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HomeMy WebLinkAbout0041 FROST LANE - Health 41 FROST LANE, HYANNIS A= I TONVNPFF BARNS FABLE LOCATION 1 "�-- SEWAGE # VUT LAGS_ LS ASSESSOR'S MAP &LOT Zg T-u24Q, INSTALLER'S NAME j6HONE_ NO. SEPTIC TANK CAPACITY 7®� LEACHING FACILITY: (type �1: (size)lo® NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet _ i Furnished by 0 ry I f ' I Q Or-) .. COMMONWEALTH OF MASACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 41 FROST LANE HYANNIS, MA 02601 Ci�Cj Name of Owner MARK O'MALEY Address of Owner: 46 BRISTOL DR. EASTON MA.02376 Date of Inspection: 316/00 Name of Inspector: JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Tfle 5(310 CMR 15.000) Company Name: TITLE V SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET MA.02636 Telephone Number: 608-664-6813 CERTIFICATION STATEMENT I 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 inspection.The inspection was performed based on my training and experience in the,prop er function and maintenance of on-site sewage disposal systems.The system: ° v t\ X Passes 5 `� _ Conditionally Passes _ Needs Further Evalu do By the Local Approving Authority 'x Fails z, 1 L yf, e'O O Inspector's Signature: Date:3/9/00 The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30ays 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 4he`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. NOTES AND COMMENTS "The inspection is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My Inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its components useful life:" THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 3/6/00 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. B. 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. 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,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n1a 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 Wa 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 revised 9/2198 Page 2 of 11 I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 3/6/00 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 failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a saR marsh. 2) 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance IVa(approximation not valid). 3) OTHER n/a t - revised 9/2198 Page 3 of 11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 316100 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described 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. Yes No - X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. - X Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below Invert or available volume Is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. - X Any portion of a cesspool or privy Is within 100 feet of a surface water supply or tributary to a surface water supply. - X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, - X 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. E. LARGE SYSTEM FAILS: You must Indicate either`Yes"or"No"to each of the following: 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: Yes No - X the system is within 400 feet of a surface drinking water supply - X the system Is within 200 feet of a tributary to a surface drinking water supply - X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner: MARK O'MALEY Date of Inspection: 3/6/00 Check if the following have been done:You must indicate either°Yes"or'No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ 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. X As built plans have been obtained and examined.Note If they are not available with N/A. X - The facility or dwelling was inspected for signs of sewage back-up. X - The system does not receive non-sanitary or industrial waste flow. X - The site was inspected for signs of breakout. X - All system components,excluding the Soil Absorption System,have been located on the site. X - The septic tank manholes were uncovered,opened,and the interior of the septic tank was Inspected for condition of baffles 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: X _ Existing Information,For example,Plan at B4O,H, X - Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance Is unacceptable)1 5.302(3)(b)] X - The facility owner(and occupants,if different from owner)were provided with Information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5 of 111 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 316/00 FLOW CONDITIONS RESIDENTIAL; Design flow: 110 g.p.d.lbedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:0 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COM MERCIALIINDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:n/a Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a— System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 18 YEARS OLD Sewage odors detected when arriving at the site:(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 3/6/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron X 40 Pvc _ other(explain) Distance from private water supply well or suction line: n/a Diameter: n/a Comments: •(condition of joints,venting,evidence of leakage,etc.) THE WELL IS 100+FEET TO SYSTEM SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"". Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle: 24" Distance from bottom of scum to bottom of outlet tee or baffle: 0" How dimensions were determined: MEASURED 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.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. GREASE TRAP: _ (locate on site plan) Depth below grade: Na Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other Explain: nla Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: Na 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.) n/a revised 9/2/98 Page 7 of I i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 3/6100 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: n/a Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallonstday Alarm present: NO Alarm level:NIA Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution Is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 9/2198 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 3/6100 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6 X 6 leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT WAS EMPTY AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a s revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601. Name of Owner MARK O'MALEY Date of Inspection: 3/6/00 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) QecK- � o � C O ray 5� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 FROST LANE HYANNIS, MA 02601 Name of Owner MARK O'MALEY Date of Inspection: 316100 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: n/a USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet n/a Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps Checked pumping records Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-10+FEET revised 9/2198 Page 11 of 11 173 , C A T ION SEWAGE PERMIT NO. ®f �ra5 Lctn � �g oa C� VILLAGE 94, E nts I N S T A LLER'S NAME i ADDRESS JOHN A. AALTO BACKHOE SERVICE 150.Walnut Street West Barnstable, Mass_ 02668 S U I L D E R OR OWNER 43dI C6yl � DATE PERMIT ISSUED 371-- r© _ 8� DATE COMPLIANCE ISSUED '1 { I � Iw ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............. OF:. : .-.i5..ikp-!_-9 .!:i'!._.C-<.''_.-...---------•---.....__...._.__ iW 41 Appliratinn for Disposal Works Tnnstrurtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. Owner Address ........................ Installer W 1 L.L i A wj 12.-DAU l S Address Type of Building Wo0D !FQA0A,4__ Size Lot___ ......Sq. feet Dwelling—No. of Bedrooms___,3....................................Expansion Attic (M) Garbage Grinder (%Jo) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a, Other fixtures .......2...- .4w.0DA�.............--•--------- -- W Design Flow.............................................gallons per person per day. Total daily flow..............r 3Q_____._._______.___gallons. WSeptic Tank—Liquid*capacity_i_aaagallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ____________________ Width.................... Total Length.................... Total leaching area....l9'5'_.......sq. ft. Seepage Pit No---------_--------- Diameter____________________ Depth below inlet.................... Total leaching area_:_Z........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by._,____�?._t :Via,...._._...J_ _O_3 i__________________ Date....... ..... .aa Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•-•-••-•••--•-----•••-•-•-............................................................•---------------=----------•---------------------------------------- `�-- ODescription of Soil..................................................................................................-----------------•------------------------------------...-----•-••-•- x U W • UNature 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 iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha th board of health. i e .............. ---- ........... .._ .__ ............ /e`/`­"`­`�"­""` � ........ -- _ Application Approv d B . - i sD te Application Disapproved or t e following reasons:................................................................................................................ ................................................ ----•-•---.._....--------------------------------•-------------•--------------------•----•--•-•---•--•-------------------------... ------•---•--- Date PermitNo......................................................... Issued_....................................................... Date MW No »........` FE.B. .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH S).W.:�.................OF.........Z?. rf uS'CI!Je(A-,._.... Appliratilan for Disposal Works Tonstrnrtinn amit Application is Hereby,made for a Permit to Construct ( , ) or Repair ( ) an Individual Sewage Disposal System at: ....,. ................:.................••-•-----•--•- Location-'Address or Lot No. .........V.t2 '..:JrA ! 1 �'�' `�`�'� ` .............................. ................................................................................................. Owner Address W . ��x_�±��.-•�'-----�'"'-�°�^.G���:�.»._MA.�..����'� Installer PU Address ivt.tAMAu� �}4 ? • S feet d TYPe.of Building add F 2 Awt� Size Lot__�. ............. q. U i g— __________________________Expansion Attic 0 1) Garbage Grinder (AO) Dwelhn No. o Bedrooms__ __.._... aOther'-,Type pf,Building _ _________________ ______ No. of persons............................ Showers ( ) — Cafeteria-( ) d �' Other fixtures .2 Ai_hY_.O,G31�&-------------'---------------------------------------------- Desi Flow.•._-: allons per person per day. Total daily flow.._.__._ a___.. Ions. W g P P P Y•- Y --- • � 041. Septic Tank—I squid capacity I4j. O-gallons~ Length----- r__._ Width................ Diameter...._.. De th -___._____.. Disposal Trench 'Vo.,_...___ ......... Width.._. __._.__.____ Total Length.................... Total leaching area ^_ ___.....sq. ft. Seepage PitNo. ___-:_: Diameter._.�m............... Depth below inlet....................,Total leaching area_ ....._sq'ft. z Other Distribution'box ( ) Dosing tank77 ( ) Percolation Test Results. Performed b .::__ .. ..... Date....... Test Pit No. I................minutes per inch Depth of Test Pit ________________ Depth to ground-„water _._.: W' .• Test Pit No. 2................minutes per,inch Depth of Test Pit.................... Depth to. ground water.............. •--_----- O. Description of Soil.................................. {. x V -------------------- --- --...-•------------•----------------------•---•--------------- ------------------------- 41, x, -----•------. --- ------------------------------ ---------------------------------------------------................................................... U Nature of.Repairs or Alterations—Answer-,when applicable.................................... .................... ----------------------••----• •-•-- ........................................................ Agreement: � ,., - i. The undersigned agrees to install the aforedescribed Individual Sewage`Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in. operation until a Certificate of Compliance ha -b th oard of health. , . . , i e Application Appro d B .............................................. --'{ Date ' Application Disapproved or tlZfjollowing reasons---------------••-----------------------------------------------------------------------------------------•_• = --.......-•--- Date Permit No..................... ` r __.:. = Issued-------------------- - Date THE COMMONWEALTH OF. MASSACHUSETTS " 1 BOARD OF HEALTH ..........................................OF....................... n Trrtifirab`of (Somptianrr z„ TH_ I 'T0 CER, , F h t� Individual Sewage Disposal System constructed (/ or Repaired ( ) - --•- f �Z _ Installer at. '' --------•-- ---- has been installed in accordance with.the provisions of T r 5 of The State Sanitary C s6cribed in the application for Disposal Works Construction Permit No. ....�0 ol-j �_' `..__.___. dated.------- _'� ___ __________ THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL fU TION SATISFACTORY. y.................................. . necto DATE•• Y. THE 1 . . COMMONWEALTH OF MASSACHUSETTS 11 , BOARD OF HEALTH �f7 f/Y ..........................................'OF...........................................................:...................._.... No...... FEE........................ Dis nsttl Work %T�, tnrtion rrntit Permissionis hereby granted............................ ......•-------------•-------•------------------•••--•--------•-._....------._...----..._...._••-•_••••- to Constru t ( orRepair ) a Individual ew Disposal- System atNo....... .,3 _� ............... = r. ,u ................................................................................. Street as shown on the application for Disposal Works Construc ion Permit No..................... Dated.......................................... 0 V Board of Health DATE.---•-------------•---------------v-...-----(-.................................. FORM 1255 A. M. SULKIN, INC., BOSTON �H GF A614S.c r S" � EiRUCE -,, f � ✓+ +,� ." LOHE L L ' o ORSE v 0.109 rsT A'PoFF fsTEPC'�4 ONA�� N /ZQ TvO Zv , u of dux ` c �7- L o L �. z { I ITV N 1 , i ;° L9 7 " ? 3 22. J�5 SA?D . sal /4 z n o iv �yvr�= z o AIF.l.A/ �f 2A° E .. 114 ' LEGEND EXISTINS, SPOT E.LENATION OAO "' EXISTING ' CONTOUR T. RlN1,8MED t SPOT ELEVATION ( ;. . �',IN�SHM,,.PONT04R - 0. CERTIFIED PLOT PLAN NQ"T'Ir,'The location of any exist ing underground sewerage, 0T 3,,3u, <3, R,4tJ (39,1 H3, P6.11 wells; .•or .other utilities shown .on t1is;plan is. approx- , ST LA,J&: 4-eYA*„„s imate,only. as determined from records and/or verbal —"" n TIP. only. on: The contractor is responsible for-}the !N ver fica, lWn of the. existing' locations: in .-_the field. !!,, We assurrie no; responsibility-for damages incurred as .9 A 9 kl S AJ 12J A ASS a,result of any' utilities, omitted"or°'inaccurately shown: gCALE$ I rc�3o ' DATE y LDREDG,E ENGINEERING , IN . CL.lEN i CERTIFY THAT .THE -PROPOSED #� EGI3TERE RE413T1RE0 33oz BUILDING SHOWN ON .THIS PLAN < " J 0'NO..:.�' . .. .. CIV►L LAND' CONFORMS+ TO THE ZONING LAWS t ENGINEER URV R y. DR..B,Yt ' OF .'BARNSTABL MASS ?I2 MAIN STREET H. BYt HYANN 1 S, MASS. VA_ SNEET.�:OF z- REG. L ND SURVEYOR v Q ` 14 U � t0ll � �ZQ ri fry N ^► 4 V Q 4 J wki vi 0 � 0 � �� =. . oa , a oa �' W � � 2 t`' W � eaQe' • • °oo`kK �d0 4 9 h ` 0 w 4 hvv \o a Q Q . ... . . . _ . .. �I �i }. U ` vQ � NO � . .. � U .r W It a OP •�a � , ,• o • a . iiiAAA t y `. n � :W U. q p p a Quo00, � . � 'r1. � F,9 �.1• IA 14 F � �a• r y -�, z t7 to071 oe - m k � � g4a oc.Woc ; '1V a WO � Qu. 22Z U�vy�T �d ql NJ Nb OC W Q W W ci m e ;• p, W 11, W w44 h e. . Q