HomeMy WebLinkAbout0844 PHINNEY'S LANE - Health 844 PHINNEY'S LANE, CENTERVILLE
A=251 102
NoP2-153LOR ', MOO
HASTINGS,MN
l Cl
24
�c�
® —�
--o/G T_-wz W e nos 4
CI _ p o
LA V
C - F
PIC-
r
idY e `
tqf
�$ e
a .
� 4
3
^ a H
, e ,
ka._�r r 4�. - � ° ,�`'�is ee .+i'•, rr a,s wi�, "d^ a rz $ .`'` - .' �' „ ,. ., 'sue '
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
I / ( ,.�/,,(�/J�j on the computer,
use only the tab 1. Inspector: 13
key to move your
cursor-do not Ricky L. Wright
use the return Name of Inspector
key.
B & B Excavation, Inc.
Company Name
14 Teaberry Lane
Company Address
Sandwich MA 02563
City/Town State Zip Code
508-477-0653 S 14595
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 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1/15/11
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****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.
bl 14,
l5ins•09/08 Title 5 Official Inspection Form:Subsurface SewADispystem•Page 1 of 17
rll
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. City(rown 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 repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
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.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
Cesspool or privy is within
❑ t 50 feet of a surface water
P P Y
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Lt5ins-o�/08 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 ,.•''� 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 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 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
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 less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® 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
❑ ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. Cityfrown 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) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•09/08 Title 5 Official 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
° 844 Phinneys Lane
�M
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d n/a
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1/10/11
Date
Commercial/Industrial Flow Conditions:
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
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:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•09/08 Title 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
°M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >20feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage
Septic Tank (locate on site plan):
Depth below grade: 8"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5.2x5.2x8.6
Sludge depth:
5"
L15in. /08 Title 5 Official Inspection 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
844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. City/Town 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
29"
Scum thickness
14"
Distance from top of scum to top of outlet tee or baffle
4"
9
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? scour stick
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection tank appeared to be in good shape tees present no sign of back up.However
recommend pumping tank.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal El fiberglass ❑ polyethylene ❑ 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
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:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
R
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
t5ins•09108 Title 5 Official Inspection Form:Subs
urface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At time of inspection the d-box appeared to be structually sound no sign of carryover or leakage.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
t
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic
failure.Water depth was one foot in pit.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1115/11
page. Citylrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is
required for every Centerville Ma 02632 1/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewa9e 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
C-i GI�Q
Gnaw L
z
AI
IQ = 12' 0
A3 = 15 '
H4= 321
p 1+z,
S+Vne
t5ins•09108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
s4'\
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: >12feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Hand augeredhole.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 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
°M 844 Phinneys Lane
Property Address
Chaves
Owner Owner's Name
information is required for every Centerville Ma 02632 1/15/11
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
t
FM DWYER CO
Landscaping E Constructfcn Services
/}-5, oO� >A) 1 16 e — I-76 7 Cat, 6 lY
glrtp A-
772 Main Street
Osterville,MA 02655
5 06-426-5555 office 506-771.2521 fox 506-237-W12 cell
fmd"erco@attbi.com
f d '
I f
.... ..
�e I
CD
a
:
,
s
i
.... -......... T ,: .. .. .. ... ..
do
I ! i
t
a
i
; ' s
j t }
;
i
:
:
.. L
1
r
r .
.i
i ;
s
:I
--U
:
:
s
t
j
:
:
:
�G
,
:
.. .... ....:..
r
3
:
....... . .......
,
:
TOWN OF"BARNSTABLE BAR-W 4903
-Ordinance or Regulation
WARNING NOTICE
Address of Offender i # .`lf S MV/MB Reg.#
Village/State/Zip ()z4.SZ )}
Business Name w • _,150 am%prri; on
Business Address
SPhature of Enforcing Officer
Village/Sta-te/Zip
Location of Offense 64AIA °R w -r.l' `t .. VA
-
T i Enforcing Dept/Division
Offense L) Sf-a-rtotl 3-
Facts Lo d Sty_ t,1 �, f tE�. +� t l< �„t ANJ 1 w e4�6-' ire►
C,��.j j`�....� t`;3.'k,'�j s,. ... ��%�� �`.'�!J ,�..� .�. f i��;:."�. �:.,,.r+c.���•� �' t::-t,i"1-�� :1,r:Y•�Gxl�,
This will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
Commonwealth of Massachusetts
Executive Office of Enviromlental Affairs
Dept. of Environmental Protection
Jolui
One winter Street' D.E.P.P. Titlee V S Boston Ma. 02108 pti
Septic Inspector
P.O. Box 2119
&I
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ell 5 PART A
1 CERTIFICATION
Property Address.
844 Phinnys Lane Centerville Map 251 Lot 102 Address of Owner:
Date of Inspection: 8115198 (if different)
Name of Inspector: John Graci Selig
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and 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:
x Passes This Inspection Is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 16.303.My findings are of how the system Is
performing at the time of the Inspection.My inspection does
_ Needs u her Evaluation By the Local Approving Authority notImpyanywarrantyorguaranteeofthelongevityofthe
F811s septic system and any of Its components useful life.
t
Inspector's Signature: Date: 8124198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 auth R`y
INSPECTION SUMMARY: RECEIVEO
(' 'MA
Check A, B, C,or D: UG 11998
A) SYSTEM PASSES:
TOWN OF BAR NSTABLE
x I have not found any information which indicates that the system violates any of the failure criteria dt HEALTH DEPT.
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes,no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, 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.
(revised 04r27)97)
One Winter Street • Boston,,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292-5500
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 844 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:9115198
_ Sewage backuR or.breakout.or hiah.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to 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 leveled 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
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 THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"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 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
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04117)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 844 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:8115198
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
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:
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
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
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.
(revlsed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 844 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:8115199
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ _ Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
_c_ — 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.
x 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)j
(revised 0427197)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 844 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:9115199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: 2
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
nfa
Sump Pump(yes or no): No
Last date of occupancy: nia
COMMERCIAL/INDUSTRIAL:
Type of establishment: nfa
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: nfa
Last date of occupancy: nfa
OTHER:(Describe) nfa
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
nfa
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nfa
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date Installed(If known)and source Information:
31 years old
Sewage odors detected when arriving at the site:(yes or no) No
(revised 04127)971
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 844 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:8115198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 4'
Material of construction:x concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age nla . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le•s•He7•'w4.10••
Sludge depth:e"
Distance from top of sludge to bottom of outlet tee or baffle: 19"
Scum thickness:6"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 13"
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 and functioning properly.System must pet pumped now,then every two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: nfa
Material of construction: _concrete_m eta l_FRP_Polyethylene_other(explain)
Dimensions: rda
Scum thickness:nIa
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:nia
Date of last pumping;i,
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.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 4-6"
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction lineto
Diameter: 4•
Qmments: (conditions of joints,venting,evidence of leakage, etc.)
(reyleed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 944 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:9115199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rVa
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nia
Capacity: r0a gallons
Design flow: nragallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
nfa
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ve:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rVa
4
(revised WNW)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 944 Phinnys Lane Centerville Map 251 Lot 102
Owner: Selig
Date of Inspection:9115199
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
n1a
Type:
leaching pits, number: one 1000 gallon leach pit
leaching chambers,number:nla
leaching galleries,number: We
leaching trenches,number,length: nia
leaching fields, number,dimensions:rda
overflow cesspool, number:n1a
Alternate system: n1a Name of Technology._we
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Leach pFt and all components are atructurally sound and functioning property.System hag never had more than T ofwater In N aygtem currently has 2'of water in It.
CESSPOOLS:
(locate on site plan)
Number and configuration: We.
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: rda
Depth of scum layer: rda
Dimensions of cesspool: rda
Materials of construction: n1a
Indication of groundwater: rda
inflow(cesspool must be pumped as part of inspection)
nfa
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nfa
PRIVY:
(locate on site plan)
Materials of construction: rda Dimensions: n1a
Depth of solids: n1a
Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n1a
(revlsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
844 Phinnys Lane Centerville Map 251 Lot 102
Selig
8I15198
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)
O c
Ati�
A �
(revised04127197) Page f of 10
" Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
944 Phlnnys Lane Centerville Map 251 Lot 102
Selig
8/15198
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
(revised04R7197) Pape 10 of 10
TOWN OF/BARNSTABLE
LOCATION ��� ns v SEWAGE #
_VILLAGE 6tA(6&1 ��`e ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) PQC-c S-T 'p\7 (size) y,(o �a'
NO. OF BEDROOMS _PRIVATE WELL OR PMetT W— A E
BUILDER OR OWNER Mo 90 faaNTO S
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
� p.ue\hcc5
6 -
0`(
�e
Emma
PboL
lt/���STo F(E
OWN OF BAp RN,STABLE
'.::?'CATION ' SEWAGE #
YII.LAGE ASSESSOR'S MAP & LOT�� �� -
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACELITY: (type (size)
NO.OF BEDROOMS l'
BUILDER OR OWNER
PERMITDATE: COXCJIANCE DATE:
Separation Distance Between the:
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 we ds exist
within 300 feet of leaching facility) /' _ Feet
Furnished by `� !
a �
,48
Ac �� e
• Y
THE COMMONWEALTH OF MASSACHUSETTS
p BOAR® OF HEALTH
�"A�� TOWN OF BARNSTABLE
�J
Application for Disposal nrk� Construction 1jamit
Application is hereby made for a Permit to Construct ( ) or Repair ( L i Individual Sewage Disposal
System at:
..----_..... �4....... � ..5....1 t . ........... ............... a� ......................................
Location-Address or Lot No.
..Q��c.. ..o -s!l I QS........................ mlic.
Addr ss
a ...••--•-G c tee ----------------------- P�_ �_ � ............. 6_.
Installer Address
Q Type of Building Size Lot----------------------------Sq. feet
V Dwelling No. of Bedrooms............................................Ex ansion Attic t-t ng— p ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g --------•----•-•------------ P ( ) — Cafeteria ( )
04 Other fixtures --------------------------------------------------------------•••--•---•-----•----------•----------------...----------•-.....-••--------•••.......•--
W Design Flow......... ...................gallons per person er day. Total daily flow...... .................gallons.
WSeptic Tank 4 Liquid capacity,.�.gallons Length... _..... Width...._..... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........I----------- Diameter....i;�:........ Depth below inlet...Wit.......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................
.-
(4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------------------------------------------------------------------------------------------•- --•----------------------------------
0 Description of Soil........................................................................................................................................................................A�
.--------------------------
--------------------------
-----------
•----------------------------------------------------------------
------------------------------------------------------------
I---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
'---
W
VNature of Repairs or Alterations—Answer when applicable.... ' ......... �.Jc�_ �.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has Peen issued by the bjDard of health.
Signe - -- ---------- - ............. Date -
Application Approved By .
Date
Application Disapproved for the following reasons- -------------------------- -------------------------------------------_--......................................................
--------------------------------------------------------------------------------------------- ------ ----- ----------------------------------- -------- ------ -------------------------------- ---------------------------------------
PermitNo. -----------7�-l----//_/--------_-_---------- Issued ..............................---------------Date------
___ _ -----__ Date.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
i TOWN OF BARNSTABLE
Appliration for Uiiposal Works Tontrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( L)- 'Individual Sewage Disposal
Systdn at:
............. ......._ � VIV--S-•..Lr,,,1_C............. - - -
..-`��- ` ---------------G c -- tJ a� --------------------
_
Location-Address or Lot No.
�. •-.- -------
Owner Address
NA Installer Address
< Type of Building Size Lot......................:'__`_....Sq. feet
1 Dwelling—No. of Bedrooms._____ ________________________________Expansion Attic ( ) Garbage Grinder ( )
p., Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria (/ )
dOther fixtures -----•-------------------------•----------------------'--------------------------------------•-----------------------------------------... ------
W Design Flow__________ ____________________gallons per person per day. Total daily flow......... .................gallons.
WSeptic Tank-!, Liquid capacity--gallons Length....W.-_____ Width....C"'_____ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width_..................... Total Length.................... Total leaching area...................sq. ft. 'r
Seepage Pit No........A----------- Diameter-----10--------- Depth below inlet-___-k(__________ Total leaching area.'................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) (J e A(
~' Percolation Test Results Performed by........................... ................................. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit__.________-____-___ Depth to ground water_.-------_--------_--_..-
f�t Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................_n.
Ix -------------------------------------------------------------------------------•--•-•-----------------------------•--------------•--•-----••••---------------
0 Description of Soil.....................................................................................................................................................................
-=-- ----------------------------------------------------------
U
W \.
U Nature of Repairs or Alterations—Answer when applicable_-__ .......f-1 -1 e.........
--
•-----•1[---........--*_==---_____, .........(,--K 40-r----L. `P-Ica--l•---���-- lit.-�-- --...-E--------- U `
Agreement: / t
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to'place the
system in operation until•a Certificate of Compliance has been issued by the hoard of health.
Sighed
• Da
r A lication A roved B '�' `...... ..��,..-c-t1... ... . ------- - ................. . ----------- ..... -- -PP PP Y ------------� U J ..
Date
Application Disapproved for the following reasons: -------------- ...........___.....................`................................................
i
t
�r Date
Permit No. ........... 7 1./........................... Issued .------------.---'-----------......---'-
.....
Date
M
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(geztifiett#e of Qlamplian e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by...................................... s .---------------------_---------------------------------....--------------------------------------------------------- i
at ... C— .v.4�--_---_-- '1/��L
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...... ........... dated ......:!.....................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED 'S A GUAaNTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...... ...................................--------------------- Inspector ------ -' `-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.... �: �� FEE..3/�
MoVinat 10ork5 Tonatrnrtion "pamit
Permission is hereby granted......-_ _ _F.._.�.: vAl &e dam .....................................•--...........
to Construct ( ) or Repair (\)/an Individual Sewage Disposal System
atNo.---_._.�U _ e t-•-----•------••--•----------•-•---•-----_---•----•____________________
Str
as shown on the application for Disposal Works Construction Permit No --------____ Dated..........................................
.t...?
(""} Board of Health
DATE..... :'" .....---•--- - v
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS `
M"CkQeI venz,e �x �N
Thinner / ol
s ).n•
Cehtee.,ieI(e,V► .40zL?.l
�exw�l f'd �9-aqo
(�ovrePlei-tc� ; �c-IS-7Q A-)7- bS-' P60
ao
a
�1
it