HomeMy WebLinkAbout0005 CIRCLE DRIVE - Health 5 CIRCLE DR, HYANNIS
aBS-
Commonwealth of Massachusetts 09Lt
w Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „
l
5 Circle Drive t
V
Property Address
Charles&Jan Wehlage
Owner Owner's Na
information is me/
required for every Hyannis annis V Ma 02601 2-23-21 r.
page. City/Town State Zip Code Date of Inspection '
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information Sl*` (5
on the computer,
use only the tab Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
Company Address
Sandwich Ma 02563
City/Town State Zip Code
► (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett HickeyDigitally signed by Brett Hickey
Date:2021.o2.25 12:54:01.05'00' 2-23-2021
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 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 form should be sent to the system owner and copies sent to
the buyer, if applicable,and the approving authority.
Please note: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.
t51nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�a
/� 5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town Satet Zip Cade Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes: a
❑■ 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:
The system was in working order at the time of inspection.
2) 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 b the Board of
Y 9 P PP y
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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
�. .
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t � ,
f� 5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Tltle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)'
❑ 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
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ El clogged
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1` 5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
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 %day flow
❑ O Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ O Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ❑ 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.
5) 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
} Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.51the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
❑ 0 Pumping information was provided by the owner,occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
❑ ID Has the system received normal flows in the previous two week period?
❑ a Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ Fx-1 Was the facility or dwelling inspected for signs of sewage back up?
E ❑ Was the site inspected for signs of break out?
E ❑ Were all system components,excluding the SAS, located on site?
El ❑ 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?
❑ E 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:
ID ❑ Existing information. For example,a plan at the Board of Health.
O ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
-.- - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
No design plans 3
Number of bedrooms(design): Number of bedrooms(actual):
NA
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
No design plans available at Board of Health.
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes [j] No
Does residence have a water treatment unit? ❑ Yes Q No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes RI No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonaluse? ❑ Yes [0 No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
3/2019- 12/2020 = 33,660gallons
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: Aug- 2020
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
-- Title 5 Official Inspection Form
iSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner-date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El 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):
Approximate age of all components,date installed (if known)and source of information:
10-27-1999 per COC date
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
j
Material of construction:
❑ cast iron ❑■ 40 PVC ❑other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Ins
pection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 500gallons
311
Sludge depth:
3311
Distance from top of sludge to bottom of outlet tee or baffle
0If
Scum thickness
Distance from top of scum to top of outlet tee or baffle NS
NS
Distance from.bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is not in need of pumping
at this time but should be pumped every two years for maintenance.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass - ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened)(locate on site plan):
o,r
Depth of liquid level above outlet invert
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c
. �!� 5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.):
NA
*If pumps or alarms are not in working order,system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: (5) cultecs
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching was dry when viewed.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
NA
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
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
�y __ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owners Name
information is Hyannis Ma 02601 2-23-21
required for every y
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
TOWW of BE+.RNS'rABL
LC3t'.A7"iC/ "��/�
'tilt3—AGE rLi�',oass �,� ASSESSOR'S MAP!1cLCX1'
nvs rw :c.>ER s PtA1Nlk:.�Mor'm tyro.. -2-7 ems_
ssi- c rAk r c^pAcrry
L 3AC'Hn4G.FACMrr T-,,(type> S —e -n j -c ac
m>,OF 88DA00101s 3
Bun-D .R QR C?"VVnwili rs Q et r G.}Y2_
PSR2v rrnAT?e "_6„^g GOINIPLSAN�E I77ATE 1 7--,� �ji
Separation D isttasxtr.He tw&w the.,.
Ma.ximuin Adjnsted'Gtouniwater Ta to to the Bottom of Leaching Facility R%W
Ptiyota'Water-Supply We and' hiitg•Facility (jf-aay,'wertis exist,
oo,sine a�w2tti9t►ZtD0(0et cif Kr_wlity) 'Feet_
�of W+¢ttattQ and C.eachin :;facility(V any wwtlamds exist
Pvi tin 3CO feet of I.. .,facility3Emm
Furmishoii by
y..
'0`16
•- t 6L
t'.iinsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
information is Hyannis Ma 02601 2-23-21
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑■ Check Slope
❑■ Surface water
❑E Check cellar
❑■ Shallow wells
No GW 4' below SAS
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
El 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:
A hand hole was augured to determine high groundwater. No water was encountered
4' below the bottom of the SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
! Commonwealth of Massachusetts
- _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Circle Drive
Property Address
Charles&Jan Wehlage
Owner Owner's Name
infcrmation is Hyannis Ma 02601 2-23-21
regjired for every y
pace. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑■ A. Inspector Information: Complete all fields in this section.
❑■ B. Certification: Signed&Dated and 1, 2, 3,or 4 checked
�■ C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached.
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
A
Y
r. �1 � I I I C I •'
� ru
nj F
p Postage $
Er
Ln Certified Fee
CIO r Postmark
Return Receipt Fee �„ Here
M (Endorsement Required) AU
r3 Restricted Delivery Fee
O O (Endorsement Required)
�
p Total Postage&Fees $
N
,a Sent To .�
rl
Street,Apt.No.; O Box No.
C3 p
I= ---:----- 2. ,1.� r A.(2-------------------------------
O C ty,State ZIP+4
r
Certified Mail Provides:
o A mailing receipt
c�
o A unique identifier for your mailpiece ;
o A signature upon delivery
o A record of delivery kept by the Postal Service for two years
Important Reminders:
n Certified Mail may ONLY be combined with First,-Class Mail or Priority Mail.
o Certified Mail is not available for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail..
e For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece 'Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt, a USPS postmark on your Certified Mail receipt is
required.
a For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
o If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking: If a,postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT.Save this receipt and present it when making an inquiry.
PS Form 3800,May 2000(Reverse) 102595-99-M-2087
-4.
Town of Barnstable
oFt"Era,. Regulatory Services
� o
Thomas F.Geiler,Director
,B"MASS. r Public Health Division
039. 10
ATfp �s Thomas McKean,Director
367 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
P
Mr. James McMorrow
17 Circle Drive
Hyannis, MA 02601
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.00,STATE SANITARY CODE II,
MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND.THE TOWN OF
BARNSTABLE RENTAL ORDINANCE,ARTICLE 51
The property owned by you located at 17 Circle Drive, Hyannis was inspected on April
17, 2001 by Glen Harrington, Health Inspector for the Town of Barnstable because of a
complaint. The following violations of 105 CMR 410.00, State Sanitary Code II,
Minimum Standards of Fitness for Human Habitation were observed:
Nuisance Control Regulation No. 1 Sources of filth, piles of branches,leaves, gravel,
pine needles mixed with dog feces were observed along the fence/property line.
You are directed to correct the violation of the above within (7) seven days of receipt
of this notice.
You are also directed to correct the remaining above listed violations within seven
(7) days of receipt of this notice.
You may request a hearing if written petition requesting same is=received by the Board`of
Health within seven (7) days after the date order is received. However, this violation
must be corrected regardless of any request for a hearing.
Please be advised that failure to comply with an order could result in a fine of not more
than $500. Each separate day's failure to comply with an order shall constitute a separate
violation.
Q:/health/wpfi les/artic5l
vo
You are also subject to non criminal citations of$40.00 for the first violation and $15.00
for each additional violation. Tickets will be issued daily until the violations are
corrected.
PER
ORDERT E BOARD OF HEALTH
P
Director of Public Health
I
Q:/health/wpfiles/artic5l
SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. �of iyery
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse C. Sig to
so that we can return the card to you.
■ Attach this card to the back of the mailpiece, X ❑Agent
or on the a front if space permits. ❑Addressee
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
p
SJ f-' c a��° 3. S�erv °Type
I�!Certified Mail I❑ EX ss Mail
❑ Registered l 'Return Receipt for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number(Copy from service label)
PS Form 3811,July 1999 Domestic Return Receipt 102595.00-M-0952
f
UNITED STATES POSTAL SERVICE First-Class Mail
i Postage&Fees Paid
r USPS
Permit No.G-10
Id
• Sender: Please print your name, address, and ZIP+4 in this box •
�j
�i Pub11C DNA
t Town of effawk
P.O.BOX 04
oyann* Massadtuseft 02601
F
4
» a .7
(§\ IN
�:
}a\�\ � 2���� �� � •
* ■ � � � � ����y%^,
•- , z``����� \ . . v
� � �\ ^• ' �
;� fV
u5
C7
N
IU
Q`r'J
I
5
I Y�
I�
Iy
II '`•
f
{
i
1
a,
7
•
7 Gio(e. P,7e
x44ati�(eWI6!s,,ov%Ktneed+of"4.G6.J
fiol.•-arh btfiwee„l °t.�,,c dy 0/7 C;eat
owl 6 t t�f,re rs �e''�� je S.
.5
(.�
��J ,'���
�� qp`
`, q.
�~
ry
a�
4i
V
f
k ' �- 3
'`
LLr. ,
�.
{t: I
{
7
3
17 Li 1-de ar, MY.aarois—Pi
S+i Gird ow.d A5 4,&CJ P v-/ o h.,0.��ory�Y
GG�.. ma,."sy9
i,k� _
_ r
f ��
.:9
w
U� ��,:
Ca
�V
.�
CJ
r..
ti�
k
I
I' �
�'
ic'
I I',`
�'� al
i �o, as
M
I
.. —�
0 Gi•Y.Gc A���c, fi�ya�ars
df'ra,el toki r
6Y Ou kO- o f 9*7 li r. �.do Sy Gt►oGt
Y� T
I -
'� N
CO
v
r-
N
m
f
i
i r=�
tk I
i
a
r.
Health Complaints
11-Apr-01
Time: Date: 4/11/01 Complaint Number: 2791
Referred To: DONNA MIORANDI Taken By: Florence SMITH
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail:
Business Name:
Number: Street: Circle Drive
Village: Hyannis Assessors Map Parcel:
Complaint Description: Trash, grass clipings, and dog waste being
dumped between two property fences. House
is located on Circle Drive. Complainant does
not know number of the house. It is the
second house on the left. Call complainant for
more information on location.
Actions Taken/Results:
Investigation Date: 4/i'h I Investigation Time: y,a�
L
144' 4.
a 14, d o r lof- a-��-, S lZ
d "J
alb
dJ . fit. W,�t
+. fit► (�� • v liA, I,"Awvw..
�e�8 -f �e.�e� �,���5 a�r�-���d`1 .¢ is �cr✓�l �(���• �'�� �Kx �e��.Q v�,��
�/ cv fCc.n
y
288035 V 001913 R 11l 0000000 �
55CC ,b
1; LOT 2 s r r �� 8 y�; 0.27 �$s
t� : BAITER,PETER B&BETH H 101
%MCMORROW,JAMES F
fi 0000 40
1' PO BOX 2862
HYANNIS MA : 02601 r"'
F� 00-0000-000
te : 000000 e E g 12802 132
� e
€ , BAITER,PETER B&BETH H u, 0000 - 2392/99
1r - m000049400 000085600 0000000000
CIRCLE DRIVE 0312 0100
HY G I w 0000 0000
y,
E
s
I,I
r a 4
72 66
v^
17 5
t
173 174 ,t; 77 79-4
7.7
\
:S ��--• \ \'''.--'mot ,..—. t
t :
1
28
t_ J
--A P6,
- _
M
,
Qa
: �:�\\� _. 7 /�,{. YC.•. ... it iti :' "\\�
,
6
tAAF 26) \� �•' i :..:
27
1 4 !
1' kF 1
.-1288
14
LJ
J
1 ;
• t
,
1 `
1
is `
TOWN OF BARNSTABLE
LOCATION C r )Q r2 SEWAGE #
VILLAGE r'y
�/4�- � �� ' ASSESSOR'S MAP & LOT
INSTALLERS NAME&PHONE NO. S— $'7 7 L,
SEPTIC TANK CAPACITY I S rr-<-)
LEACHING FACILM: (type) — /T.& k J (size)
NO.OF BEDROOMS .�T
BUILDER OR OWNER J�'n O A- G' YZ
PERMUDATE: 16-Y- 9 2 COMPLIANCE DATE: /d
Separation Distance Between.the:
Maximum Adjusted Groundwater Tattle to the Bottom of Leaching Facility. Feet
Private Water Supply Well and chin Facility PP Y. g (If any wells exist
on site or within 200 feet of aching facility) Feet
Edge of Wetland and Leachin Facility(If any wetlands exist
within 300 feet of lead//facility) Feet
Furnished by
} i
0' f
I
l
oq4�fj
J, d __�
1/ N ' 0 -
o. -3 s.. ,� Fee
THE COMMONWEALTH OF MASSACH SETTS Entered in computer:
Ys
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Migooal 6p!5tem Construction permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System O Individual Components
'Location Address or Lot No. Owner's Name,Address and Tel.No.
S Circle Dr. , Hyannis , MA Evelyn Spooner
Assessor'sMap/Parcel 126 Brags Lane , Barnstable , MA
I s aller's ame d ess,and Tel.N Designer's Name,Address and Tel.No.
r M. to inson peptic Service
P 0 Box 1089, Centerville , 1viA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic S S t e
Tank, D-box and. **4; .Lr�-6 . `
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental C de and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B d o e Ith. �����✓
Signe Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
+Fee $ O, Qx
THE COMMONWEALTH OF MASSACH SETTS r E'ntered in computer: :®
Yes
PUBLIC HEALTHDIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS '
0(pprication for 30i9;pogaf *pgtem coon.5truction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
5 Circle Dr. , Hyannis, MA . Evelyn Spooner
Assessor's Map/Parcel 126 Brags Lane, Barnstable, MA
I���yraller's ame d ss,and Tel.N !Designer's Name,Address and Tel.No.
NYme . o` inson §eptic Service .
P 0 Box 1089, Centerville , WA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. ' Garbage Grinder( )
` Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date ` Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic s Ystem.
Tank, D-box and isLtTtiao -s . �, n q l�
Date last inspected:
Agreement: �\
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental C de and not to place the system in operation until a Certifi-
cate of NCompf ai nce has been issued by this B and okleplth. // Q
Signe J AA A Date
Application proved by / Date
V / /
Applicatioalsapproved for the following reasons
Per nAo. J Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Spooner BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service pg
at 5 Circle Dr. , Hyannis, MA hagben constructed in accordance
with the prgvi:ioT of Wi0 D 1riS he for—Disposal:posal System Construction Permit No. dated
Installer Designer �r
The issuance of this pe tft';rf
l ng be strued as a guarantee that the ystem ill flu/ ti 'n as designe"IdI. 'D f
Date _ co Inspector -I 1/U D �' l �� l r� -C
5
V �
-- - ------------ -
No.of ' r Fee_$5 0
(/ •THEQIIONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACjjIL4S# C>
Spooner
igpogal *potem Conotruction Permit
Permission is hereby gr te�to Cofstrug.( )13epair(X )Upg ache( )Abandon( )
System located at irc e r. , annis, 1H
and as described in the above Application for Disposal System Construction Permit. The applicant recog izes hi /her duty to
comply with Title 5 and the following local provisions or special conditions. -`- O
Provided:Construction st e c ted within three years of the date of t pe
Date: I Approved by / G� ® /
1/6l99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I W i l l iain E . Robinson,S,rhereby certify that the application for disposal works
construction permit signed by me dated 16 concerning the
property located at 5 Circle Dr. , Hyannis, MA meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
•] T�Ie soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• T re are no wetlands within 100 feet of the proposed septic system
here are no private wells within 150 feet of the proposed septic System
e is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
® If the S.A.S. will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B G.W. Elevation + the MAX High G.W. Adjustmert Jowl
=
DIFFERENCE BETWEEN A d 13 _
SIGNED : DATE:
[Sketch proposed plan of system on backl.
q:health folder:cen
��
.�.. .. �,
,.,..
� �-
C�
'�
��
TOWN OF BARNSTABLE
LOc;'AT1Ot �� C C /_ fZ, SEWAGE # �
VILLAGE / /o z, ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. �o f �-dz F'�.. 7 S '7 Z,
SEPTIC.TANK CAPACITY Ise
LEACHING FACILITY: (type) (size)
NQ.� F,BEDROOMS '"
BUILDER OR OWNERS
PERMITDATE }/ --Y-`i -1 °` COMPLIANCE DATE:
Separation Distance Betwee.a.the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply WelVandching Facility (If any wells exist
on site or within 200 fehing facility) Feet
Edge of Wetland and Leality(If any wetlands exist
within 300 feet of leacty) Feet
Furnished by "J
r...-. t
t+3¢..
r
-. d �
� ,
,/'J !
�:;: ,.
1��
N � � ^
N ;�.
_""
;.:,;
,�,�r:
`! 0. _ ` �
b
3 ��
ii�
s
,. t
�' ..�,
,: � x
_. � �.., __. - -_J
r rt ;j`p,,Jr
CRAIG ME®EIR®S
ruc ing V TulldoKlng
—idyannis, Mass 775-0898
I
0
C�
w
No y... � Fu$... .:G..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
''''°"...................OF....Z......................................
Appliration -fur Miipoiittl Workii Towitrurtinn Vrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: �.
------------ ........................................s .�_......... ----------- ......----------•---------••• ......•-•---......•---- ��__•_-.........----- y '
Location-Address or Lot No.
ow
v o S ('a e "'r %Via^ 15
..--••--•---•-.....----•- .........................
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of pet-soils............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------------------------------------------------•---------------------------------------------------
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 ( )
aPercolation Test Results Performed bY----------•--------------................................................ Date---------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...----.------..-..-----
Gi, Test Pit No. 2----------------minutes per inch Depth of Test Pit......._............ Depth to ground water.-.-.._..-_.------_-----
9 --------------------------------------•-•---•---•--------•---•-----•----._..__...---••-----....•.............................................................
ODescription of Soil.......................................................................................................................... ---------------------------------------------
x
Z --•----------- ------------------ ------------------------------------------------------------- - --------------:----------------------------------- -�-
V Nature of Repairs or Alterations—Answer when, applicable._.___ _ 'az1 S..____--._1. .... _,
---- ----
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued b the board of health.
igned- •. •-•----••--••--••-••-------••--••--••-•••--•--
l ate
Application Approved BY---------•��f- -------- ---- -- -- - �� ... .- ------------ -----1,d- -
Date
Application Disapproved for the following reasons---------------------------------- ------------------------------------------------------------------------------
--...--•----•----•--.•....-•-••-•--......--•-•------------------------------•-•-•-----....••--•--------•....•-••••--•...............-•-•-----.•-----------........----------------.........-------•------
Date
PermitNo......................................................... Issued........................................................
Date
No. .... .._....� FEE...>.! ...... .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...... OF................. .................. .........
Appliratiun -fur 11-4po l Workii Tomitrurtiun Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location.Address" or Lot No.
7 Syr,
Own / t Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling ' No. of Bedrooms-------------------------------•------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
0.1 Other fixtures -----------•------•----------------•-----------------_------------------------- ------ ------
Q
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity-.---_-__--gallons Length________________ Width................ Diameter................ Deptl-_--------------
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-------.--------------------------------
W Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_.......................
t� Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water---------------------
------------------------------------------------------------------------•--•--•...........--•--•----•-•----•..........---....--------------------------------
ODescription of Soil------------ ---------------------------------------------------•------------------ ----------------------------------------------------------------- ----------------
x
U --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------
___
Nature of Repairs or Alterations—Answer when a hcable..........:. .�� !'. :.._...... �._ _ _s9.. _
U P' PP �.. . _ . .. - ...
---- ---------------------------------------------- �� == '
// 7 YY✓ , CTM;a..fie 61"�-r
Agreement: ...�
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed•: f7
1-12 1 �
�' •- � � 'T'�'... . ........ ....-- ------sf _ Jute �r
Application Approved By---------- ....'..--a------- '�'/ ��•/ J 1--------------- �-75"�
............(//�......................... Date
Application Disapproved for the following reasons:................... ....
.................---•-••-•-------...-----•--------------------•--•----------••••-•--•----•--••••---.......•-•-•-....•--...............----------••••-------•----•-----------•---------------............
Date
PermitNo........................................................ Issued...................... .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
r_ BOARD OF HEALTH
............`.... .r...............0 1... Y '""......................................................
QIrrtif irair of 01.1,amphatt r
THIS�IS TO CERTIFY Tl.at thg Individual Sewage Disposal System constructed ( ) or Repaired ( ,.a
b `�--- ............."---•-•------------------. --•---------------•---•-----••....... -----------...---••--••••--•--- _
Installer ,_,_,/ -----------•--------------
at..---------- ✓�r-�' '! C'� .... '
!.�.`"?-. .� t.±-. ,.� r " ` ,
has been installed in accordance with the provisions of A t)c f I of The State Sanitary Co dE as described in the
application for Disposal Works Construction Permit No.� '.__ .....SV_..... dated'.."_.. r!?..."""�.�."
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
n G �
DATE--------- d o�FJ ---------- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
7 � BOARD F HEALTH
OF
No.............. ........ FEE........................
Dispuiittl urk Cuntr rtit rrmit
Permission is hereby granted•._._ ________-�-t-" �_!��/.________..-__IVI�.G_.. :.,_0`"."-
---------------••-•----- ---------------
to Construct ) or Repair ( an Individual Sewage D'�posal System J
atNo-------- =—`�'------ `�...........................................^ �� ' C./�-- �---------------------
"street "�
. .
as shown on the application for Disposal Works Construction Perri t No..._.:-:<----------- Dated.... -'_7.6_..__....
DATE.-••>/ � 7o"'` Board of Health
?------' -- - --- ------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS