HomeMy WebLinkAbout0040 ELIS DRIVE - Health 40 ELIS DRIVE, HYANNIS
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Commonwealth of Massachusetts
�. ,io Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r.,
40 Ellis Drive E `
Property Address t'
Ann Ahokas .5
Owner Owner's Narrye
information is71
required for every Hyannis ✓ MA 02601 816[2019
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:
Men A. Inspector Information
filling out forms
on the computer,
use only the tab Patrick Rutledge
key to move your Name of Inspector
cursor-do not Tittle Five Specialists
use the return
key. Company Name
22 Taft st
Company Address
Dorchester MA 02125'
city/Town State Zip Code
5082374628 S141198
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. M Passes
2. ❑ Conditionally Passes
3. ❑ Needs,Further Evaluation by the Local Approving Authority
4. ❑ Fails
7/10/2019
Inspe or'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.7/2612018 Idle 5 Official Inspection Form Subsurface Sewage Disposal System-Page 1 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page. Cityrrown 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:
® 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:
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.7l WM18 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
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information
required for every Hyannis MA 02601 8/6/2019
page- City/Town state Zip Code Date of Inspection
C. Inspection Summary (cunt.)
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:
r
t5insp.doc-rev-726/2018 TMe 5 Official Inspection Farm Subsurface Sewage Drsi s l System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
rage- 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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool,
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp-doc•rev.7P260018 Title 5 Official Ins
pection Form Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
�. ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page- City/Town state Zip Code Date of Inspection
C. Inspection Summary (cont.)
J
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
0 ® 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 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 rivate water supply Y 1 well.
P
❑ ® 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
154nsp.doc-rev.7l2612018 K Title 5 Official Inspection Form Subsurface Sewage Domsal System-Page 5 of 18
f
Commonwealth of Massachusetts
�m 9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is
required for every Hyannis MA 02601 8/6/2019
page- City/Town 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
❑ M Were any of the system components pumped outin the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ M Have large volumes'of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A) `
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ -Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sevage Disposal System•Page 6 of 18
a
Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is
required for every Hyannis MA 02601 8/6/2019
page- City/Town state Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents: 0
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 ears usage NA
9 ( Y 9 (gPd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
t5insp.doc-rev.7/28/2018 Tdle 5 Official Inspection Farm Subsurface Sewage Dsposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page. City/Town 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:
e
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: y
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 lnspecbon Forme 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
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name :
information is required for every Hyannis MA 02601 8/6/2019
-
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/Altemative 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:
1977 Asbuilt
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5'feet
Material of construction:
®cast iron ❑40 PVC ❑other(explain):
` Distance from private water supply well or suction line: >100
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
No leakage noted
t5insp.doc-rev.7/26/2018 Tdie 5 Official Inspection Form Subsurface Sewage Deposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
in formation is Owner's Name
required for every Hyannis MA 02601 8/6/2019
page- City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
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
Dimensions:
1000 Gal
3,.
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness 01f
i Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle 10,
How were dimensions determined?
Comments(on pumping recommendations;,-,inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No leakage, Baffles in place, liquid level with invert
i
l
t5insp.doc•rev.7/26/2018 Tdle 5 Official In
spection Forme Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete 0 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 battle
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 Inspectim Form Subsurface Sewage Disposal Systern-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is Hyannis MA 02601 8/6/2019
required for every
page. Citylrown state Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cunt.)
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 Level
Comments(note if box is level and distribution tol outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Level, No solids, No leakage
t5insp.doc•rev.7rM2018 Title 5 Official Inspecbm Form Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is Hyannis, `
required for every H y MA 02601 8/6/2019
page. Cityffown 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"
t
Comments(note condition of pump chamber,condition of pumps•and appurtenances, etc.):
J
*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:
F
Type:
® leaching pits number. 1 6x6
❑ leaching chambers number
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/aftemative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Farm Subsurface Sevmge Disposal System-Page 13 of 18
r
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner information is Owner s Name
required for every Hyannis MA 02601 8/6/2019
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.):
No signs of hydraulic failure, pit was empty at inspection
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
I
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.7126f2018 Tile 5 Official inspection Form Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
rr Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
CS
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page. Cityrrmn state Zip Code Date of Inspection
D. System Information (cont.j
13. 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.):
J
6
l
3
M1 R !
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 15 of 18
cam. Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner
information is Owner's Name
required for every Hyannis MA 02601 8/6/2019
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
Tank
A=24'
6=38'
DBox
A=40'
B=25'
Pit
A=48'
B=24.5'
#40
D Box
Tank
Pit
- r
Ellis Dr
t5insp.doc•rev.726=8. Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 16 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page. Cityfrown 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:
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
Asbuilt at board of health at 30 Ellis
Before filing this Inspection Report,please see Report Completeness Checklist on next page..
t5insp.doc-rev.7/2&M18 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 18
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
40 Ellis Drive
Property Address
Ann Ahokas
Owner Owner's Name
information is required for every Hyannis MA 02601 8/6/2019
page. Cityfrown 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 8r Dated and 1,2, 3, or checked
® C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For8: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.7262018 Title 5 Official Inspection Form Subsurface Sevm9e Disposal System•Page 18 of 18
NTROY WILLIAMSSEPTIC INSPECTIONS
WOb
Certified * MA Department of Environmental Protection .� 13 8) 385-1300
19 Hummel Drive l -/'q
South Dennis, MA 02660 �p
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Coxe
Governor .se—t-Y
Argeo Paul Calluecl David B.Struhs
U.Gonrnor comr"55 0(wr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION L / I U,H 19 o krti S
Property Address: 7 r S r. �y /n vt r S Address of Owner. p n A�o (<A S
Date of Inspection: /$ 7 / (If different) _
Name of Inspector ,r oy t r ( I. �v-
Company Name,Address nrr9 Telephone Number.
I�(,r a n H• S �
SC, /,qE,oc)'e. ,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signatury� Date:
Sill. 7 i /8 /� 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check & B, C,or D:
A) SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES: A�I/�
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or enfltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health
(revised 11/03/95) 1
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Property Address:
Owner.
Date of Inspection: / / /B)SYSTEM CONDITIONALLY PASSES (continued) A/1�
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed ,
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:/ Y
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT`.
_ The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
fl surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Property Address: 196 (/sue.
Owner.
Date of Inspection: " S
DI SYSTEM FAILS: I 1 n
I have determined that thesystem violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
— Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
— Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
— Any portion of a cesspool or privy is within a Zone I of a public well.
— Any portion of a cesspool or privy is within 50 feet of a private water supply well.
— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E1 LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
— 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
PP Y
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a public
.Dater supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: LI J C
Owner.
Date of Inspection: 7
Check if the Y/following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
j. ALs built plans have been obtained and examined. Note if they are not available with N/A.
✓1 he facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow
>/The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
v/The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffies or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/
The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_ l ne facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: yVA
Owner.
Date of Inspection: h
RESIDENTIAL. FLOW CONDITIONS
Design flow: � V ona
Number of bedrooms:d,
Number of current residents: o-2
Garbage grinder(yes or no):_,i
Laundry connected to system(yes or no):Ytr S -
Seasonal use(yea or no): NO
Water meter readings, if available: , oVp
Last date of occupancy:, 'j `mil .
COMMERCLAL/INDUSTRIAL: IV
Type of establishment:
Design now:_---gallons/day
Grease trap present: (yes or no)_
Indu
strial 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:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING ORDS and source of information:
IJ
System Pumped as part of tnspecUon. (yes or no)_.LV(S.
If yes, volume Pumped gallons
Reason for pumping-
TYPE 9F 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)
Other (explain)
APPROXIMATE AGE of all com nents, date installed (if known) and source of information: �S !I �p /t�/ /�
�� , / °
Sewage odors detected when arriving at the site: (yes or no) /v o
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Add-.w
Owner. � !h o
Date of Inspeotion
SEPTIC TANK:
(locate on site plan)
Depth below grade:
Material of construction: (/concrete_metal_FRP—other(explain)
Dimensions:_ cS ' - 5 ' X G
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thicknees: f
Distance from top of scum to top of outlet tee or baffle:
6 "
Distance from bottom of scum to bottom of outlet tee or baffle:�"
Comments:
(recommendation for pumping, condition f inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage etc.) /1 (! G I c /� L -`
�4 L
,
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP _other(ezplain)
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontlnued)
Property Address y G ! s 0".
Owner. ��
Date of Inspection
TIGHT OR HOLDING TANK /V
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(ezplain)
Dimensions:
Capacity: zallOns
Design flow:_ gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Gf c
Comments:
(n%level and distribution
/l is equal, evidence of solids carryover, evidence of leakageinto or out of box, etc.)
PUMP CHAMBER:__Jy/A?
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL$YS'I'E1►{ INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Addre" f
Owner.
Date of Inspection: / w
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible;excavation not required, but may be approximated
by non-intrusive methods)
If not determined to be present, explain:
Type:
leeching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number,dimensions:
overflow cesspool, number:
Comments- (note condition of soil, signs of hydraulic failure, evel of ponding, condition of vegetation,etc.)
!.v r 6 (�
—1 IJ n L S + W v ✓F. �. v-t� L
CESSPOO :_A//,_�q
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer-
Depth of scum layer:
Dimensions of osspool:
Materials of constriction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: yU E7/
Owner. ,q
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
025
�y
n
• G
c5c40 It, 701, It (�
1
DEPTH TO GROUNDWATER
Depth to groundwater: feet adjusted high groundwater level
method of determination or approximation: _ r o✓ 4�—� ,�,, r S G w
6Ja r
a
9
Lr TOWN OF BARNS/T�ABLE
Ode
LOC.'TION �` �Q � s ✓�` SEWAGE # 2 �Yb
VILLAGE /►ASSESSOR'S MAP&LOTgbq-o?IS
INSTALLER'S NAME&PHONE NO. / 70
SEPTIC TANK CAPACITY 6 d IL C
LEACHING FACILITY: (type) /-e7` (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 7 1-2 3 177 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
- J1
f
a
S
J
S
f�'
r
CO.CAT ION � SEWAGE PERMIT NO.
VI L.LAG E
_1�v�.yser s
INSTA_ LLER'S NAME ADDRESS
/3s�.et�s ,r
B UIIDE R OR OWNER
zZ Ahokws
DATE PERMIT ISSUED
q-23- 217
r
DATE COMPLIANCE ISSUED , � _ ,y_ 7 -7
a
�; v
„7
9
No. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
_..._.1� ...............OF.......All�-.-i f` .�..................................
Appliration -for Bi-gVviiat Workii Tomitrurtion Prrutit
Application is hereby`made for a Permit to Construct (6-11"Or Repair ( ) an Individual Sewage Disposal
System at:
--------------------
�(o 3
Locatio - ddr ss /. �. / or Lo Iio y�
................. ...
---------------•-•-----------------------•----- ................ ..... .........•--•-- -
+�— Owner �pddres
W J�3Li c. S�.��/�r,.. S•/ �� �wviv�to ...�
Installer Address C?o 0
d Type of.Building Size Lot----___.�__________________Sq. feet
U Dwelling—No. of Bedrooms------2..................................Expansion Attic ( ) Garbage Grinder ( )
Oyl er”—Type of Building ............................ No. of persons.--_-_-__-_----_-_----_._- Showers ( ) — Cafeteria ( )
Q' Other fixtures --•..............................•--.._......_..-------••---..---•
Design Flo ............................................gallons per et-son per day. Total daily flow__________________-_-____-_---_.--.-..--_-__gallons.
W e g w g P P P Y Y
WSeptic Tank—Liquid capacityM_q�g__gallons Length---------------- Width------.......... Diameter---------------- Depth__.----_--.._..
x Disposal Trench—No-_______________--- Vidth-------------------- Total Length_-_-_____-__-..__--- Total leaching area--------------------sq. ft.
Seepage Pit NoA?'00_`�7/_ Diameter.................... Depth below inlet_ .._._ �.--.... Total leaching area..__-_-.-._.___--sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) vv�l— �` �ob�1�— /i- /q 7e
aPercolation Test Results Performed bY-------- -------- ........................................................ Date................------•------••------..
Test Pit No. 1................minutes per inch Depth of Test Pit_.._.___-___--______ Depth to ground water--------__--------------
(14 Test Pit No. 2................minutes per inch Depth of Test Pit_................. Depth to ground water..................
p4 ..........................................`..._......__........_......... ..------ _ -------------•' r
• h i'd9!✓ !---- �� �------•
Description of oil -��._. .. 0-._/ .• �' a�t ` �z-------•----
V f
W
V Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------------._-------.__.........
.
--------------------------------------------------------------•---•---.--------------------•--------------------•----------------------- -•--•-------•---•-----------------------------------------
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 b is ed by the board of hea
..... •. ...... -•--.1/f,. ....._.._..-••---... ------------------------
y e
Application Approved By--- / _Ipll....--••---- f s2
Date
Application Disapproved for the following reasons:---•-----------•-------•--------- -------------------------------------••-•---------•-----.....••-•-......---••-
-----------------•---------•-------•••--•-•....--------------•---•-----...-----------•--••-•-----••--•--.---•-•.....----.-_..__..........•-•-----...-----........_....-----....---...-----•------•••----
Date
,
Permit No......................................................... Issued- --- 2 f - 2,---------------------7•-•-•----•-••-----...
Date
...............................................................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......e� ... .. ........OF_....... ,............
IT.rdifiratr �rf (�nxt li ttrle
THIS IS TO CER �Y, That the,II d•vdual Sewage Disposal System constructed ( 4<or Repaired ( )
by...................•-•-----•-------••-.....: l..../ � /7�// •-----------------------•------------------------------------------------------------------------..................
11 Instal i
at........................C---------•------ f------------1--!v- --•-•------------ ems?.h ,-•--------------------------------•---•--••-•-------------.-------------------
has been installed in accordance with the provisions of Art � I of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No... ....._..___ ----------- dated-------1-;Z--__:7-----7-4.............
THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................... .....7 2-•••-•----••-••----•------••---......... Inspector-----�O
....11........
THE COMMONWEALTH OF MASSACHUSETTS
/00.4
BOARD OF HEALTH
..... ....__._f .0 0.4.......OF.............5Q li/Cfa '��Q::...._..................
"ppliratioo -for ]i� ooal Morkii Tonstrortioo Prrotit
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
x 5 �viv-C A/v t 63
-----------------•-----------•--------------------------•---------- ---------•-•--••-•••---••-••••----•-------••-----------•-----••---•--...........................
s , Lo i Address W g Lot No.
------------------------•-•---------•- .
/ O er ?�dd,
Al
---------------•- ----------Y. /D r,o r�
Installer Address
Q Type of Building Size Lot...... ....................Sq. feet
U DwellingNo. of Bedrooms._---Z----------------------------------Ex Expansion Attic— p� ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons_____-.--__-_-_-__---_--.-- Showers ( ) — Cafeteria ( )
QOther fixtures ------------------•--------------------:----•------ ------------ -•-
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
94 Septic Tcuik—Liquid capacityiW O-gallons Length---------------- Width................ Diameter-----........... Depth................
xDisposal 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 ( ) -!>d— IR• Ci ryL "-
Percolation Test Results Performed by------____------------------------------------------------------------ Date-------------.----.--------_--------._..
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water____--___-__.__._....
44 Test Pit No. 2----------------minutes per inch Depth of Test Pit.--___--_-___---_- Depth to ground water...........___-----.---
W ................. ----------------•----------------•------•------ = -----•--------•-----------•-----------------------------•- ........
D Description of oil---------------S�'�
br?v l +1 �
� �`�-'mac--•----�---- ----=-/-.2--- -cc�,
v : - -� .��-m,= ------------------------------------------------------------------------------------------------------------------- ------------
W
x ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------
V Nature of Repairs or Alterations—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 b is ed by the board of
Si ed----- ............. G�/dam
•---•--------------------------------•-- _ _--•--•-------------
Date
Application Approved By...:-_______ //
Date
Application Disapproved for the following reasons------------------------------- ----------
-•------------------------------------------------------•----------------.-------------------------------
Date
PermitNo......................................................... Issued---- .......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALT 2
...v�'.-Z:...............OF....... ...........GvLu�� .
.............................................................
Q'Iff,rrtif irate of TOmpliatirr
THIS IS TO CERZ F That the, ad'vidual Sewage Disposal System constructed ( or Repaired ( )
by--......----•--••--•-•---••-------••---`J-o��-----. ............. . ------
/�9 V . �i�✓9 �staller
at -----------------------•----••--•--------•--.._.. .�_ t. -------------------------------------------------------------•••-----------------
has been installed in accordance with the provisions o ArQ11LLq,�ihe State Sanitary Cho e_as;Atse i?d in the
application for Disposal Works Construction Permit No..................---------------------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............. .. b' ' 7 Inspector C�
-------------------------------....................
THE COMMONWEALTH OF MASSACHUSETTS
7� BOARD F HEA TH
r .......7 ..............of.... ....... ....".''�............... ..............................
No......................... FEE-.......................
IorkCn ` trortioit rrOtit
I — d
I Permissio hereby granted.....�.p
...
to Cons ct a o� Ree&W
•) avid ewag i sal System
atNo� (j 5 ... ---- ------------------- '----------- ------------- y /
treet /� — � 7G
as shown on the application for Disposal Works Constructio mit : __ . .__/ Dated---/ - ---------•---------------- {
. •
GpJ_ �1 _ /
DATE................ �---�-/---•--._......_.....--------------------
Board of;Health
a
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
i
I I
58 .79
• 22 �
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L0CATI O Nt h/Y�9 ../N/S� /YIASS �j.,�c -c.•,.,_ �„f ,,r .,� - ��.. -t� /3
5 C A L E Z 3�! 0 A T E
R E F E R E N C`£: AS
A
DATE
I HEREBY CERTIFY THAT THE BUILDING G. LAND SURY OR
SHOWN ON THIS PLAN IS LOCATED O N �-----------�
THE GROUND AS SHOWN HEREON AND *� •Ap�,,
THAT IT '�o'�s CONFORM To TH £ '��,
YONINIS GY — LAWS OF THE TOWN OF
M ,8i9.e2�/ST7g6G E W H E,N CON-, T R U C T E D .
:��`h�Gn•i�ati
S ASSOCIATES, INC .
REGISTERED ENGItJEERS a LAND SURVEYORS + �'
MID -CAPE OFFICE BUILDING — 1 265RO UTE. ZO
�- SOUTH YARM O UTHi, M ASS. 026 G 4