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HomeMy WebLinkAbout0016 CONNEMARA CIRCLE - Health i 1 G cbr h.mara Circle` Hyannis l ° 0 f ° o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address p Diego Baveloni Owner Owner's Name ' information is -v required for every Hyannis ✓ Ma 02601 . 9/26/2018 I ;y page. Cityrrown State Zip Code Date of Inspection I^T g Y7 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information sl 3�a3 filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Company A Lane Co Company Address Centerville Ma 02632 Cityrrown State Zip Code 508-658-3456, 774-248-4850 SI 4522 sean@smjonestitle5.com 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 9/26/2018 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 DI Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owners Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 mhave 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 dwelling located at 16 Connemara Circle Hyannis is served by a Title V septic system consisting of a 1000 gallon septic tank and 2 precast leach pits in series. 'The system was found to be in proper working condition 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 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): 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 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 . 9/26/2018 page. Citylrown 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: r ❑ 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 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/2 61201 8 Title 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 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 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: i 4) ,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 El 1 clogged SAS or cesspool f, Discharge or ponding of effluent to the surface ofthe 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 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owners Name information is required for every Hyannis Ma 02601 9/26/2018 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 water supply 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 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 , l5insp.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 16 Connemara Circle Property Address Diego Baveloni . Owner Owner's Name information is H required for every annis Ma 02601 9/26/2018 y page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the 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 ® ❑ 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? ® a 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)] 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 zp< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owners Name information is required for every Hyannis . Ma 02601 9/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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: 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known) and source of information: original system 1976 with leach pit added 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑ cast iron. ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet - Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leaks or blockages. Vented through roof t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 611 Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? opened covers and took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•'rev.726/2018 Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Y f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System .Information (cont.) 7. Grease Trap (locate on site plan): I Depth below grade: feet Material of construction: i ❑ 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): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form <a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owners Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown 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): Depth of liquid level above outlet invert N/A 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown 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.): 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: 2 ❑ leaching chambers number: leaching galleries number: leaching trenches number, length: 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 < Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . � 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 . 9/26/2018 page. Cityrrown 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.): s.a.s. consists of 2 leach pits in series. The second pit inline added 1995 was located and opened and was found to have 2' standing water with a stain line 1' higher. 12. 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 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 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owners Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11 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.): t5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 115 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown 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 Y A �\ a J j` (� i3Z z ro r �33 y3 t5insp.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 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps. 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 16 Connemara Circle Property Address Diego Baveloni Owner Owner's Name information is required for every Hyannis Ma 02601 9/26/2018 page. 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 l USPS TRACKING# First-Class Mail Postage&Fees Paid USPS Permit No.G-10 9590 9402 1933 6123 1425 77 I � United States •Sender:Please print your name,address,and ZIP+4®in this box• i Postal Service: j a Town of Barnstable ,; Health Division 200 Main Street Hyannis,MA 02601 ' I `I 'SEN • ■ Complete items 1,2,and 3. - A. Sig ■ Print your name and address on the reverse X ❑Agent I so that we can return the card to you. ❑Addressee I ■ Attach this card to the back of the mailpiece, y rioted Name) C. Date of Delivery or on the front if space permits. I 1. ArticlLH dd t - D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑ No I ond Johnson a�S MA 0? nemara Circle 61 is, MA 02601 T 3. Service Type ❑priorii Mall Express® II I IIIIII IIII III I II II I I I I 1111111111 1EI I I III ❑Adult Signature \ Registered MailTM ❑Adult Signature Restricted Delivery 0 Registered Mail Restricted ❑Certified Mail® N., (i C?-,Delivery 9590 9402 1933 6123 1425 77 ❑Certified Mail Restricted Delivery=��❑Return Receipt for ❑Collect on Delivery Merchandise ❑Collect on Delivery Restricted Delivery ❑Signature ConfirmationTM 015 1730 0001 4990 2 9 6 0 ❑Insured Mail ❑Signature confirmation ❑lnsured Mail I Restricted Delivery Restricted Delivery over PS Form 3811,July 2015 PSN 7530-02-000-9053 ir-� Domestic Return Receipt Town of Barnstable MAB&`� ' Regulatory Services Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 23, 2017 Raymond Johnson 16 Connemara Circle Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE BOARD OF HEALTH REGULATIONS. The property owned by you located at 16 Connemara Circle Hyannis, MA was visited on August 23, 2017 by Timothy B. O'Connell, R.S., Health Inspector for the Town of Barnstable. This inspection was. conducted in response to a complaint filed with the Public Health Division. The following violations of the Town of Barnstable Board of Health Regulations, Chapter 54 Building and Premises Maintenance were observed: 454-3 (A) Outdoor StorajZe Multiple items are being stored outdoors on this property which are not screened from public view and are not within an enclosed structure as required by above ordinance. These items include but are not limited to: car parts, trash, garbage, broken lawn mowers, and various types of tools, furniture, mechanical tools, car parts, Lumber, various types of hazardous materials and other assorted debris. You are directed to correct the violations listed above within (15). days of your receipt of this letter by removing said items from property and/or storing them in an enclosed structure You may request a hearing before the Board of Health if written petition requesting same is received within 10 (10) days after the date the order is served Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable . . Health Master Detail Page 1 of 1 Logged In As: TOWN\oconnelt Health Master Detail Monday,August 21 2017 Application Center Parcel Lookup Selection Items Parcel Septic Perc Well Fuel Tank Parcel: 291-278 Location: 16 CONNEMARA CIRCLE, Hyannis Owner: JOHNSON, RAYMOND H &JACQUELINE A Business name: Business phone: Rental property: ❑ Deed restricted: ❑ Number of bedrooms : 0� Contaminant released: ❑ Fuel storage tank permit: ❑ Save Parcel Changes I Return to Lookup Parcel Info Parcel ID: 291-278 Developer lot:LOT 59 Location:16 CONNEMARA CIRCLE Primary frontage:135 Secondary road: jar Secondary frontage: Village:Hyannis Fire district:HYANNIS Town sewer exists at this address:No Road Index:0345 Interactive map: > ',i `r'`= �. Town zone of contribution:SPLIT(parcel is split between districts and should State zone of contribution:IN be looked up on the map) Owner Info owner: JOHNSON, RAYMOND H &JACQUELINE A Co-owner: Streeti:16 CONNEMARA CIRCLE Street2: City:HYANNIS State:MA zip: 62601 Country: Deed date:4/13/1994 Deed reference:C133494 i Land Info Acres: 0.27 use: Single Fam MDL-01 zoning:RB Neighborhood: 0104 Topography:Level Road:Paved Utilities:Public Water,Gas,Septic Location: Construction Info ufldlng N ear Bufl Gross Area iwng Are Bedrooms lBathrooms 1 11976 11868 064 12 Bedroom 1 Full-0 Half Buildings value:$78,100.00 Extra features: $19,600.00' Land value: $68,900.00 �Q�♦ ./ . y httpJ/issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=291278 `� 8/21/2017 ' Citizen Web Request Page 1 of 3 r i � r • 8.i<ILTSTAZ�LE, y MASSY Logged TOWN\ coon Citizen Request Management Monday,August212017 TOWN\oconnelt Route to Users Search Requests Create Requests Request Information Request ID: 59022 Created: 8/21/2017 12:25:35 PM Status: Assigned To Staff Assigned To: O'Connell,Timothy Health Office Anonymous: Yes Request Category- Chapter 54-5 : Rubbish and Garbage edit Routine work: No Estimate: No edit Date scheduled: 'edit Estimated 9/4/2017 Change Estimated Aug September 2017 Oct Completion . Completion Date: Date: Sun Mon Tue Wed Thu Fril Sat 27 28 29 30 31 112 3 4 5 6 7 8 9 10 11 12 .13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 Created By: Soto, Kathryn Priority: Medium edit Health Office Citation Numbers: edit Requestor Information Requestor Request DETAILS: LOCATION: 16 CONNEMARA CIRCLE Hyannis, Ma 02601 Request Parcel Map: 1291 (Block: 1278 j Lot: 1000 Trash Number complaint Parcel Lookup Email: Edit Requestor Information 'Track Request Progress http://issgl2/lnternalWRS/V,Request.aspx?ID=59022 8/21/2017 TOWN OF BARNSTABLE LOCATION �� C / C®yI�IL 1/`Cle SEWAGE # VILLAGE A/ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER V®,`l a✓r�S'Q �� i PERMITDATE: COMPLIANCE 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 wetlands exist within 300 feet of leaching facility) / Feet Furnished by i :' . W� � - `� � �., �� w . .. r ;. i i- f �� e � - y �.. . � � � y LOC&TICiQ SEWO.CtE PERMIT- Q'O. VILLAGE INSTALLER 5 1 &ME ADDRESS BUILDERS Q &MF- P, A-DORE SS ' DN-TE PERMIT ISSUED D A.TE COMPLM acE ISSUED — _ — ti,w#ai \nr'•y. a a i Aw.w Si �rs. Ftzs... ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Ubip oul WorkB Tonotrnrtion Errant Application is hereby made for a Permit to Construct ( ) or Repair De� an Individual Sewage Disposal System at: - ` ---- --- ----- fUiJ Location-Address G( or Lot No. _.�.�� ./.�..._....----C Gv�1- g.✓l. ✓��4 -�"a:' ' .�,g Owner ddre s -------GeJN.3�-----�7� 1�-- W-4� 18 y A.. / .1 �l e..S 4 a Installer� Address U �� Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............. •:-:---.--------_-.._-.-Expansion Attic ( ) Garbage Grinder t—�iCIC� aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures ............................... . . W Design Flow...............5. ................gallons per person per day. Total da.1 flow..--.-._-__----0,7 _..__.._.._._._gallons. 1:4 Septic Tank—Liquid capa6ty_l994---gallons Length-_F_(__ _ Width... ... Diameter................ Depth....C/.1--l.T. W Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. x 3 Seepage Pit No----------I......... Diameter.._...L.4........ Depth below inlet................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..............................................••-------•------••-••---•--- Date----------------------------------...... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p� ..:..............................................................•-••--•••------•--•-----------•••-•......................................................... 0 Description of Soil........................................................................................................................................................................ x U .....•-•------•--•---...•-•---------------•--------•------------••-••-•-••-•-----•-•-•---------•-----•••-•---------------------------------••----•-•-----•-•---------••--•••-•-••••-•----••-•-------•••-- x ----•-------------------------------------•------------------------------------------------....----------------...--------------...-------------------•-----•-----------------••-------••......-•--••-• U Nature of... Repairs or Alterations—Answer when applicable.._.._/�.....__...I..000 �L •Lfif.fiM,,, 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 s b en iss d the board of health. igned .......... .............................'.......................... ......... a. ..... ............... .... .... Application Approved By ........... .. ........... >/E'� .... ............................. ..... .. Due Application Disapproved for the following reasons: ...................................................................................................................................... .................... ............................................ Permit No. --..f .. .. ............... Issued ...............d .....�. ....Rom- M[e...... ........... Dare e R- 9s /G f No. ---•--_....... Fr;:s...3Q............. e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di!ipwml Work,6 Tomitrnrtinn amiV ` u� Application is hereby made for a Permit to Construct ( ) or Repair (rVQ an Individual Sewage Disposal . System at: r .nlp.._.......C c v.l ��...a�Z19-----------C.-i ���--•-- ,...------ /f"`�!....5--•--••----------------••-•-----....-----•---.. su l Location-Addressor Lot No. .. 4 Owner Address w � c v�►s-r- t^�'�L�y..._. ...._ r�'� is c.s .--------- -----------------------•........--------------------- ----•-. --------------------- . .................. 'Installer Address UType of Building Size Lot.................... Sq. feet Dwelling— No. of Bedrooms.............. �_--_.-___.---._---.-.. ---Expansion Attic- ( ) Garbage Grinder f---�w Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) lOther fixtures -----------•....................................•-----.......---------------•----------- ------------..............----......-----------.....------... W Design Flow............... _ gallons per person per day. Total daily flow..-_--._-------0��. g -� -------- ------------g P P P Y• Y --- -- ......_..------gallons. WSeptic Tank—Liquid capacity__/.PQ...gallons Length._9�..,3. Width_... -_-- Diameter--_----.-.-_-- Depth.....y.!�7 x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No........./......... Diameter......1..4._...... Depth below inlet......e............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of .Test Pit.................... Depth to ground water......................... (rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ..........................................................................................••--------......................................................... 0 Description of Soil........................................................................................................................................................................ V ------------ -----------------'---------•---------------------------•-•-----•----•-•------------------------------------------------------•-------•-------•----------------------------------------....-- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable........ .......... -Li}-9 ��1 t -- =S%Zc:J. ............/.+J - �J£...�°��A----------- .. .. ......................... 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 h s b en iss y d y'the board of health. �� �ig ��........................... ......:... .. ................. ................. .............:...... reApplication.Approved By ........... lr..�/E .... ... ...... �c............................. ...... ... Application Disapproved for the following reasons: . . .. ...................................... . ........................................................................ Q O Dare Permit NO. ...........I..... ..� ..�..................... Issued ...............I 7 psi............ Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE LLErtifi ate of (111IIittyliance THIS IS TO CEFX That the Individual Sewage Disposal System cnstructed ( ) or Repaired ( pv by .............................................. . ............................................- ^1 ........................................................� /.. Insrd�er at .............................................. .C../ . C.0 V N�%vim (/e C C�. f"/ /_ 1 Vl tj .................................................. has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .. .-..��v.Cv..CD.....:1... dated ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....... ............ .�r.. '. � ................ Inspe ...... . __.--__—__—.___—__,__—___—_ —__,__.____,_,_,_,____ THE COMMONWEALTH OF MASSACHUSETTS 2 "Z/_7 i BOARD OF HEALTH g TOWN OF BARNSTABLE -3G / /-- FEE........................ �ts�n�tt1 nrk� �nn�tr�rti.>an �rrmit Permission is hereby granted-------:............ . �1 Q..-�1--.!---... --- ..�/S?ih.. .................................... to Construct ( ) or Repair (��'�j/—/an Individual Sewage Disposal System at No----------------------------------------- !.iP.................. .���-f_lam.Gv?i1-4•/lv-------C.-(�C..---- ----- -f`--------.--. Street ��J/ �D as shown on the application for Disposal Works Construction Permit N ..-.-_----/---/o-__-. _ D ed_._.� .. �/.._...... ....--.... • � 1 n Board of Health DATE................ ......--------------- FORM 36508 HOBBS R WARREN.INC..PUBLISHERS I CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated �� r� ,concerning the property located at /fie O'J1'jeNv4AA G14" meets all of the ON t.4 following criteria: i •. There are no wetlands within.300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED:. DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. LOCUTION 5EW 06(,E PERMIT . 1.I0. VILLAGE IWSTALLER•5 U&ME ADDRESS BUILDER 5 Q &MF- ADDRESS - MTE PERMIT ISSUED G ATE COMPLI &MdE ISSUED : I _ ......... r -A w r S86°43'00"W. 45. F28 ' LOT d . sre 57 � o O 4� o red � o dec,K s. 4 0± 82`55 '40T 0 00 ' L=75.5 7 - N ; R CONNE'MA ' A CI)RCLE. RES. ZONE: "RB" This MORTGAGE INSPECTION L�IOZBj39 Plan is U For 1 DEED REF: Bank FLOOD ZONE.- "C" TOWN: �lYNI� — _ _ _ REGISTRY OWR .BE'FINER: EYAM&P d�&�gI CQLEE I�A—L2H=N —BUYE �AN� ... ._._.....,....b:�� gib¢•:,..: . DATE: _W 7,�4 — PLAN REF: L C 27�B S 1_SCALE.-1"= 20 _FT. I HEREBY CERTIFY TO �'T�Y.E1Y _PIZZA U---------- ��r of ,y ---------------------------THAT THE BUILDING - YANKEE SURVEY SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS o`' PAUL y� CONSULTANTS SHOWN AND THAT ITS POSITION DOES ---- CONFORM � TO T11E ZONING LAW SETBACK REQUIREMENTS OF THE 3 MER THEW N 40B INDUSTRY ROAD OF e No. 32098 3d� d _—AND THAT >Q VS MILLS, MA. 02G4E3 NET IT DOES-- - LIE WITHIN THE Sk'LCIAL FLOOD HAZARD ', tC►SiC�`" AREA AS SHOWN ON THE H.U.D. MAP- DATED °s/pygi iA���S�Q TEL 428-0055 /1,�'l��— FAX 420-5553 C •—P e 250001 :0005.`'C:. : , ; ; . ;THIS PLAN jNOT MADE,FROM,AN„.JNSTRUMENT ' ,`,-SURVEY• SNOT TO 1BE `:USED •FOR$FENCES r` .�....w.�.�..�+�• .®... .__...... .. .. .._... ...-_..._.�..._,......e ...-... ::..w...�.•-....o+-..... ......- ...�....•.�r... ..�.�......� .r�1. / Ale 10 ` -•"yc { ^ }' nAT �'' .J ..ems+.a�.�..+.-.w,►.�...�.�.:......:. • + I\ 'C t T' f r r, t �, c: �,� t' t tH Oi�'4� i}:c °r1!•'i .� r' }�. ., !r ?'' 7 .. r (: �� GEORGE S LOW.JR. y i �. o ti No.---•--........(........ F�a...(.. ................_ THE COMMONWEALTH OF MASSACHUSETTS BOA F HEALTH Appliratiori -for Disposal Works Tonftrnrtion Vrru..iit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy tem at: '' 6?A;,VA,.1?'11��9.P.- �.1 L:.� -------- / 6?A;,VA,..1.nb9.P .------a•--l- .I..................................------. %Location-Address a or Lot No. ------------------------------------- ...... ----= ....... % '�`�° ......... c. Z4 m__t:.� C-----Do17.4w_�--Y---••-...-------------- -Q �o� 5'Z1 - ...-•-- C. ✓L � �G Installer Address UType of Building Size Lot-----_-_-_-_•_______________Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (N� aOther—Type of Building CG'�................ No. of persons...... ------------------ Showers (44 — Cafeteria ( ) Other fixtures W Design Flow............................................gallons per person per day. Total daily flow....._.._.._........._..___.....__......._..gallons. W' Septic Taitk—Liquid capacityJac4?__gallons Length...... ....... Width... 1�...._.. Diameter_.-•-----....... Depth................ x Disposal Trench—No...:................. Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter..........:......... Depth below inlet.................... Total leaa;huig area_.._._...._.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) B�� 3-,Z- 76 - �`'G Percolation Test Results Performed bY--------:................................................................. Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water........................ L14 Test Pit No. 2................minutes per inch ' Depth of Test Pit.................... Depth to,ground water.-._---..-.--.---__--. - �: ------------------------ ---------------------• • ................................ �•--•-•------------•-- O Descripti of Soil.---------- - - . ............................... VA`.. .. - ..�... a la 9� U Nature of Repairs or lt�ns/—Answer when applicable----------------------------------------------------------------------------------------------- ------- -------------------------......................................................... 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 iss d by board of he h. Si ed- �...V bay _mi....�. ............................ Application Approved B h n• yy� - co Z ,L� Date PP PP Y .................... . � ---------------- Date Application Disapproved for the following reasons:................................................................................................................ J ................. ----.........-•----.....--•----•--.._..-•-•--•----•--...--•----•-•--......-•------••--... 7/Date PermitNo......................................................... Issued.- ------------ /.401 Date r_-- -- -------- _ —----------------------------------- --- --- .. - - _ ................. THE COMMONWEALTH OF MASSACHUSETTS BOA F HEALTH J . .N........OF. . . Appliratfnn -for Uhgposal Workii Tonntrnrtiun Vrrnift Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: COI-�'s........ ..�1AL.L--------- ------= U..T- ......y-............................................................... 4. •---•--•-"'-•'-�-�---1 :----- _�O_1T.1.1..................................... ..... d.�ss..._.��. '----•--• f Locat,on-Address or Loot No. WC= = /---------------•-••.... ' ----�A.�-c.....�� .... ....... Installer Address Type of Building ; Size Lot............................Sq. feet Dwelling—No. of Bedrooms............:...............................Expansion Attic ( ) Garbage Grinder (40) 0. Other—Type T e of Buildin 1 YP gc&4k-•------------•--- No. of pel-solls....:. -------------------- Showers (//S — Cafeteria ( ) QIOther fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. P' Septic Tank—Liquid capacit _�Uo ..gallons Length_____?________ bVidth._��� ....._.. Diameter________________ Depth................ W Disposal Trench—No- --------------------- Width.................... Total Length..................... Total leaching area....................sq. ft. - x Seepage Pit No..................... Diameter----------.--------- Depth below inlet-------------------- Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of 'Pest Pit.................... Depth to ground water........................ G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water._.____.______.____----- a -----••---••..................................................................•-•---•-----•-....-•-•......................................................... ODescripti n of Soil................. _ . ------------------- - -------------------------------•--------------. x _ U Nature of Repairs or lt�ns—Answer when applicable................. ..................................:........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been Xissed by board of he th. Si ned Date A lication Approved B ....................�_ .._________----- PP PP Y_.... � Date Application Disapproved for the following reasons:----------•-•................•-•-•--•--•---...-•-------..........................---------......-----------•---- •-•------•--------•--------------•--------------- -------•-----.---------------.---.-------------- pate Permit No.-•--•--•-•••-----------•-------------•-.....:_ ... . --•--..... Issued-------!-'-,-----2=--------. Date THE COMMONWEALTH OF MASSACHUSETTS Cj .7 BOA F HEALTH Ol!(/ ............oF.. fmil...Cf:........................... Cn rrtifiratr of f�umphaurr r ".� TH TO CERTIFY P That h' Individual Sewage Disposal System constructed ( ) or Repaired ( ) y , by........... ... ` ----...-------- =--------'- - .�.�(Gil.. . .. nstall�r at..``:..-I--- ....... ` '.k'�-f- has been installed in accordance with the provisions of Ar 's e XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. ....../,/ / ..� ........................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----. .......................... Inspector.__._..............---......-- .---------------------•---------- THE COMMONWEALTH OF MASSACHUSETTS eye/ 7� BO F HEALTH No. l /_ 1 U V..lN..............oF.. .. //t ri /c -[D--y------ FEE........................ Di polial luor,kii CIT'nnstritrtion Prrntit Permission is hereby granted_ .��32......... .7.... to Construe ) Repair ( ) an Individual ewage Disposal System at No._.,5__V.......�,O.IAV%J- _d ��..__ //.�.J.f/r` ................. Street as shown on the application for Disposal Works Construction rmit o. .......... ........ Dated�.� '.Y-'..Z_`_...........:.:.... 1 C._..A44t-l/1 •- •------•-----------------•---------__ Board of He f •�•,,,' DATE ............................................................. FORM 1255 HOBBS-.&-WARREN. INC.. PUBLISHERS �� 00 41 O T', "�' m G p p o C'ERT ( FIE- D PLOT P-LAN CO C A T t O N: r EL,1&Z,1._.,_�.. S C A L'E: �'�.�D_"_ G A T E .dQ�'.QlcY � 2lr_ T Ft E' F E.R £ N C E•. :C�':�/4.'G ' 4 07'11119 5 A/b n/;(J D 4) A .Q V 0. G OU?T ,©A A A) /WW2 7-117_4L r DgAT E T. l H E A E 8 Y -C'E R.T I F Y T H A t:1 ST T-H E 8 .1 L, DING R .E G. N D 5`lt ai `f E Y 4 P SHOWN ON TKIS P_LAN . tS L. 0C.ATF ON ' THE GR'OU,N .O 'AS. SH0WN HEREON AN0 — T A A T I,,r I--' C Q N F O Raul T U. t H IN OF Z6NtNG 8Y - LAW5 OF "III TOWN OF Pt A9�sr �R� w tj .t N CONS T R v C '!" C 0. �� GfoaGELOW, o BAR rj5-TABj- F- SURVEY C 0 N 3ULTANT'ritJ NC `',/S-rc,���o�"g� WEST VAPMOWCN V.ASv OSU VE '.!'! YC.�G.i�•.'..tw.,r � '. 4i.to- w Y 4i hiti'y . ,4•. — w•-•.•ate^• R.—'- -a i��....u. a..ar.�'�.�..K.;. . - .wx„ed", - - .•..�wy.r;Mr-�t,rF--;'v�+id+L.+►f...:,r,ti.:TC.C, o . • •_ � +tea v,��,o�r'�a.�> . : -, 00 A.F- Ar- RENC E, ,G', r AIP7-5- 0AT , t 'HE'RIEBY c .FR. ,.iFY rat TkE e1. , ILD , .N G, AE r,. . L A 1.1t 0 � I 5 H d iv N O N is f•!`'i j P L, A e� t.;r k,-0-.C, A T F U Cr fa T•H E- G R O U N'U A -• S +1 V dv Ty' .H E R E•0 14 A f) D •-��� I T H 1► 'F 1 �' ,. �,.� 'C o T F O F L4 r, G% - T H -E - ` F G , 7. ONt14G . BY -- LAWS w-OF T-idE': TO '^ r4 �•��� ��sf� �. e. T! G 0-"N S.T. p u i r_ �U GEORGE - co, LOW.JR. cn ' .r�4RittS�' A� 1 ! SURVeY C 0-NSUL1"Ahl `9 , tKC . VVEST SURyE . stsea�:lre:•r�+.r.�:.�--fir na. i',.t�+c f�':t v•.:r....u.