta COMMERCIAL/INDUSTRIAL Type of establishment: n& Design flow: nta gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):�LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):No Water meter readings.if available:n& Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n(a GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):YES If yes,volume pumped nLa_ gallons Reason for pumping: n& TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: SYSTEM WAS INSTALLED IN 1999 Sewage odors detected when arriving at the site:(yes or no) NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1 Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: E Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) Wit If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO nLa Dimensions: L 8'6'H 5'7"W 4'10" Sludge depth: Z'_ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:- Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: nLa How dimensions were determined: MEASURED 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) D& Dimensions: n& Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:jVa Distance from bottom of scum to bottom of outlet tee or baffle WA Date of last pumping: D& 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.) nLa revised 9/2/98 Page 7 of 1 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 65 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: WA Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n1a Dimensions: nla Capacity: Wa gallons Design flow: Wa gallons/day Alarm present: NQ Alarm level:,nl& Alarm in working order:Yes_No—: NQ Date of previous pumping: WA Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION Box IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) PUMP CHAMBER WAS INSPECTED UNDER NORMAL USE HOUSE WAS UNOCCUPIED PUMP WAS FULL revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: D& Type: leaching pits,number: nla leaching chambers,number: 4-FLOW DIFFUSERS leaching galleries,number: -n& leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: nta Alternative system: nta Name of Technology: joLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE FLOW DIFFUSERS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY CESSPOOLS: - (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: n& Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: nLa Materials of construction: n& Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: _ (locate on site plan) Materials of construction:nLa Dimensions:nta Depth of solids: nta Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9/2198 Page 9 of 11 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a — l rn c a /}b'S7 4 a Ac �3 A&) 3Y revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 66 SHORT BEACH RD.CENTERVILLE Owner: THEORDORE PRZYBYLA Date of Inspection:4/26199 NRCS Report name: nla Soil Type: Wa Typical depth to groundwater: n& USGS Date website visited: Wa Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 4 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers _ Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) GROUNDWATER DETERMINED FROM HAND AUGER AT 4',BOTTOM OF FLOWS AT 1'6" revised 9/2/98 Page 11 of 11 DATE: 6/1.9/.98 PROPERTY ADDRESS: 65 SK64each Road Centervi le,Mass. 02632 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1500 gallon tank. 1 . Pump chamber with 1 -pump. On&Off&Pump with a light. 3 . 4-flow diffussors packed in stone. Based bn my Insoactlon, I certify the following conditions: 4 . This is a title five septic system. C�1-8 Code ) 5 . The septic system is -in proper working order at the present time. SIGNATURE: G`'1 Name: J. P.Macomber Jr... Macor�ber & Son- . CF 0 Company:-------- ----------- , ��Address: � `t8__Centerville , Mass__02632 _EPhone: -548Z73338----- 1, THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • JOSEPH P. MACOMBER & SON, INC. Tanks-Ceupools-Leachfields ; -Pumped & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292.5500 WILLIAM F.VELD TRUDY COa: Governor Sccrctar ARGEO PAUL CELLUCCI DAVID B.STRUH Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission PART A CERTIFICATION Property Address:65 Shortbeaeh Road Centerville Address of Owner. Date of Inspection: 6/19/9 8 Mass. (If different) Name of Inspector: Josegh P.Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: Box 66 C x1f-P y i 1 1 Py Mass _ 02 6 32 Telephone Number: 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 Appr ving Authority _ Fails Inspector's Signature: 0 Date: 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. P Y P 8 INSPECTION SUMMARY: Check A, B, C, Or D: AI 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. COMMENTS: BI 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. 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, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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. (revimed 04/25/97) Page I of IO DEP on the World Wide Web: http:/Mww.magnet.state.ma.us/dep + Printed on Recycled Paper . U • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 65 Shortbeach Road Centerville,Mass . Owner: William Maher Date of Inspection: 6/1 9/98 B) SYSTEM CONDITIONALLY PASSES (continued) V�d"e 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). Describe observations: 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 CJ' FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: 400 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. i) 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 10 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: .44 The system has a septic tank and soil absorption system (SAS) and the SAS 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 the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. ,� The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance V10' (approximation not valid). 3) OTHER N19 i'J , Alp (revised 04/25/17) Yap• 2 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:65 Shortbeach Road Centerville,Mass. Owner: William Maher Date of Inspection: 6/1 9/9 8 D) SYSTEM FAILS: You,Must indicate ei; .er "Yes" or"No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans Health should be contacted to determine what will be necessary to cornea for this determination is identified below. The Board of the failure. Yes No/ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. ZDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or nn cesspool. G Static liqu'd level in the d' ibution box trove outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private 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. El LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 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: Yes No AA the system is within 400 feet of a surface drinking water supply ,,/r 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) 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 04/3S/97) Pay• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST r Property Address: 65 Shortbeach Road Centerville,Mass . Owner: William Maher Date of Inspection:6/19/98 st indicate either "Yes" or"No" as to each of the following: Check if the following have been done: You mu Yes No _y( Pumping information was provided by the owner, occupant, or 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,45Ccluding 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: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (revised 04/25/97) P&ge ♦ of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\' FORM PART C SYSTEM INFORMATION Properly address: 65 Shortbeach Road Centerville,Mass . ` O»ner: William Maher r Date of Inspection:6/1 9/98 FLOW CONDITIONS RESIDENTIAL' Design floN qql> P. /bedroom for S.A.S. Number of bedroom$. q Number of current residents: Caroage grinder (yes or no). Laundry connected to syst Iyes or no)., � Seasonal use Iyes or no). &% aler meter readings, if available (last two (2) year usage (gpol: �L Q Sump Pump (yes or no): 41 � log �S � t.L �/ • +� :ast date of occupancy.k—d 1 COMMERCIAUINDUSTRIAL: � Type of establishment: AA Design flow:1gallons/day Grease Irap present: (yes or no� Industrial Waste Molding Tank present: (yes or no)j2�',on•sanllary waste discharged to the Title S system: ryes or no)x)A Water meter readings, if available._ AL4 Last date oI occupancy. AIH _ _ OTHER: ;Describe) _ .4 Last dale of occupancy A CENERAL INFORMATION PUMPINC RECORDS and source of information: Not available System pumped as pan of Inspection: (yes or no)-9 If yes, volume pumped: gallons Reason for pumping TYPYSTEM Septic tank/di6is 6014A 6e /soil absorption system 4)b Single cesspool 196 Overflow cesspool 40 Privy Shared system (yes or no) (if yes, anach previous inspection records, if any) VA Technology etc. COPY of up to date contrast ()lher KJ,s APPROXIMATE ACE of all components, date Installed (if known) and source of information: S,twage odors detesed when arriving at the site: (yes or no) lr•vt�•6 0�/1!/971 Y4p• 5 of 10 ' 1 • V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 65 Shortbeach Road Centerville,Mass. \ Owner: William Maher Date of Inspection:6/19/98 BUILDING SEWER: (Locate on site plan) Depth below grade: �U /40 Material of construction: cast iron PVC_other (explain) Distance from vivate water supply well or suction line 9L-ld r Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight No signs of leakage mhP gystpm ; g vpnf-PH SEPTIC TANK:ffSU` Through the roof of the house. (locate on site plan) if Depth below grade: 0 Material of construction: _Lconcrete _metal _Fiberglass _Polyethylene _other(explain) if tank is metal, listt/age dA Is age confirmed by Certificate i of Compliance (Yes/No) Dimensions: /�rf�YAW ��I��• 3r��tt�'l�i'/1 Sludge depth:���4 Distance from tq�sludge to bottom of outlet tee or baffleJ4g(,6:.f­j Scum thickness:IeA"— Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to botto of outlet tee r baffler How dimensions were determined: 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.) Pump septic tank annually,System is in a very sensotive area. Inlet & outlet tees are in place.LiQuid level at " and snows no signs ot leakage. GREASE TRAP: (locate-on site plan) Depth below grade:4/h Material of con structions✓Aconcrete+A4meta141AFiberglass i0 Pol yet hyl ene,?L-*ther(explai n) Dimensions: 4419 Scum thickness: AYf Distance from top of scum to top of outlet tee or baffler 1 Distance from bottom of scum to bottom of outlet tee or baffle:&A Date of last pumping: AM 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.) Grease Erap is not present. (revised 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 65 Shortbeach Road Centerville,Mass. , Owner: William Maher Date of Inspection: 6/1 9/9 8 TIGHT OR HOLDING TANK:6&-&ank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction:d lconcrete4l&etalA1&iberglasso&olyethylene.((mother(explain) Dimensions: d/A Capacity: 04 gallons Design flow ,A gallons/day Alarm level: Alarm in working orderVA Yes;�No Date of previous pumping: AIA— Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks arp npt nrccont DISTRIBUTION BOX:AL E. (locate on site plan) Depth of liquid level above outlet invert: NJ� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box is not prPgPnf- PUMP CHAMBER: � (locate on site plan 1 Pumps in working order: (Yes or No) c✓ Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is e pump and float are in working order at the prpcpnf- ti n,o (revised 04/25/97) Page 7 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 65 Shortbeach Road Centerville,Mass. Owner: William Maher Date of Inspection: 6/1 9/9 8 f SOIL ABSORPTION SYSTEM (SAS): W�(.r*N 1 ' (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: , leaching pits, number:Q, leaching chambers, number:a�,k,, )lf leaching galleries, number: G; ►i+ leaching trenches, number,length: leaching fields, number, dimerions: overflow cesspool, number: CJ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to fine beach sand No signs of hUrlranl.ir• fa; lnre ,or ponding All vegetation is normal CESSPOOLS:&&/e— (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) Cess-pools are not Present Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present `` " PRIVY: (locate on site plan) Materials of construction: Dimensions: J?' Depth of solids: AM Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privies are not present. (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 65 Shortbeach Road Centerville,Mass. Owner: William Maher Date of Inspection: 6/1 9/9 8 SKETCH Of SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ze4ex`u AF,, V-%V e'r 7S3,1 / ,•'t3 _O Oc�r>4,rtsbU C�� o (s•vI••C (it/75/97) P•q• 9 of 10 I SUBSURFACE SEWAGE DISP,. I. SYSTEM INSPECTION:FORM I C SYSTEM INFOI. . 'ION (continued) Properly Address: 65 Shortbeach Road Centerville,Mass . r ` Owner: William Maher Date of inspection:6/1 9/98 Depth to Groundwater 2 Feet Please indicate all the methods used to determine High Groundwater HL--ation: Obtained from Design Plans on record Observation of Sit (Abutting prope bservation hole basemtN simp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records �eck local excavators, installers use USGS Data Describe n your own words how you established the High Crouncf-valtrElevation. (Must be completed) Used water contours map. Hand augered test hole five feet Gaherty & Miller Model below the floww diffussors •12/16/94 no water was encountered. 7 ' (revi..a 04/25/97) 10A 10 y •.rnrv.—n.rsr•-�—a.nrmnnnnr�.rtr.nrer�rn�r+a.mras.+�*+m+mrw•+u na-srs+en o�+ .r►r-rrr-r�.•n*•-r-'..t-.r'•� 1 TOWN OF Barnstable BOARD OF HEALTH + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFi,CATION I ��. F-•rn-r•:-::a-nir.-•�rrwrrmrr+nrn�ms+rrnrrr.Ott.-wrnrtarnr+r�-ve+vvmrm�.srar�+�rs ' t+ann+mrnrsrv.arr+rnr•.rvrrr•rr-. -..A -TYPL OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$ 65 Shortbeach Road Centerville,Mass. ' ASSESSORS MAP, BLOCK AND PARCEL # oz/o D OWNER' s NAME William Maher PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber �& SoYT Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Straot Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX (508 ) 790 -1578 � Rt CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : ; -LA/- Systeui PASSED ' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or Lhe environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con Uicted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . L -Inspector Signature Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF H EALTII. * If the inspection FAILED, the owner or operator shall upgrade ' the avetem within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 , partd .doc `'9 O� rWn ti THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION . BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. Junc X; 199S Acting Dirccior of the on of Water P011U1i011 C OMMI TOWN OF BARNSTABLE LO(:;ATIA915 J L�l SEWAGE # VILLAGE \ - ASSESSOR'S MAP & L@ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1600 LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: r p DATE: uo 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 leaching facility) 6 Feet Furnished by � C '� AA V 13 l DL an 6e �5y TOWN OF BARNSTABLE ' LOCATION 65 Shortbeach Road SEWAGE # VILLAGE Centerville,Mass. ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY 1500 ,pump chamber LEACHING FACILITY: (type) 4 f low dif fussors (size) 24 'x1 5 'x1 ' NO. OF BEDROOMS 4 BUILDER OR OWNER William Maher PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: j Maximum Adjusted Groundwater Table and 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 e t within 300 fee of leaching i ' ) Feet Furnished b v e c 75� �� ® rdcp cB b ^- TOWN OF BARNSTABLE LOCATION�S S`L�rc 7- /�C���l� SEWAGE # VILLAGE ivTb 2 of � ASSESSOR'S MAP LOT w,INSTALLER'S NAME €u PHONE NO. SEPTIC TANK CAPACITY/J 66 DGti ihiCG,SL�2S( X o2 LEACHING FACILITY:(type) size) _ NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER A, "n- r ATE PERMIT ISSUED: DATE COMPLIANCE ISSUED___- —� VARIANCE GRANTED: Yes G� No _ s. . � � ._ �J �c 3,�- �� �� /1 � 3 � (n ' 0 � � . � , _ ,� ,� l/ i� Now G� Fm$...���t�.r6"� THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ... ...0E./ ! n .. ApplirFation for Bi�vnii�al Works C�nnitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: / W Loc -Add ss Owner Address ..�.G!` `�✓` T Installer Address UType of Building Size Lot............................Sq. feet Dwelling No. of Bedrooms......iZ..........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons..........................-- Showers ( ) — Cafeteria ( ) Other I,fixtures ................. WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length.............•.. Width................ Diameter................ Depth................ x Disposal Trench—No.,.................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No-------:'............ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution'box ( ) Dosing tank ( ) Percolation Test Results Performed by---•---------------•--•--•---•---•-------•-------••--•-••--------•------- Date........................................ 1.4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..--..........--........ 0-4 44 Test Pit No. 2................minutes per inch Depth of Test Pit------.............. Depth to ground water........................ 0 04 --•-•--•-----••-•--•----------•-•-•---•----•---•-----•----•-------•...•-•...................•.--•---......................................................... Description of Soil......................................_................................................................................................................................. x V •---•-••-----•-•-••••--•--•-•---------•-------------•-•------•-•---•-•-•---•--•-•-••------.....-----•----•--•--•------- W x •-----•----------------------------•-•--------•-••----•------------•--------------•--------•-------------------------------..--------------- ----------------- U Nature of Repairs or Alterations--Answer when applicable-1 S'o.6_.�T..........� /( ¢ ------ ----•----•--•-••-•-----•-•----•-•-•-••------------•-•------•............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'IT114, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation-until a Certificate of Compliance has been issued he b h of Sig .•-• ... ..... •-------------•--..... ......... ............. 1 .........::/� Application Approved By.... � ._. '!� a Application Disapproved for the following reasons:............................................ ...... _....._...........---...........___._.Date----...__.__-- .......-----••••------------------------•---•--,-....s.--------•----•--------------------------------------.......--•-------------- .............................................................------•-- Permit No. ap d'... --••_..... Issued...........' l�l--�s t . Date I�R - .�� THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH v. OF.............!4.........._......-...--------------.....-----------......----------•---- Apli iration for Disposal Varks Cnnnsirurtiaan Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .......... ................................................................................ -•-••---------•----------..._----_...--- -...-----•--------••-•----------•-•------- ....._....-•---_.. /H...y' . ----......./ .-••-•-.....-r ....................• ----•--••----••--. ..-----•-•---•••-•--•..............__...--•--• Owner Address a � C2_e �U� s- .....---•----•--•---- ----•••--------------------•--._._..__..._------- ...........................................................•-••••-------------•------------------- Installer Address Type of Building Size Lot____________________ _____Sq. feet �. Dwelling—No. of Bedrooms______ ____________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons____________________________ Showers ( ) — Cafeteria ( ) d Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity___..__.____gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width..........._-------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----•------•--------•--•-•----•-------•---•-•-••._...----•-••••....--•-••........................•---•---•-----•-•••-•-•----------••••••. ........ ---------- O Description of Soil.......................................................................................................................----------------------------.................... x V ._...•-•••••----•---•------•----••--•------------------•-••---••.....-----•-----....-•--._......_._....----••••--•---------•-•-•••-•----------------••---••---------•--•------•••--...---•------------•-. W ------------------------------------------------------------------------------------------------------------------------------------•--•---- U Nature of Repairs or Alterations—Answer when applicable. So' D S_ /-- =/Z ----------------------------•----.....-----•-------•----......-•--------.._...------........---......---•------------------------------------------------------------------------------------•--....••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue th/ell rd of li Sigrf�i C�-� �C �� 3 �` ------------------- Application Approved BY..... r�p.• ,�,� ---_-- ..... �� --- /�CfC- '� Date Application Disapproved for the following reasons-------------------------------------------•----------......................................................... -•...................•-----------....----••-----,-q-----------.....•-------,-----------.......-----..._........-•--------------------------------------------------- _.l /------------------------------------ Permit No...... .. ------•--•---•-�•----•--.. Date ..... .� Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF..................... ..................................... CUrdifiratr of Taautplianrr THIS IS TO CERTIFY, That t Individual T Sewage Disposal System constructed ( ) or Repaired by................................. ..........�L�/�'- f-/ � Installer c c , ..---•- _^•...............*--••••-•--...---•._........--•---._...----•---••---•--•--------•---•------------•--...--•--•---------------------•••..._..-----•---------.. has been installed in accordance with the provisions of "-1 TIES 5 of The State Sanitary Code as scribed •n th application for Disposal Works Construction Permit No..... `_g:_-_.: da.ted_.... ��i7 P_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE._.....--•• ................................ Inspecto .--•----g.... �----._...._ _.. _......, THE COMMONWEALTH ,QF. MASS-ACH-U,SETTS BOARD.-OF ' � HEALTH- � . OF..... � 2 o. 1 ........................................ .._.._...-_.._........------....... ......................... FE _.. .. . Disposal Marks T-Paantrndiaorn rrmit Permission is hereby granted........Z�.) '_ ff ----_._._...•-•-----.--------------••--•-----•...-•-•-------••-••--------••-•------••••----_...•.................... to Construct or p it ( an�Individua Se rag ispos:�l stem at No...........��_..._� �_ -_.T_-_.� A E ivT, .................................................................................................................................. as shown on the application for Disposal Works Construction Permit N _�! at/ed�_..�°_ _. .__ / Board of Health � DATE f...... •40 ......................... , FORM 1255 HOBBS & WARREN. INC., PUBLISHERS PROJECT NORTH OSSSyCD ALDf`- � ram_ LAM I 6 a' I OP FISTING OF FNG "TT o-- tl0f81L_—_—_---}--------------� -_ -_''1' --�I I ---- ---- �--- -------;.,I--------- --}---o ��y NHLYI FR6N7 PORCH AD I l^ I_ O_—_—_ O_—_ I ` m I ? LIMIT DF WORK r\ s ©— — I— — — — — — — -------_--- -_ --__-_ _ — — —� L_= - I _______ E— �� C— —o w 7 - I------------ -------------- ----- ---- ` -- I - ' '— :i�. --- - - I -_ - -- - --- IAA---- - -lO '-I ] NEWM OBOARD V EHLE I O I I II Ll (, a _—_1__—_—i—i -----------—_—_—_— I _—____—_—_—_ I BL CHAWRAU.RAR _—_ I KITCHEN---- ITCHEN i I @BASE 105 I PO CH I I I I Dj o- - ; -� - °- - -� A0 _WSTNG (L �' V —-—-—-—-—-—-— � — � - - — — v CLOsm 106 `-' N v o — - - - --- - - - - — — INERT- -i - - - ---_------ - - i < �/-��?��-- LIVDVG ROOM IEYV GAS EDG I ]09 FOIE PROTECTIGN LEGEND 4 'I POA IR2 I pmla I 10 1'-t01/2- 1'-101/Y I B, I I ,I I TYPE SYMBOL p F la DETECTOR M --�-------------�-- I - I I I 1 I I I TEAT DETECTGR CLOSET CAEWORK—] --FlLLDOSRNG _------_ ILO —_ _ _ I GARAGE II 1 DODW.ED ACCESS UPEIWIG DINING ROOM I 113 I SMDIE DER[iW 709 I 1 CC/VR./R.U. 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