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HomeMy WebLinkAbout0014 DOLPHIN LANE - Health 14 ,Dolphin Lane Hyannis P A = 267 048 00 I �I I o li e 4., COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION R'ECEiVED NOV 17 2004 TOWN OF BARNSTABLE TITLE 5 HEALTH DEFT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address• / L040A ti' L.� PARCEL � Q LAA44- k 4 orb .j 0016 9 d Owner's Name: PA is Owner's Address: 1, e— es n .4 Od 61 2 Date of Inspection: Name of inspector.(please print) / o/se#. ' Company Name: •f't/i'f1 — "EC y Mailing Address: AQ O ©vt 6 41,Z Telephone Number CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is,true,accurate and complete as of the time of the inspection The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved systern inspector pursuant to Section.15.340 of Title 5(310 CMR 15.o00). The system: t//Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Ida- Inspector's Signature: g�� x, Date: /0 v1 a, 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 in If the system is a shared system or bps 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 DER The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not adores conditions of use. 'how the system will perform in the future under the same or different I page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) property address: too/ ' LAI s n, ,l! Dv C Owner: �J Date of Inspection: 119ZIA 0 inspection Summary: Check A,B,C.M or E/ALWAYS complete all of Section l) A. System I have not found any information which indicates that any of the failure Criteria described in 310 CUR 15.303 Orin 310 CN R 15.304 exist Any fail- criteria not evaluated are indicated below. Comments: B. Syste Conditionally Passes: / ftc or more stemcom vents as de " sy scribed 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. Answer yes,no or not determined(Y,N,ND)in the 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 exi-sting 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced NO explain: 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 obstruction is removed ND erpi_ain: 2 page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: T 0� ft►►� L y "ner. Q/ Bate of Inspection: C.,/ lu Further Evaluation is Required by the Board of Health: /l� Conditions exist which require Rutlter evaluation by the Board of Health in order to determine if the system is failino to prow public-health,safety or the envbVMnt. L System will pass Unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not-functioning in 9-manner which will pretest public health,-safety mw the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or Privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail untelg 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a Private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that.the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: i t. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) ptaperty Address: 0� �►h 1-41 oa o2 pwvner: r.t{� Date of Inspection:1011A D, System Failure Criteria applicable to all system!; You must indicate`yes"or"no"to each of the following for all inspections; Yes No� ✓✓_�.tp 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 flogged SAS or cesspool j c liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool quid depth in cesspool is less than 6"below invert or available volume is less than /z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number Vtunes pumped y portion of the SAS,cesspool or privy is below high ground water elevation. _�Atty portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. portion of a cesspool or privy is within a Zone 1 of a public well. _ �`portion of a cesspool or privy is within 50 feet of a private water supply well. _.L 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 coliferm bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure.. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gld• Your must indicate either`yes"or"no"to each of the following; (The following criteria apply to large systems in addition to the criteria above) yes n the system is within 400 feet of a surface drinldng water supply the system is 200 feet of a tributary to a surface drinking water supply stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone Il of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304. The systetri owner should contact the appropriate regional office of th_e 9epattmen_t. I ' page 5 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B // CHECKLIST Property Address: l q' eJ Owner. i Date of Inspection: IV Check if the following have been done.You most indicate`yes"or"no"as to each of the following — Yes o Am ' g information was provided by the owner,occupant,or Board of Health Werea of the system components pumped out in the previous two weeks system received normal flows in the Previous two week period largo-volumes of water been introduced to the systemrecently or as part of this inspection Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out V177— G 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�a$les 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: Yes �. xisting info7th on. For example,a plan at the Board of Health. _ _ Determined yield(if any of the failure criteria related to part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION p%-eperty Address: / 0/06 4 /-4/ �� �� Imil4 pwner: 2 I�jo / DAate of Inspection: / d OW CONDITIONS RESIDENTIAL N&AMber of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: U Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection mquiredl Laundry system inspected(yes or no): Seasonal use:(yes or no): .4 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): ( Oi Last date of occupancy: COMMERCIALlINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present.(yes or no):— Industrial waste holding tank.present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping.Records Source of information: 7- 0r4 vMj?e C1t- Was system pumped as part of the inspection(yes or no): If yes,volume pumped pllons—How was quantity pumped determined? Reason for pumping: TYP 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/Altemative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): I p go7of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) property Address: /if SOIAIVI L41 E "ner. 2 �f Date of Inspection: oto BUELDING SEWER(locate on site plan) Depth below grade: / Materials of construction:�iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_('� locate on siteplan) Depth below grade:-� Material of construction:_s concrete_metal_fiberglass_polyethylene --other(explain) If tank is metal list age:_ is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) � / „/ Dimensions: 2 Sludge depth: -7 // Distance from top of sludge to bottom of outlet tee or baffle: o?9 Scum thickness:_Q_ Distance from top of scum to top of outlet tee or baffle: *0 .fc N '") Distance from bottom of scum to botto�¢ outlet tee or baffle: How were dimensions determined: P ReiA --cTp v,c Comments(on pumping recommendations,inlet and outle tee or baffle condition, structural integrity,liquid levels asslated to outlet invert,evidence of jeakpge,etc.): c.Wf 4 p4-✓1 - ✓� G G %f DWI OI v��y GJ►w p� GREASE TRAP:/V(locate on site plan) Depth below grade:_ 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 Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): r page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C S STEM INFORMATION(continued) property Address: N. 0 F�,in ovvner. Date of Inspection: Q /y O 'FIGHT or HOLDING TANK: (tank must be pumped at time of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: anllons Design Flow: —gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:L lu present must be opened)(locate on site plan) 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.): PUMP CHAMBER: e(locate on site plan) Pumps in working order.(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): PgAge 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS M INFORMATION(continued) Ptbperty Address: / A'n' L- 41, r. ' 0/4� /J9 "ne Date of inspection: /119 6 lay SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tleachin number 6 /l �Pi '— �q 51�-- g leaching cbambers,number: w leaching galleries,number: leaching trenchm number,length: lm%ingfields,number,dimensions: overflow cesspool,number: innovativetalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): -el ond� h - L, Ste, • a • o S �s 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:.�ocate 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.): • /mil � pgEe 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contimied) property Address: I dJo +w► G-/✓ llve5 vl�J�o� /f1,¢ �.C72 s-c_- Diate of Inspection:' / /0 y SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. C / GIG Ir , $ % ' jd,- d,3 � L i + L/ 3- a9 63 - 39 � pgge 11 of 11 OFFICIAL INSPECTION FORM, NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) p*vperty Address: At O `►1 h - /t crwner. O� p xte of Inspection: O (04- SIM EXAM S140M Sisrface water Check cellar Shallow wells EStimated depth to ground water�3 7 feet Please indicate(check)all methods used to determine the high ground water elevation: 3 / Obtained from system desigp plans on record-If checked,date of design plan reviewed site(abutting property/observation hole within 150 feet of SAS) with local Board of Health-explain: Y'?�,les' Checked with local excavators,installers-(attach doculnentation) Accessed USGS database-explain: You must describe how you established the high d water elevation: G., f h A1 is A ov�e- r < r 169 J c QV,••4-i0V) /,p`• D TOWN OF BARNSTABLE LOCATION I tj D2.o k�- It g✓ SEWAGE VILLAGE �u-1 ASSESSOR'S MAP & LOT `-6 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) , (sue) NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: .�- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes O Ol r l Fizi3 ......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH � TOWN OF BARNSTABLE Appliration for Disposal Works Tonstrur t Application is hereby made for a Permit.to Construct ( ) or Repair (vr an Individual Sewage Disposal System at: ` \ ... ................ ...---•-•--t't -At rigs. a< .............................................. Location-Address or Lot No. ................................. ------•---. 5..._.... ............. a Owner Add J �-•----------------�.!fie=�=�`.- .-------------------- .................. .. ......VL�ll�t_ 1S--.......... t Installer Address U Type of Building Size Lot............................Sq. feet U a Dwelling—No. of Bedrom3......os.___ ............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixturr S ----------------------------------------------------------------------------------------....------------------------------------------..._....-------- WW Design Flow..... ...................gallons per person per day. Total daily flow___'�3Q.........................: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...........1......... Diameter...1.0_!........ Depth below inlet....Ja........... 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........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ a --•-----•--•-----------------•--•--•----••••--•-----•-•---------.....-----------..._.........---•---....................................-----•-----•------••- 0 Description of Soil...................._................................................................................................................................................... x c., w U Nature of Repairs or Alterations—Answer when applicable...=t`f5T!a�!J�..._ pu�_S�t,�1•��-- ! -•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the boapd of health. Signed......... .. ........ - .... ........ -.10....r'... -y' Date Application Approved By .................< �� � -�^= ....... ��Date Application Disapproved for the following reasons: .- ................................................... .....:.......................... ......................... ------------ ---- ---------------------------------------- ----- ------------------------ ----- ....................................................... ---------............................... q....................... a . Dare � Permit No. ....---C�.�..._-..--.J�.`./..-. . Issued --...... -- ....... ' Date........-- ........ ...-- No..-� 5..19 �-� 7 _o L( Fes$.. ........ ._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Bhnpoiial Marko Ton,5trurtWitf /er#1 Application is hereby made for a Permit to Construct ( ) or Repair ( V-)r an Individual Sewage Disposal System at: l ................'--�.` !. �.(�1; 1�1(�1 �- 'd r`'` -• 4 `C�--j�c�r��t c` -1)rf v'__........---•-------..._..................._. Lociition Address br Lot No. ............. -��. :... T Z�_^_- fz�.zr_-'-..............._.._.._._..._ ............ ........ Owner Addrlesss •----------'-'-'•"-•'.... .........'•-•-•--•--------....._...-----_.._..-'--............-----'•-•'----....•................. Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms-_�................................._---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ...................................................................................................................................................... Design Flow________.:=.-"__......................gallons per person per day. Total daily flow-__`7�...........................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----------1---------- Diameter...�,.�? ......... Depth below inlet....(rt_t.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 4 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0i 4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •-•••--...................................................................................................................................................... 0 Description of Soil........................................................................................................................................................................ x U .....................................-•--• --------------------------------•-------------------------------------------------•-•-----------•--•---------------------.... W x ------------------------------------------•----•---•------•--••------•---------•--•--•-----------••----•-•••......-----------••---- ••---•--••-•---••----------•---• ••..-• .... U Nature of Repairs or Alterations—Answer when applicable__ �`4-4 `�__._ ---••------------------------------------------------------------------------------------------ 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 has been issued by the board of health. Signed `�...: .-....✓'�. ..... .� r-" '............. ;/./� .... ..y tJ -.. t l5ato .. Application Approved By ..' .: N r �r r�..... :. ..- .,/ t € is` Date f Application Disapproved for the following reasons: ............. .......................... .. ..............---................q.......--. ...................:--.--..----.------......--------------...---------..--..---------.--------.---..---..--- -------------------------------------- Permit No. .--. ell - (/ - Issued ...... Date Date THE COMMONWEALTH OF MASSACHUSETTS "Mk BOARD OF HEALTH TOWN OF BARNSTABLE Certifir to of Q o nlylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�/) by------------------- ----------------------------------------------------------------- ------------------------------- Installer_.- u-1, at ............................ . -U `'°" `/ C /� !2/{� G--,k1'('-( �Y.`.t..a. -fs..^..� 1X!? ................................................. ........---.- .........: .................. has been installed in accordance with the provisions of TITLE 5of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....l..rrZ.......�2..�..Q.............. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------- U - Inspector . ' 1 THE COMMONWEALTH OF MASSACHUSETTS Y BOARD OF HEALTH No.. / TOWN OF BARNSTABLE ............... ..... FEE'--•' ............... Permission is hereby granted............r_ _____________________ to Construct ( ) or Repair (�)•-an Individual//Sewage Disposal System at No....•••.. !11 � /r? i A r �.i rtl �` 1E-1���_f,�u c_:�'_.:�s •-'.... . .---•-'--•-----'-•.----••..... r Street 0 as shown on the application for Disposal Works Construction Permit NAyyq}��`"�!_�___._ Dated.......................................... ...............................�A ................................ V Board of Health FORM 38308 HOBBS&WARREN,INC.,PUBLISHERS