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HomeMy WebLinkAbout0024 FIFTH AVENUE (HYANNIS) - Health 24 Fifth Avenue Hyannis P L2 190 r F p w r � � `Z315 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTA MAP 240 R�CE6i/E® PARCEL AUG U 9 2004 LOT r-I - TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2 4 F i f th Avenue , W. Hyannisport. Owner's Name:_Donald-Cam_eron Owner's Address: 1) Quisset Br6,] 1 d _Milton-,--MA_ .i ` s Date of Inspection: "dl-l—MT'/ C, > ifs Name of Inspector:(please print) William E_ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville. MA co Telephone Number: t508) 775-8776 CERTIFICATION STATEMENT 1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15-340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Farther Evaluation by the Local Approving Authority Fails Inspector's Signature: � � _ _ Date: 'f '-" The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approxing 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 address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 24 Fifth Avenue Owner: Donald Cameron Date of inspection: G Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy tem Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: � B_ sy� em Conditionally Passes: O e or more system components as described in the"Conditional Pass"section need to be replaced or repaired. he 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 s ptic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,6d ibits 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 sel tic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating th t the tank is less than 20 years old is available. ND explain: Obs rvation of sewage backup or break out or high static water level in the distribution box due to-broken or obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval o Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND expl in: e system required pumping more than 4 times a year due to broken or obrntxted pipe(s).The system will pass insp tion if(with approval of the Board of Health): broken pipe(s)are replaced K obstruction is rcmovcd ND explain Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 Fifth Avenue _ W. Hyannisport Owner: Donald Cameron Date of Inspection: . —b V C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fail' g to protect public health,safety or the environment. I. ystem will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the s stem is not functioning in a manner which will protect public health,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. Sys em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system i functioning in a manner that protects the public health,safety and environment: _ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surf a water supply or tributary to a surface water supply. e 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 fronl a pri to water supply well•• Method used to determine distance •• his system passes if the well water analysis,performed at a DEP certified laboratory,for coliform b teria and volatile organic compounds indicates that the well is free from pollution from that facility and presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other f ilure criteria are triggered.A copy of the analysis must be attached to this form. 3. (her: 3 A Page 4 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 24 Fifth Avenue W. HYannignori Owner: Donal d Cameron Date of Inspection: !-/�=o 7 — D. System Failure Criteria applicable to all systems: You Must indicate"yes"or"no"to each of the following for all inspections: Yes o _ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than 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 I OO.feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a.public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 fret from a private water supply well with no acceptable water quality analysis.(This system passes if(lie 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.] ( esMo)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: La ge Systems: To be nsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 Epd• You ust indicate either"yes"or"no"to each of the following: (nic ollowing criteria apply to large systems in addition to the criteria above) 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 11 of a public water supply well If you h ve answered"yes"to any question in Section E ilu system is cmisidered a significant threat,or answered "ycs"in Section D above the large system has fined.The owner or operator of any large system considered a signirca t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. he system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 24 Fifth Avenue W. Hyannisport Owner: Donald Cameron Date of Inspection: 2�9—in j Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? ✓ — Has the system received normal flows in*the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection?.. Were as built plans of the system obtained and examined?(If they were not available note as N/A) �— Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? //— Were all system components,excluding the SAS,located on site? t/— Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of t he baffes or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ 4 /l 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 no JJ 1/Existing information.For example,a plan at the Board of Health. _ Determined in the field if an of the failure criteria related to Part Cis at issue approximation of distance.. — ( Y PP is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 24 Fifth Avenue W. Hyannisport Owner: Donald Cameron Date or inspection: -® FLOW CONDITIONS RESIDENTIAL Number 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:_f)�, Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): &t)[if yes separate inspection required] Laundry system inspected(yes or no):&O Seasonal use:(yes or no):le S' Water meter readings,if available(last 2 years usage(gpd)): 2003 - 18, 000 Sump pump(yes or no): A-a 2002 - 27, 500 Last date of occupancy: Z A COMMERC USTRIAL Type of establi ent: Design flow( ed on 310 CMR 15.203): pd Basis of desi flow(seats/persons/sgft,etc.): Grease trap esent(yes or no):— lndustrial w ste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water mete readings,if available: Last date o ccupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: -e> i Was system pumped as part of the inspection(yes or no): O If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: n_ TYP OF SYSTEM _LAeptic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool —_Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _lnnovative/Altem.ative 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)4L& 6 r I'agc 7 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Fifth Avenue W. Hvannisport Owner: Donald Cameron Date of Inspection: 2--;?-7 re) r/ BUILDING SEWS (locate on site plan) Depth below grade: Materials of cons ction:_cast iron 40 PVC_other(explain): Distance from pr' ate water supply well or suction line: Comments(on ndition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: /(locate on site plan) Depth below grade:_j Material of construction:_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: ,S '7 v ) 73 ' Sludge depth: --- ) , Distance from top of sludge to bottom of outlet lee or baffle: Scum thickness: Q J j ot Distance from top of scum to top of outlet tee or baffle: 3-1 Distance from bottom of scum to bottom of outlet tee or baffle: y 21' How were dimensions determined: G Ed A-, o Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �O® CI w w 1 ti GREASE TRAP: (locate on site plan) Depth below grade:_ Material of eonstru tion:_concrete._metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from t of scum to top of outlet tee or baffle: Distance from ottom of scum to bottom-of outlet tee or baffle: Date of last pu ping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 i Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Fifth Avenue W. Hy nn i cr�nri Owner: , Date of iospeetioD n:­ �. o TIGHT or HOLDi NG TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of constru lion: concrete metal fiberglass_ Dolyethylene other(explain). Dimensions: Capacity: gallons Design Flow. allons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pump' g: Comments(condi on of alarm and float switches,etc.): I DISTRIDUTIO BOX: v (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: C� 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.): PUhiP CHAMDER: (locate on site plan) Pumps in working or er(yes or no): Alarms in working rder(yes or no): Comments(note c ndition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Fifth Avenue W. Hyannisport Owner: Donald Cameron Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): v(tocate on site plan,excavation'not required) If SAS not located explain why: Type aching pits,number:_ leaching chambers,number: a" leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOL (cesspool must be pumped as part of inspection)(locate on site plan) Number and co figuration: Depth—top of I quid to inlet invert: Depth of solids 1 yer: Depth of scum 1 er: Dimensions of c spool: Materials of cons ction: Indication of gro dwater inflow(yes or no): Comments(note c ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (loc ite on site plan) Materials of constr iction: Dimensions: Depth of solids: Comments(note c(ndition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Fifth Avenue W. Hyannisport Owner: Donald Cameron Date of Inspection: '7- ;?-9—©z'I 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. oe.A et 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 24 Fifth Avenue W. Hyannisport Owner. Donald Cameron Date.of Inspection: —0 G SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Jehecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 13 / 5 d A 6 Xbv 11 TOWN OF BARNSTABLE LOCATION ,�' i N J G� SEWAGE # I VILLAGE ASSESSOR'S MAP & LOT 170 INSTALLER'S NAME & PHONE NO.'17d� c cs .,,- SEPTIC TANK CAPACITY )C, LEACHING FACILITY:(type) ?� C (size) I NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: i) -- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 ,) . C. �� �� � �� ,� � a i �t � t .rr' i ��. - s,b. No... 3................... Fim.-3.0...GO............. . THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Ui"viial Vorko Tonstrurtiun Prrinit Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: ... 24 5th Ave W: Hyannis rt ......._... .... .. ..... ......... _......--•••-----------•••----•------------------•-•---------------............_.................. Location-Address or Lot No. .... ?11IIn S?A----------------------•--------•---•---•--------........--------.....•.... ..........-••--------•--...................... ............................................... Owner Address W I . ..-.k�ala�zisan. tip..Sexvi. ............................. P- Q.bax._1-QB9-..Centexviue........................................ Installer� Address Type of Building Size Lot............................Sq. feet U Dwelling_No. of Bedrooms----2......................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures -------------------------------•-•-•-------------------------------------------------------------•------------•-----------------......_......._...... w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width—............. Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------ -......................................... Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 444 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ R+ --------••------------------• --------------------•---......-----------..........-•-..........•.............................................................. ODescription of Soil......sand-------•--------------------------•---------------------•---•-----------------------------------•--------------.--------.-.---------------------•-------- x U w UNature of Repairs or Alterations—Answer when applicable................................................................................................ ••----Septic--tank--{--.t:-box.-and--z---gtmepaciced..infiJ.trators.......................................................................... 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 iss�byboard of health.Signed'+ a....... . "----'-..........-" �.------?-------_............ Date Application Approved BY ... .. _--- - _ .-- '------------------------------............._._...._...... Dace Application Disapproved for the following reasons- ................... ----- "-- '--------....---...----......................................................--------------------- .................................... Da[e PermitNo. .....T.D-L._ �._T--&------------------------- Issued ...................................................... Date • J - j !,/ f . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Application for Disposal Works Toustrur#tuxt lirrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at: -- 24 5th Ave W. H.annis rt ----....- .............__.-.._...._._.. Location-Address or Lot No. .._. �__....-------_- --------------- ---- ------------------•----....... ----- --------- Owner Address -Spent c,ge ..... P Installer ----------------------------------------- Address � Type of BuildingSize Lot----------------------------Sq. feet Dwelling—No. of Bedrooms----2-------------------------------------Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building --------------- No. of ersons_-_____-__-----_------_-_--- Showers � YP g ------------- P ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------------------------------------------------.-----------------------•----•-•---- w Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. 94 W Septic Tank—Liquid-ca.pacity_._.__.__._.gallons Length---------------- Width................ Diameter--.------------- Depth................ Disposal sposal Trench—No -------------------- Width•..._--._.__._._.._. Total Length.._._.....__....___. Total leaching area................... ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1-4 Percolation Test Results Performed by........................................................................... Date........................................ 1.4 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 ----------------------------------------------------------- O Description of Soil...... a&_________________________ x �., --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------............................... ciaff -1-t—rstans-------------------------------------------------------------------------- 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 y t e board of health. n _ _ e�' Signed . ► ------ `—'` rDam------_------- Application Approved BY -- . �^^ ------------------------------ -- 10..-.?Z Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------- -'------- ` ..............-................... Date PermitNo. ----- _-------------------_ Issued ------------------ --------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ger#ifirak of C1-1-mylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by---- .Se vi C..---------------- ---------------------------------------------------------------------------------------- ---------------------- ------------- 24 5th Ave,.W. Liyannisport Insm°ef at ----------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 9The State Environmental Code as described in the application for Disposal Works Construction Permit No. .--.----- ..a. .Z3___-.-. ----- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------! " ----------------------------------- Inspector ------------ -._... - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH pQ 22 pp� TOWN OF BARNSTABLE 30 00 No...,/_�_'J O'�_ Fes-----------------•------ �ioposat arks Tonstrudiatt FrrrAft Permission is hereby granted-------W.E.-_Robinson Setat_ .c_-jjexv .!7e-----------•-----------------•-----•-••-------............. to Construct ( ) or Repair ( X) an Individual Sewage Disposal System at No.. ....._._24 5th Ave-W.__H�annisrt----------------------------------------------------------------------------------------------------------- - Street q �j as shown on the application for Disposal Works Construction Permit No.-l__'::.f AZ Dated...................................•...... -�� --------------- - -- Board of Health DATEg � -= -------------------------------------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS