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HomeMy WebLinkAbout0172 MEGAN ROAD - Health R. .. , I� �l i �rowN o � LQCAlION M� SEWAGE# VIL€.AGE , AS Fss WS RrfA$� GT IlTA .LEIt' . tAiE&PYiOt►lE ivO SEMG TANK CAFAtSt'Y LEAC>ffl`iG FACB3`"l tom} - I�TO OP�EDROOP/iS �tJSLCtER OR C)W�IER - I RA TDA'37: CflR 'I.IAI�tC:E DA" Sepamon UisEay►cc Bet ►esn 4hc 77. Feet N(axugtt{m Adjustecl Graonti�rater Table to the Bottom of Leach'tttg Fac�iity Pnvate Watai, upply dell andLeacbing Facht)► �Yel exist; #. on,site or a+xthin?AO fit of Ieaeh�g faci3uy) Edge of Wetland andI.eactung Faca'1t}'(If azLY�etlarids eusfce vnthtse 30 ee,t f:teacFuri f ) f r Funushed _ -_ -�_ .�^ C2 'I ,.� Commonwealth of Massachusetts Title 5 Official Inspection Form HI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' r 172 Megan Rd ell Property Address Bank Owned Owner Owner's Name information is Hyannis MA 02601 7-11-19 required for every page. City/Town State Zip Code Date of Inspection ' Awn 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. A. Inspector Information Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l 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 theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7-11-19 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth"of Massachusetts r� ,w Title 5 Official Inspection Form ! C�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r � � 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 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: System is in good working order with no sign of failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "Co nditiona[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 El ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �.1 1�4W Title 5 Official Inspection Form f� w"' i�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >1 172 Megan Rd �rn Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y El ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El ❑ 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts r7 Title 5 Official Inspection Form r�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments > 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system SAS and the SAS is within Y P P Y (SAS) 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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 t5insp.doc•rev.7126t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts rr Title 5 Official Inspection Form 'I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 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 ❑ ® 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? ® ❑ 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? ® ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp,doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form i;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 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: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 ., Commonwealth of Massachusetts 3 Title 5 Official Inspection Form w_ o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 2012 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"feet Material of construction: - ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Good condition. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form � ibl Subsurface Sewage Disposal System Form Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 6"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 Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts r� 4. Title 5 Official Inspection Form C�'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 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 ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): B. 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.712&2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Ini Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is Hyannis MA 02601 7-11-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): Good condition with water at working level and no sign of back-up from field. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 0 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 24-Infiltrators 11'x24' ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,. Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p Y rY rx_ ? 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town 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.): Leach field in good working order and empty at inspection with no sign of back-up. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 l Commonwealth of Massachusetts Title 5 Official Inspection Form 14 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 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 l� I� i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts r� ;w. Title 5 Official Inspection Form ! c;i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every Hyannis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: ® Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database- explain: You must describe how you established the high ground water elevation: Original design plans show no groundwater at 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form w: IMI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 172 Megan Rd Property Address Bank Owned Owner Owner's Name information is required for every y H annis MA 02601 7-11-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Town of Barnstable P# 45 'SL L/ . Departinent of Regulatory Services SPO& Health Division z{ MA Date lF1 trt►�",� 200 Main Street,Hyannis MA 02601 � dO Date Scheduled CJ-V -� ' Time Fee Pd. ( Q 0 Soil Suitability Assessment for Sewage Disposal Performed By: Witnessed By: C/ LOCATION& GENERAL INFORMATION Location Address -�I rM 6 a� a� Owner's Name ��(j CL '►"K k S �LG OZ.G u r. Address �J� ►tiLt� Assessor's Ma /Parcel: 1, J 1 p �9 F ""'—' � \ Engineer's Name NEW CONSTRUCCTIIO�ON REPAIR ` Telephone# is5e5—S L 7JCJ��Land Use: � a+ S . 3ukr�/.Q `'��Ltu o _C o o Slopes(%) Z�b Surface Stones .� Distances from: Opcn Water Body ft possible Wet•Area Drinking Water Well Drainage Way ft Property Line �s^ �ft Other_ SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) '6 2 26 *Ir4' 1.5- filyc `tom. r V SOAK N 3�se a � Sao f-� � � .(' - - � ,.. ® �_ � • Parent material(geologic) A d3&a e � • (g g )� C.k� 'r 1--���i/Jev�� Depth to Bedrock ,,r Depth to Groundwater. StandingWater in Hole:,y -- Weeping from Pit Face rvd�'�P Estimated Seasonal High Groundwater/ DET ' ATION FO SF.�ASQN HIGH WATER TABLE Method Used: (yt�l Q b (/�,t t `mil • r Depth Observed standing in ob .hole: In. Depth to soli mottles: N1 in, __j r Depth to wee ing from side of obs.hole: 1�„Z � in, Groundwater Adjustment fr. Index Well# Reading Date:_� Index Well level Ad.thCtbr�.: J Adj.Groundwater Leval Observat°n- PERCOLATION TEST bate ZG h&o (D4M ' Hole# / Tima at 9" Depth of Pere �� d �Ov Time at 6" Start Pre-soak Time @ �l/< V, Time(9"-6"). /a End Pre-soak -SZ 12 h1t►1 ' Rate Min./Inch Zltil Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back-------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:IS EPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# ?� ¢6 -Z Depth from Soil Horizon Soil Texture .Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. • o i ten�y,46'Gravel) I I DEEP OBSERVATION HOLE LOG Hole# x 7- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. � -(Longislency,%Gra e -7�y/Q DEEP OBSERVATION HOLE LOG Hole# 3 ?� We.Z) Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.%G et /P / ¢ 5-4',- 7,5" B .f a 7 Q 78=/W. c soar 01 !o R DEEP OBSERVATION HOLE LOG Hole# -0—, Z ¢9.a Depth from Soil Horizon Soil Texture Soil Color. soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones:Boulders. Consistenev, Gravel) �y 144. U'a s e "IQ Flood Insurance Rate Map: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes Within 100 year flood boundary No._ Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that o rt/ 9r (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required tr ` in ,e pertise and ex ien described in�10 CMR 15.017. ` Signat %' / Date 244�zlZ QAS.EPTIMERC-FORM.DOC Town of Barnstable FtHE Tp��o Regulatory Services Barnstable Thomas F. Geiler, Director fflWfteriCaCjW '~ AP MAS&LE, Public Health Division I f 039. s � Thomas McKean,Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 CERTIFIED MAIL#70083230000251778254 Luiz &Adriana Coelho 172 Megan Rd. Hyannis, MA 02601 NOTICE OF VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND TOWN OF BARNSTABLE CODE 4 353-9- DISCHARGE ONTO GROUND PROHIBITED. On April 10,2012, Health Inspector Donald Desmarais, R.S. investigated a complaint regarding sewage odors at the property owned by you located at 172 Megan Road, Hyannis. The following violations of 310 CMR 15.00, the; State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and the Town of Barnstable Code were observed: 310 CMR 15.3030) (a): Septic system is in hydraulic failure. Sewage was observed overflowing onto the ground. Town of Barnstable Code �353-9: Discharge of sewage onto the ground. (1) You are directed to keep the on-site sewage disposal system pumped as many times as necessary (daily if needed)to keep it from overflowing onto the ground. f (2) You are ordered to obtain a septic design engineer to design the repair plans for the failed septic system at said location and apply for a septic permit with the Health Division within thirty (30) days of your receipt of this letter. (3) The septic system shall be installed in strict accordance with the approved engineered plans within sixty (60) days of your receipt of this letter. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in the issuance of a non-criminal ticket citation of$100. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OF TH BOARD OF HEALTH Thomas A. McKean, CHO, RS Director of Public Health : itizen Web Request Page 1 of 1 y 'eL0.�s Citizen Request Management h, Request ID: 37802 Created: 4/9/2012 4:28:01 PM Status: Assigned To Staff Assigned To: Desmarais, Donald Health Office Anonymous: Yes Category: Title 5 : Section 353-7 Sewage E.C. Date: 4/24/2012 Created By: Parvin, Lindsay Citations: Health Office Time Worked: 0 Response Time: 0 Request Location: 172 MEGAN ROAD Hyannis, Ma 02601 Parcel Number: Map: 291 Block: 261 Lot: 000 Request: Requestor reports a strong septic odor coming from the property. Request Work History: a http://issgl2/InternalWRS/WRequestPrintPub.aspx?ID=37802 4/10/2012 Town of Barnstable �OFtHE tp� Barnstable do Regulatory Services0 Thomas F. Geiler, Director ANUm;ra V * MASS. # Public Health Division ' I �prEn 39. 6. Thomas McKean, Director 2007 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 CERTIFIED MAIL#70060810000035253435 Luiz&Adriana Coelho March 12, 2013 48 Oakhill Rd. Hyannis, MA 02601 NOTICE OF VIOLATIONS OF 310 CMR: 15.00 THE. STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE AND TOWN OF BARNSTABLE CODE 353-9- DISCHARGE ONTO GROUND PROHIBITED. On April 10, 2012, Health hispector Donald Desmarais, R.S. investigated a complaint regarding sewage odors at the property owned by you located at 172 Megan Road, Hyannis. The following violations of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and the Town of Barnstable Code were observed: 310 CMR 15.303(1) (a): Septic system is in hydraulic failure. Sewage was observed overflowing onto the ground. Town of Barnstable Code 353-9: Discharge of sewage onto the ground. (1) You are directed to keep the on-site sewage disposal system pumped as many times as necessary(daily if needed)to keep it from overflowing onto the ground. (2) You are ordered to obtain a septic design engineer to design the repair plans for the failed septic system at said location and apply. for a septic permit with the Health Division within thirty (30) days of your receipt of this letter. (3) The septic system shall be installed in strict accordance with the approved engineered plans within sixty (60) days of your receipt of this letter. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. Non-compliance will result in the issuance of a non-criminal ticket citation of$100. Each day's failure to comply with an order shall constitute a separate violation. a ER OF BOARD OF HEALTH . McKe , CHO, RS Director of Public Health `M TOWN OF BARNSTABLE BOARD OF HEALTH ` ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date 1 (�0600 Time: In Out L.Owner Ai� Tenant Address 99 ©AV V1I-L (`'D Address I z WAMfjusl Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities loe 3. Bathroom Facilities V 4. Water Supply Ma 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use Lz _ 12. Exits PAC�SSG2 IS $LIOGKItJ67 FKVNT D0012, 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART If 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms -3 Number of V lesAll ed ( ax) i Number of Persons Allowed (max)_ ` f Person(s) Interviewed �9KAO-M Inspector If Public Building such as Store or Hotel/Motel specify here Date: TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: 51q6&_f' KA I �) I- lk)6 BUSINESS LOCATION: IVS-6 IV 2 , MAILINGADDRESS: 5404C Mail To: TELEPHONE NUMBER: 00 11bD - /'3 e Board of Health CONTACT PERSON: rn.-3/0 �� f//�l,�y Town of Barnstable P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO Vo This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site other than your mailing address: ADDRESS: TELEPHONE: ^ LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED - _ (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers S(_ Paints, varnishes, stains, dyes PCB's _ Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Ck A- Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers Metal polishes hydrochloric acid, other acids) Laundry soil & stain removers Other products not listed which you feel (including:bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Z3 1T3 1110 16'11 0 0 2'6 UP m N GO N N 23'5 N O 43 UP 31'S � E .r r- LIVING AREA 1046 sq ft Town of Barnstable Barnstable oFj"E Taw Regulatory Services Department yam? 0� Ae-Americacigr w Public Health Division + BARNS-TABLE, ` D 9°0 MASS, �� 200 Main Street, Hyannis MA 02601 ArEn trSA'I A' 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO Certified mail 7006 2150 0002 1038 7466 August 26,2008 Luiz M. Coelho 48 Oak Hill Road Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.300 and 310 CMR 15.00, AS WELL AS TITLE V. The property owned by you located at 172 Megan Road, Hyannis was inspected on August 8, 2008 by Jaime Cabot, Town of Barnstable Health Inspector. The following violations of the State Sanitary Code were observed: 105 CMR 410.4827 Smoke Detectors and Carbon Monoxide Alarms CO detectors missing from bedrooms, Smoke detector not working. 105 CMR 410.300 and 310 CMR 15.00: There were a total of four(4)bedrooms observed at this property. However, the existing septic system (permit# 73-666) was not approved for four(4)bedrooms. It was approved for three (3)bedrooms only. You are directed to correct the violations listed above within twenty—four hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire Codes. You are ordered to correct the violations listed above within thirty (30) days of your receipt of this notice by pulling any required building permits to restore the property to a three bedroom home. You are ordered to remove the bedrooms by removing entrance doors and by opening door-way entrances to the room to a minimum of five feet wide openings. This will bring the total bedroom count down from four (4) to the appropriate three (3) as designated by your septic permit. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violation, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable Certified Mail 70062150000210417668 I ' Cea ro rtc O W.4A%t Z 00Co Z/d0 600Z to / Zb6t$ A �0,*1KE Town of Barnstable Barnstable Regulatory Services Department BARNSTABL& 9 MASS. 039. Public Health Division �ArFDN4A�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO August 12, 2008 Luiz M. and Adriana Coelho 172 Megan Road Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.300 and 310 CMR 15.00, AS WELL AS TITLE V. The property owned by you located at 172 Megan Road, Hyannis was inspected on August 8, 2008 by Jaime Cabot, Town of Barnstable Health Inspector. The following violations of the State Sanitary Code were observed: 105 CMR 410.4827 Smoke Detectors and Carbon Monoxide Alarms CO detectors missing from bedrooms, Smoke detector not working. 105 CMR 410.300 and 310 CMR 15.00: There were a total of four(4) bedrooms observed at this property. However, the existing septic system (permit# 73-666) was not approved for four(4) bedrooms. It was approved for three (3)bedrooms only. You are directed to correct the violations listed above within twenty—four hours of your receipt of this notice by installing smoke detectors in accordance with Mass Fire Codes. You are ordered to correct the violations listed above within thirty (30) days of your receipt of this notice by pulling any required building permits to restore the property to a three bedroom home. You are ordered to remove the bedrooms by removing entrance doors and by opening door-way entrances to the room to a minimum of five feet wide openings. This will bring the total bedroom count down from four (4) to the appropriate,three (3) as designated by your septic permit. a' -You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served.' `F Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Should you have any questions regarding the above violation,please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH df Thomas A. McKean, R.S., CHO Director of Public Health Town of Barnstable 'r 4 3 No...4. �.....•. Fes$......Z ...... THE COMMONWEALTH OF MASSACHUSETTS ®AF�D F HE TH o�L C .............OF..... . .- .....- �o� z Appliration for r Bigpaoa1 Workii Tonfitrurtiatt Prrutit \ Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: oea •, Location-A s a or Lot No. ----------------------------- - ----- --•---- --•- ---------- --•------------------------------------------------------------•------------•------------------ .........Own T. ......-•----•-----------------Address W .. Installer Address U Type of Building Size Lot-----/,?,.�S2Sq. feet Dwelling—No. of Bedrooms_________________._.._...._....._._..Expansion Attic ( ) Garbage Grinder (1-4 ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a d Other fixtures --------------------•-------------------------------•----•-----•----••------•-------------------•----•-•---•-- -•-•--...---•---•----•--•--•--...._ W Design Flow................. ____-------_-_-gallons per person per day. Total daily flow.............T��-______----____--_gallons. WSeptic Tank—Liquid capaci �t - _gallons Length................ Width_-__-_-_--.-._ Diameter.-_--____-_____ De)th-__-_--____-.-. x Disposal Trench—No......_.... .. Width___________________ Total Length.................... Total leaching arez.___ V. .sq. ft. Seepage Pit No._____ Diame . .._. -........ Depth below let....... -• Total leaching area__________________sq. ft. z Other Distributio ) "sing l aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1......._--------minutes per inch Depth of Test Pit.................... Depth to ground water-.---------------------- PLI Test Pit No. 2----------------minutes per inch Depth of Test Pit-__-____....______ Depth to ground water----___----_--__-_--.... ----•----••-•------------------------------•---•••--••--••-••-•----•---•---•••••-----••----•--------- Descriptionof Soil----------- ---- ------------------------------------------------------------------------------ Ux ....................:--------------------------------------------------------- ------------------------------- - `��4 --------------------- ---------- ---------------------------------------------- -------------------------------------------------------------------------------------------- U 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 1I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issu the bo of lth. f/7 Si e �.. e.. l .j� -- •- ---•--------- 1 Date Application Approved By--- - C + P �<f �-���_ Da Application Disapproved for the following reasons:....--•-•--••-------'-•---------------....................................... ................................ ...........................------•-•------------------------••'-----•------•'•--..............-----•-•'-•-•---.---•-----'-••-••--••---•-------'----•--------•-----••-------•-----------•-----------... Date PermitNo......................................................... Issued........................................................ Date _ l�/ C _ � I' k � \,r` P �_ �� � - � c � �, e � � � �� ,� p P -. � , 0 y66bp � i E 6 �' . � �.� N ...... FivE............t................. THE, COMMONWEALTH OF MASSACHUSETTS BOARD F HEA TH l � ..... .... . . ..................... ................... Appliration for deposal Works Toustrurtion Prrutit Application is hereby made for a Permit to Construct (C- or Repair an Individual Sewage Disposal System at ,, ------------—----------------........................ J�.................. ......................................................................... s Location-Ad s� or Lot No. ------------ Owner Address ............. ...... ....... .......... .................................................................................................. Installer Address Type of Building Size Lot--- Sq. feet U Dwelling .No. of Bedrooms.................. ....................Expansion Attic Garbage Grinder ( ) Other—Type of, Building ----------------------- - No. of persons-.________._.____..________. Showers Cafeteria ( ) Otherfixtures .................................................................................. ------------------------------------------------------------------- Design Flow..................5 ................gallons per person per day. Total daily flow------------Ti��. --------------------gallons. WSeptic Tank—Liquid capaci gallons Length________________ Width.__....-.-_... Diameter___.___.._._____ DLepth---------------- -Disposal.Trench—No.. � idth .............. ... Total Length-------------------- Total leaching area-- _; __sq. ft. Seepap Pit NO DiameW. .......... Depth b I let...... ------- Total leaching area------------------sq. f t. Z Other -Distributi2-oo�PCVI)--$Z-lr-gP7'-Wosin Percolation Test Results Performed by.......................................................................... Date.---------------_-----------------_- Test Pit No. 1................minutesperinch Depth of Test Pit____________________ Depth to ground water__________________.__... L14 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------ P4 .......... ................................................................................................................................................. 0 Description cription of Soil---------------- ---------------- ............................................... --------------------------------------------------------------------------------- U ----------------------- —---------- - -_ ........;��........... . . . .. .................................. ............................-------------------- ------------------------------------------;-------------------------------------------------------------------------------------------------------------------------------------------------------------- U 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 be issu. . y the boprd of ehlth. X , " �7? /,,n/ , S. igni - ---------------------------------- ;/------------ Date..... ........ /' 71 Application Approved By.---- ------------------ Da e Application Disapproved for the following reasons:-----_----------------- .................................................................................. A Y .................................................. ----------------------------------------------------------------------------------------------------------------------------------,,t,e---------------Da PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HE A T H / ...............OF..... . .... V. . .....X...................................... %T.Wrtifirzitr of T utphana THIS IS T, Y, at the B�WvidualAewage Disposal System constructed (6,<or Repaired ,Q--CERTIF ............by........ .. ... . -_---------- ---------------------------------- - ------- ----- r ------------------------------- 's---5;;P at _ -------------- --------7r;14............ 0 .. ..................----------14 . .................................... has been installed in accordance with the provisioKs"of Article X 0 'Ve State Sanitary ndy�as as in the application for Disposal Works Construction Permit No......... .. ............. 2 ...........dated'-../o/ 64 Y ...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE f:ONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL tAF UN1(C 'ON_ SATI,SFAq 00 .Y. DATE........... -- ------ '0 ]....... Inspector....................................................................................t HE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ................of..... .......... . ........................................... p1w17 Dispolial Alorkii T tr flot FE ................ _� Permission is hereby granted........... _�--------- - - - -- ----------------------------------------------------.................... to Construct ( -4--6r- an Individual Sewage DiSposAl System . ........... I at No. ------- ............... -- -------- ....../e;osilre.' Ae�_ _-lez..... -------- ................. as shown on the application for Disposal Works Construction Perinit7NO......e.,:.en).......Dated..;................... ............ I.......... ------------------ '-'—Boadof­he.1t�- DAT ............. -------------------------------------------- E? "-----.1- -----Z--, FORM 1255 HOBBS & WARREN. INC., PUBLISHERS