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Home My WebLink About0325 MEGAN ROAD - Health 325 MEGAN RD. ,HYANNIS MAP -291 PAR -256 1 1 a Commonwealth of Massachusetts z Title 5 OfficialInspection l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 325 Mean Rd ......... _. _._ . Property Address Ciliberto .............. _ Owner Owner's Name information is H annis MA 02601 9-14-17 ........... required for _..y - every page. Cityrrown State Zip Code Date of Inspection Inspection results mutt_be submitted on this form.Inspection forms may not be altered in_any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out '57# forms on the computer,use 1. Inspector' only the tab key to move your DOUGLAS A BROWN cursor-do not ---_—_ ,._ — .__ ...._ _ .... use the return Name of Inspector key. D A BROWN INC _ —_...... Compan y Nam e - _ _. P.O. BOX 145 _ .__..... _. Company Address CEt`ITERVILL€ MA — _ State _........ . Zip Code City[Tow.n 508-420-4534 SI4297 ....... Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported.below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site. sewage disposal systems. 1`am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR'15.000)..The system: ® Passes [] Conditionally Passes [❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority < . ) ~� 9-14-17 — Inspectors inature, 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 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 DER. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the.approving authority ****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. Tire 5 Official InspeetionFonna Subsurface Sewage Disposal System^Page t of 57 t5ins•Y13 � � . " u�^ Commonwealth of Massachusetts Titl��~��U �� ~ N Q~� ~ �� e �� 0�~N��N NBN��m�^�� Form Subsurface Sewage Disposal System Form'Not for Voluntary Assessments Rd � Property Address C\|iborto Owner Owner's Name information is H � WA 1 �1�17 required for every page. °r'~~^ State— Z- Code Date of Inspection B. Certification (cont.) Inspection Summery� Check A^B.CI} orE/always complete all 0f Section D A) System Passes. I have not found any information which indicates that any of the failure criteria described hn31DCW1R15.3U3o[ih31UCKAR15.3U4 exist. Any failure criteria not evaluated are indicated below.. Comments: At time cf inspection system met all passing requirements. This report does not predict the future Mance under the same or increased ' EU System Conditionally Passes: [� O n� n n�d� be � replaced or repaired. The system, upon completion of the replacement or repair, au approved,by the.8oard of Health, will pass. Check the box foe,yes^. ^no^ or"not determined! . . N, ND)fnrdhe following statements. |f"not dehennined.^ please explain. The.septic tank ismetal and over 20years old* mrthe metal ornot) is structurally unsound, exhibits substantial infiltration prexfboation ur 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 ifbie structurally mound, nct|eeKingandifaCertifioateof Compliance indicating that tone tank is less than 2U years old isavailable. 0 Y E] N [] ND(Expiainbe|mm): ' | ��'y`� nx��om�/m�"am"m�.x��nmoo�x�w�"�n��m'p�°2wn __ | ' � Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments .o 325 Me an Rd _...._.. .....—._..... __._._....... _.._. - Property Address Ciliberto Owner Owner's Name information is Hyannis MA 02601 9-14-17 required for _—.... . . ....._ _ ... ..... _ ._. ..... _ ........._.- every page. CitytTown State Zip Code Date of Inspection B. Certification (cone.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cone.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System.will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N F j ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times.a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): _ .............. ._............----.._.._._---................__._.._....._...._-._..... ...........................:._._.............._.................---- 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 public health, safety or the environment. 1. 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: ❑ 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 t5lns•3/13 Title 6 OhcW Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form a % Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments 325 Me awn Rd Property Address Ciliberto ....... Owner Owner's Name information is aunts MA 02601 9-14 17 ..._.....- required for .___....._ —.—.- ..._... ......_ ._ ___... _—....... .......... every page. Cityrrown State Zip Code Date of Inspection ..__....... B. Certification (cont.) 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, safety and environment: ❑ The system has a septic tank andsoil 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 aseptic 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. 3. Other: D) 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 po.nding 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 '/2 day flow t5ins•3113 Tale 5 Official Inspertinn farm:Subsurface Sewage Disposal System•rage 4 of 17 ' ^ � «� M��use�� K��mMmM��N Official N Inspection Form ��~��Q�� "�Q00��0�� Q��&��0�� —��mmmm Subsurface SevvwgeDisposal SyatemmForm 'NnthnrVo\un�ary�oeuuamenns K0 N Property Address 0wuo, Owner's Name � information is �A �01 3 14 l ��u/mumr '''~^��— -------�-----'---' �� v«* o��o�/vo»*cuon— --� ��« �m � every page. CityTrown � B. ~,~."=".~.~..~.. `~_—' Yes No � Required pumping more than 4 times in the last year NOT due bo clogged or E] 0 obstructedpipe(s) Number pf times pumped: _____' 0 0 Any portion of the SAS, cesspool or privy ia below high ground water elevation. Any po�ionof cesspool or privy \svvithin1OU feet ofasu�aoe water supply or �] 0 . tributary hua surface water supply. [] z Any portion ofa cesspool o/privy io within a Zone 1 ofa 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 lessthan1OO feet but reaber'dhan50feet �� -- hn' '~ h�m*,�ater� pmyweU with nV acceptable vvoterqu |i |n/m system passes if the well water analysis,` performed at a DEPoenmeo laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen provided that no other failure on�eriaare triggered.A copy of the analysis d chain mY custody must be attached to this fm,nn.] The system ie=a=cesspool sem\nga facility w�ha design�mw of 2000gPd' El 10\0 ~ ` mueof� hoabovofaihuvo �� The system ' \ determined that one or mfaUo The criteria exist as=desoribadin31OCKR15.3U3. theref re the syst system owner should contact the Board of Health ho determine what will be necessary to correct the failure. � E) Large Sywtmnnec Tbbe considered o large system the system must mervmaYnciUtyxv�ha � design� 8ovv oY�n'0Qo gpd to1S,08Ogpd. � For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions m Section u. Yes No the.system� \s within 4nO feet ora surface drinking water supply El Fl the system io within 2O0 feet ofa tributary hoa surface drinking water supply | | the system is located in a.nitrogen sensitive area(interim Wellhead Protection [] [] Area—|V0PA)oru mapped Zone || odapublic water supply well If you have answered^ n^V»anyquestionin Section F the system ia considered a-significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the System in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. mieumnmaimwoum Form:Subsurface sewage Disposal System'Page 5m/r � ,m""-m,u ___ ................ _ Commonwealth of Massachusetts �F Title 5 Official s e i �, ;; Subsurface Sewage.Disposal System.Form-Not for Voluntary Assessments W= /` 325 Me an Rd Property Address Ciliberto .-..........—_._._....._._..._..._..... Owner Owners Na me information is H annis MA 02601 9-14 1..Y_._._ .._ —._._ every page. City/Town _ State Zip Code Date oInspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each.of the following: Yes No Z ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Z. 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 Q ® this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected forsigns of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ® Were all system components, excluding the SAS, located on site? Z ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles:ortees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? 0 ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface.sewage disposal systems? The size and location of the.Soil Absorption System (SAS)on the site has been determined based on: ® ❑. Existing information. For example, a plan at the Board of Health. ElDetermined in the field (if any of the failure criteria related to Part C is at issue IR approximation of distance is_unacceptable) [310 CMR 15.302(5)] ®. System information Residential Flow Conditions: Number of bedrooms (design): 3------ - Number of bedrooms(actual): 3 - 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): — ..........._........ .._........... t5ins•3/13 ritle5 official tnspe!aiunfurm.Subsurface Sewage Disposal..System•Page 6.of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fir - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 325 Me!c an�Rd __._._. ___. _ ,, _ _ _.... — . _. Property Address Ciliberto —_._._ _......_......_—_..._.. _..__.._—...—.._.__. --- _ Owner Owner's Name information is Hy annis MA 02601 9-14 17 ___..._. required for _._ p"-- State Zi Code Date of Inspection every page. Cityrrown D. System Information Description-. stern consists of a 1000 gallon septic tank d-box and 2-500allon h 1O chambers with 4_ft_of stone. 4 Number of current residents: Does residence have.a garbage grinder? ❑ Yes No IS laundry on a separate sewage system? (Include laundry system inspection ❑ Yes"® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes No Water meter:readings, if available(last 2 years usage(gpd))- Detail: 2015 303gpd......201E 3499Pd ..._............... .. _._..... ..... ........._............. Sump pump? ❑ Yes ❑ No currently Last date of occupancy: occupied Commercial/industrial Flow Conditions:. Type of Establishment: .. llons per da Design flow(based on 310 CMR 15.203)-. -- y___.._.__..__...._ .— — Gay(gpd) Basis of design flow(seats/personslsq.ft., etc.):. - -- .-....... ._...... Grease trap.present? ❑, Yes ❑. No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Title 5 M icial Inspection Form:Subsurface Sewage:Disposal System Page 7.of 11 sins•3n 3 Commonwealth of Massachusetts Title 5 0ficial Inspection For ! = 1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 325_Me an Rd �_.....—...... Property Address Ciliberto __.._...._._.—_.—_.....___...--........_..... __.__..._—_—.—.—..— Owner Owner's Name information is H annis MA_ 02601 9-14-17 required for ____ ..._.. —...— __...._. ......._— - -- -- ..... State. _ Zip Code Date of Inspection every page. City/Town D. System Information (cont.) currently_occupied ___—. ._.—..... Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Owner states regular pum Ing every 2-3yrs. Source of information: Was system pumped as part of the inspection? ❑ Yes No —._..—_... ..............__ ------ If yes, volume pumped: gauons How was quantity pumped determined? - _... ..:..._.__..:................—__.._—....._..._...__._. Reason for pumping: Type.of System: z Septic tank, distribution box, soil absorption system [] Single cesspool Overflow cesspool Privy (� Shared system (yes orno) (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 El Tight tank..Attach a copy of the DEP approval. [� Other(describe): Tetle s OfBdal Inspection I OM Subsurface Sewage DisrlOsal.Sysiem-Page 8 of 17 (Sins•3113 Commonwealth of Massachusetts: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 325 Megan Rd....— . —....... - ...... Property Address Ciliberto __..............—.......—.._..-_---..—...... --—....�...— Owner Owner's Name information is H aunts MA 02601 9-14-17 required for —� _— _—__— ....._._ __ _... _...._.._ .....— .._.. _. ._. .. —._..— .—...---...._. every page. cityrrown State Zip Code Date of lnspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tankoriqinal..._s.a.s...2001 ................._.._........._. ___ —............_......_._........_._........ Were sewage odors detected when arriving.at the site? ❑ Yes JZ No Building Sevier(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): 1.5 —.........._..........._._................. ....---....._.__---........_ Depth. below grade: .— feet Material of construction ® concrete ❑`metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: ye.a _._.. ..........—........ — .._._._. rs Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1000 gallon _. Dimensions: moderate Sludgedepth: ___..........._....__.. ..._ ........—...._............. ._. — 15f s .3/13 Title 5 ottitaal inspection Form:Sobsorface:sewage Disposal System-.Page.9 oh1 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 4 325 Megan Rd _.... _—._....—..—.— Property Address Ciliberto -- ................. Owner Owner's Name information is H annis MA 02601 9-14-17 required for y...............—_. _..._ ....___-- ....... Cit /Town —....._____.__......__.............—_-,..,............._._...._....__........_._- State_ Zip Code. Date of Inspection every page. y _ D. System Information (cont.) Septic Tank(cont.) Distance from top of sludgeto bottom of outlet tee or baffle --- moderate 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 -- ._. ................ _......_.................._ wooden pole _._...._. How were dimensions.determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels,as related to outlet invert, evidence of leakage, etc.): If Tank has not been pumped in the last 3 yrs 1 recommend pumping at time of transfer and every 2-3 yrs there after for maintenance. __.—....... ........—....--_......._—_..._..._ _____—._......._.... _...— Grease Trap(locate on.site plan): Depth below grade: fe_..__._..........._ et. 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 t5ins•3113 Title 5 Official Inspection Fo❑w Subsurface.Sewage Disposal-Sysfem•Poge 10 of 9' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 325 Me an Rd ............. ......................... .............. ................... ..........— Address Property . Ciliberto ........................................_......................... Owner Owners Name information is MA 02601 9-14-17 ........ required for H .................. .......__ _ , yanni§................................. ............................. ................... every page. Cityfrown State Zip Code Date of Inspection-_ D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.),. ..................... ..........................._............._............ ..................... .......................___...............-............ ....................................... ................. ..................... ................ .......... ...................... ........................-........................-............................. ............................... ....................................... ....................... .......... .................... Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below.grade: ......... Material of construction: ❑ concrete R metal ❑ fiberglass El polyethylene ❑other(explain): ..................... .... ................ ............... .................. ................... ........ Dimensions:. ................ ................ .---—-------- ...........__................... Capacity: gallons ........... Design Flow: gallons per day Alarm present: [I Yes E] No Alarm level: Alarm in working order: El Yes ❑ No Date of last pumping: Date__........................ ............ ........ Comments (condition of alarm and float switches, etc.): ...........I.......................... ................. .................................... ..........................__----------- .................................................................................. .............. ............. .....................................__............. ....... ................................. .................................................... .............................. Attach copy of current pumping contract(required). Is copy attached? ❑ Yes Ej No Title 5 Official Inspection Form.Subsurface Sewage Disposal Systen,-Page 11 of 17 ............ Commonwealth of Massachusetts _ N Title 5 Official Inspection Or a Subsurface Sewage Disposal System Form-Not.for Voluntary Assessments y 325 Me an Rd .. _..... —.. -_9__.__....._.......--_._ _._. ..... _ Property Address Ciliberto ............... .... ... _.—_. ....___....._.....__.......—_......___ Owner Owner's Name information is Hy annis MA 02601 9 1417 �,...__. ._ _.__...... required for _ __—.,.. _...— _.p ...__. ....._ _.. .—_... every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.). Distribution Box(if present must be opened) (locate on site plan):. 0, Depth of liquid level above outlet invert -- Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was functioningkroperly at_fime of inspect ion._ Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order. El 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Suh..surface Sewage.Disposal System•Page:12 of 17- r -- Commonwealth.of Massachusetts V Title 5 Official Inspection Form i;' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 325 qan Rd.._..— —__ . Property Address Ciliberto —.._.....__.._._.._.___—_...—.,_._.._....—...... . _.......__......_—_.._...._— . -....._ Owner Owner's Name information is H is MA 02601 9 14 17 ann required for _.....Y_ __ .._..— _._ . _—_.. . ._._ _.. _. State Zip Code Date of Inspection. every page. City/Town^D. System Information (cont.) Type: [] leaching pits number: �_.._—_ .......... ....._......_.__ Z ® leaching:chambers number: _...... � leaching_galleries number: —......._--............. ._....... number, length. g _ [] leaching trenches leaching fields number, dimensions: -- overflow cesspool number: ._.....— ❑ innovativelalternative system Type/name of technology: ......................_......---......____.............._._............ --. Comments (note condition of soil, signs of hydraulic failure, level ofponding, damp soil, condition of ve9etation, etc.): Chambers were empty at time.of inspection with no signs of failure ........_....._ ..._ cesspools (cesspool must be pumped as part of inspection) (locate on site plan}: Number and configuration — .......:........_...._.._.__.._— Depth—top of iiquid.to inlet invert ....-............_i...... Depth of solids layer — Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Title 5 Official hispection Form:Subsurface Sewage Disposal System•Page 13 of 17 15ins•3/13 e Commonwealth of Massachusetts Title 5 Official inspection Form " i Subsurface Sewage Disposal System Form Not for Voluntary Assessments ' —....... ._—_._ _... S� 1 -� � 325 Megan_-Rd_.... _....._.. _ ......_— _ Property Address Ciliberto ._..-. —....._.—_ Owner Owners.Name information is Hyannis MA 02601 9-14-17 required for -- -- �-�� State Zip Code Date of Inspection every page. CitylTown D. System Informat on (cont.) Comments(note condition of soil, signs of hydraulic.failure,level of ponding, condition of vegetation, etc.): 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.): Title 6 Official Inspection Form:Subsurface Sewage oisposai-system•-Page 14 of 17 t5ins•3113 L7wb", :01 3� (G (( 1 - a vp c - Vic' ru Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 325 Me an .... _ Property Address Ciliberto -_. __. ........_..._. ____.................._ Owner Owner's Name information is Hyannis MA 02601 9-14-17 required for _y__—_ __._...—.. — _....__....- every page. City/Town — State Zip Code Dafe of Inspection D. System Information (coat.) 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 t I i I I .......... t5ins-3113. Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-.Page 15 of 17 Commonwealth of.Massachusetts z a Title 5 Official inspection Fran Subsurface Sewage Disposal System Form-Not:for Voluntary Assessments 325 Megan.Rd___.....___. __....... Property Address Ciliberto ..._........._—......._............_....—:......—........ _...._-- ....— Owner Owner's Name information is H annis MA 02601 9 14-17 .......... required for -------- -- - —" State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Site Exam: Check Slope Surface water Check cellar ® Shallow wells greater than 5..__..__..�............._......_—.-- Estimated depth to high ground water: feet Please indicate all methods used to determine the high groundwater elevation: ® Obtained from system design plans on record 9-2017 __....__. If checked, date of design plan reviewed: pate ...._....__......� ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. Title 5 official Inspection Form:Subsurface Sewage0isposal.System..page 16 of 17. t5ins•3113 _.. _ ... ....... _ .... Commonwealth of Massachusetts _ - Title 5 Official Inspection Form. 1=i1. Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 325„Megan Rid _....._......... w.._._...... ._..... Property Address Ciliberte ... .......__.......... ----- Owner Owner's Name information is required for is Hy ann MA 02601 9=14-17 . is —............_— .. . ........ — ..._.... _._. every page. Gity(rown State Zip__ Cod,_—e Gate of Inspection E. Report Completeness Checklist • Inspection Summary: A, B, C, D, or E checked • Inspection,Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information--Estimated depth to high groundwater Z Sketch of Sewage,Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 officlat Inspection Form:Subsurface-sewage oisposahSystem•Page 17 of:17 TOWN OF BARNSTABLE `J LOCATION Q S MeQ RA) ad SEWAGE # aQQJt VILLAGE 14 Van/1,1 5 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. W•A5 9�f n 661056-0 775'I T 7 4 SEPTIC TANK CAPACITY ®' !8 B- LEACHING FACILITY: (type) -o°Z-6 4en 6e r3 (size) NO.OF BEDROOMS v^^Z BUILDER OR OWNER C PERMIT DATE: ' DO- O 1 COMPLIANCE DATE: 4- -01 Separation Distance Between the: Maximum Adjusted Groundwater Table to the 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 I chingfacility) Feet Furnished by V • t I �t 4 i `} No. .'� l1 Fee 5 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ves PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for Migo!6al *pgtem Conotruction Permit Application for a Permit to Construct( . )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 325 Megan Rd,Hyannis Anthony Ciliberto Assessor's Map/Parcel Installer's Name,Address,and`Tell.No. G Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Ser. P O Box 1089 Centerville Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) D403.xe ggpti G s y s t g m Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system# in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a.Certifr cate of Compliance has been issue by this" oar of Health. _ Signed " Date 3 6 0 Application Approved by Application Disapproved for the following reasons Permit No. ✓ Date Issued --------------------------------------- Fee$�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ves PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 21pptication for Mizpaal *p.5tem Cbn!5truction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. . l�e an Rd f annis Anthon Ciliberto Assessor's M1 ce g i y Y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Ser. _ 10-89, centerl.gilla_ Type of Building: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) • Move septic - s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed "'� Datei 3-3 G•-o1 L Application Approved by Dated s f Application Disapproved for the follow ng reasons Permit No.� !Y. ,� s� Date Issued f. OQ ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Ciliberto (Certificate of (tompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by W . C. Robinson ob n son Sect i _ Servleee at ��`� "began Rd. , Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NA*7401� dated Installer W,-,. B. Robinson Sr. Designer The issuance of this permit shall not be construed as a guarantee that the syste will function as desig ed. Date j�� ;�,• / Inspecto''V . --------------------------------- Fee rti® THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Ciliberto'WifSpo-5ar *pgtem (Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 325 Megan Rd. , t and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. ` Provided:Construction must be completed within three years of the date of this , - it. Date: 1, Approved by ,c NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERUff MTrHOUT DESIGNED PLANS) L William E_ Robinson,s y cu*dat the application 6r disposal works construction permit sighed by ttte dated 3 3 6 0 , Concerti*the PAY located at 325 Megan Rd. , Hyannis meets all of the Mowing citerk • The failed system is aomwed to a asklcotW dwelling only..There are no commercial or business Uses associated with dwelling. • The soil is dassifiod CLASS 1 and the pmohmm rate is i=than or aqua!to 3 minxes per inch. There are n0 NiGrWwo wtthtn toll fee[of dae proposed SePtic k*UCM 0 • There arc to private wells within 150[eel of the proposed septic s)vem t There is no inapse in flow andfor Change in use posed • There are no requested or needed • The bonam the luoposed leahOg facility will�t be located teas than five fax above the ma�rimum groundwates table elevation(Adjust the g munch ater table using the Frimptor method applicablei If the S.A S.will be Ian v"250 feet of any vegCUMA weda ds.the bottma of the proposed le achint;facility will-w be located iris than foauteen(141 fea above the maxunum adjusted groundwater table elevation, Please comptese the fdkwbW' j A) Top of Ground Satdaoe Elevation(using GIS Wbu aaau) L/ B i G.W.Elevation +cite MAX i•Iigb G.W.Adjustmmtt -= G DIFFERENCE BETWEEN A and B 3 SIGNED DATE: J 6` J7 [Sketch pmposed plan of system on badcJ_ y beam fotw'M �� ~� � � ----� l i � � :� i _ TOWN OF BARNSTABLE _ LOCATION „_ / r I�Ct AII� SEWAGE # ;�2 -.rqc� VILLAGE ASSESSOR'S ASSESSOR'S MAP & LOTs7� INSTALLER'S NAME &PHONE NO. ^,I G 9'i66 rrl5on �7 5" 77,6 l SEPTIC TANK CAPACITY LEACH-llvG FACu x ((types' size) NO. OF BEDROOMS BUILDER OR OWNER I be PERMITDATE; �30" 0 1 COMPLIANCE DATE: Separation:Distance Between the: i Maximum Adjusted Groundwater Table to the 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'le ching :ihty.) Feet Furnished by — t < a e oo� ',4q TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE �.� ASSESSOR'S MAP&LOT _� INSTALLER'S NAME&PHONE 0 � , SEPTIC TANK CAPACITY 07M —LEACHING FACII,TTY: (type) ��Ar'T-avld(size) NO.OF BEDROOMS BUILDER OR OWNER -r��-� V s PERMTTDATE: ��/ ' COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet " Private Water Supply Well and Leaching Facility_(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Tel i No. ��' Fee THE CO ONWEALTH OF MASSACHUSETTS Entered in computerlYe Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0ppYication for Migool *pztem Cow6truction Vermtt Application for a Permit to Construct( )Repair( vl/upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 -� 1 wvu ner's�Name,Address and Tel.No. Assessor's Map/Parcel 2— G 6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � �6a- -1-�-'i� � ter,•S Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures C� Design Flow 3 S C7 gallons per day. Calculated daily flow 3 Y / gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank EK t S' ! 6-w' Type of S.A.S. Description of Soil E !� Nature of ep 'rs or Alterati ns�A swer when applicable�� Ol1L�C' N Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee o ea Signed �- Date Application Approved by ` Date Application Disapproved for the following reasons Permit No. Date Issued j } No. a..✓ Fee" 1 C THE CO ONWEALTH OF MASSACHUSETTS Entered in computer: .i� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 9 01ppficatiou for Migogar *pgtem Conttruction Permit Application for a Permit to Construct( )Repair( /upgrade( )Abandon( ) ❑Complete System ❑Individual Components `Location Address or Lot No. ''�� • ner's Name,Address and Tel.No. Al1 w ' 1 ..,,� AssessorsMV/PazceE �} q �,,• r- c+ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. A4 � ctti.n - Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building of Persons Showers( ) Cafeteria( ) Other Fixtures Y Design Flow 3 3 gallons per day. Calculated daily flow 3 4 / gallons. Plan Date Number of sheets Revision Date Title ` Size of Septic Tank Type of S.A.S. :_ C-Z 112c Description of Soil ON C7 S Nature of Repairs or Alterati ns(Answer when applicable) �h oCAY' C► C �'1/hSc ,rC&CS y 'S-6y\ e, 1 ,1 /1 kvN�k<- tj Date last inspected: Agreement. ` The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bees&ta lti o Hea --. Signed Date 9-1�-� Application Approved by , ° Date ✓��''�� —T Application Disapproved for the following reasons Permit No. �' Date Issued --------------------------------------- 'THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Conmpliau%,/ THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( Abandoned( )61S) '('"�:c -��n T C1 at � 'R 04 hw been constru ted in gccordance with the provisions of Title 5 and the fo isposal System Cons ction Permit No. �" dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will filction as designed:,,' Date g G'f ''"1 Inspector g y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSET S Migozal *pgtem Cott!6tructiou Permit Permission is hereby granted to Construct( )Re air( }Upgrade( )Abandon( ) System located at a and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. - Provided:Construction mu st be completed within three years of the date of ' rmit. Date: Approved `�./ � %/ / l J "c NOTICE: This Forn) is to he Used for the Repair of hailed ' '~ Septic Systems Only CEii','I7FICA'I'ION OF SKETCH AND APPLICATION FOit A DISPOSAL 1VUfiIiS I✓UNS'17tU( '1 lUN 1'1'Iti191 I'(1VI771UU'I' DESIGNED I'LAIND p l ` hereby certify that the applieatiolt for disposal works construction permit signed by me dated s all of the . concerning the property located at �� t ,0 meet following criteria: LI—o there me no wclhnds within 300 feet of the proposed septic system rf There are no private wells within 150 feel of the proposed septic system ./ The observed groundwater Iable is 14 feet or greater below the bottom of the leaching facility v �- There is no increase in(low and/or change In use proposed There are no variances requested or needed. DA7'13: SIGNED: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE N"ER (Allach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan, this plan should be submiticdj. �a-- 1 �1 A TOWN OF BARNSTABLE LOCATION SEWAGE # LAGE ASSESSOR'S MAP& LOT. INSTALLER'S NAME&PHONE go. Q��,: h, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) T L ,. . (size) NO.OF BEDROOMS BUILDER OR OWNER'S —` 9wir PERMTTDATE: J-7 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) Edge.of Wetland and Leaching Facility(If any wetlands exist Feet Within 300 feet of leaching facility) Feet Furnished by �sr�M �s�Z1n1 �>lst�1 t i 9 LOCAT_IOP1_: 60-7-_r_. - .IWSTQ,LLER-S IJ�ME ADDRESS_ _ D laTE -P.E R M1T 155U ED DATE COMPLI W-ACE ISSUED : N I wol i v L No......ZY� (-------•• Fic$.......�0 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF Appltratiutt -fur Biupuuttl Works Tomitrurttutt Vaniit r Application is hereby;made for a Permit to Construct (, ) or Repair ( ) an Individual Sewage Disposal System at: ..............................----- .......................................... ----------••• --• ---•--------... .. ... Location-- ddress q�ot N • i ........ . --- ---------------------------------------- -------------•-•--.. ► . s�.w 4................................... r`.. Ownf�p��y Address..... Installer Address UType of Building �._ Size Lot---1®. .......Sq. feet Dwelling P No. of Bedrooms____________________________________________Expansion Attic (�(� Garbage Grinder ( ) pa, Other—Type of Building ---------------------------- No. of persons............................ Showers (I ) — Cafeteria ( ) a' Other fixtures _•--.-.--._•___________________ __ W Design Flow.....� ............................gallons per person per day. Total d�ailflow.._.._.._...��'...................gallons. WSeptic "Tank k7iquid capacity�U�-_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 ( ) Percolation Test Results Performed by...... ------------------------------------------------------------------- Date--------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.-_.-.-_-.-------.-...-. fZA Test Pit No. 2----_-----------minutes per inch Depth of Test Pit.................... Depth to ground water.-.--.---__----------. - R+ ---------------------------•-----•-"---.......------......--•-----•--------------•......------......................................................... ODescription of Soil-------------------------------------------------------------------------------------------------------------------------------------------------------------------- x ----------------•------•--"-----•----•-•---•-•"---••-•---------------•------------------ _._. - 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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of healt e. Signed_ • ----- -2 3-7 Date Application Approved ByJ114'____________________ _ � ----- -- Application Disapproved for the following reasons:. --------•------------------------•-••---•----_----------•-•----------------•--•"--•------Date--•—"•------- .....................•----------------------------------••--•-------•---•---•-------.--•-• Date Permit No......1 5...•--------••---•----•............... Issued.---; d�r ................. Date �� --------------------------------------------- �b /J .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ . _......._.OF..................................... .................................................. AVVIiiation -for Ui.iponttl Works Tonitrnrtion Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: G1 -- ca4:— ------------------ ------_---- j � yy --------------------•......---.........-•••-- Location-Addresses! Gr Lot No. �T ---,--. Aa �.../------- ------------------ -- o° `� ------=----------------------------- ;� 5 t, w Installer r Address d Type of Building Size Lot_-_. .. Sq. feet U Dwellin o. of Bedrooms................. 'g ��________________________Expansion Attic ��//) �ar}�age Grinder ( ) Other—Type of Building ____________________________ No. of persons._________________.___!.Y(.1Showers (� ) — Cafeteria ( ) dOther fixtures -------------------------------------------•------•--------------------------- --------------------------------I Flow____.__..'` ...........................gallons per person per day. Total daily flow_______________ __ gallons. IxSeptic Tank j/1`squid capacityl ..gallons Length--------4------ 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. fl. z Other Distribution boxes( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------.. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.._.-___--.--..-..---. Li, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ 9 ------------------------------------------------------------------------------------------------------------------------------------------------------------ 0 Description of Soil--------------------------------------------------/�-----Tir'----------------------Y U ------------ ---------•----••- �i..........------�.�•�(�r�_:_............•---•-.................... fsl ------------------------- ----------- ------------------------------------------------------------------------ - f ...:------. 1-•=,e-------�j s.—_..._... 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 \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificat of Compliance has been issue by t ,board of health. t A„2 7-7 Signe '`. . ...... - Date Application Approved By---••------------------------------ ............................................................ ....................................... •------•---•------• -- ------------... Date Application Disapproved for the following reasons----------------------------------------=- ":':-:-_-_.--.-.-------------------------.-.----.---..-----_. JJ �& .......................................a-1 41 .,•- --- -•--•----•---•--------------- - ----------••----------•--- ....--..---- ----•---•----••----------�-----------•--••----- ,. Date Permit No. - - ---------- :" Issued..................... .................................. Date e THE COMMONWEALTH OF MASSACHUSETTS BOARD QF.t+E'*LT.H ..........................................OF...................................................................................... T'rrtifirnte of Tontplittnrr 7 ei �ly'7�. / / C 1.-(i!'„d„ /j.6 s. 1 THIS I�' �C�e�RTIFY, Thai' the Individual Sewage Disposal S;�stem constructed ( ) or Repaired ( ) ---------------- ....... •-•---•-•-••-••-•-------•---------------------•--•--•-•-•--....----•--•--•-- Installer at....................................................................................................................................................................... - —---------- has been installed in accordance with the provisions of Arti'elkfl'bf.Th`� State Sanitary C°ofe a described in the application for Disposal Worl4-Eonstruction Permit No----------------------------------------- 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 F,--HEA' 1�1`-H- ..........................................OF.................-----........ ............................................... No...... ................. FEE........................ err-nit#'`, Permission is ereby grante is moo,.-- ------j----! /:.:_...... j j ��; -•. ..... to Constr4((T )�'Or Repair ( ) n Individual Sewage Disp )System -•-------....----------- - ?' at No. :� y. cation for Disposal Works C t'it o _ mat as y(o t/% Cs --•-----•---------------------------------------•- --...------.... ----------•----------------- Board of He h DATE................................................................................ FORM 1255�HOBBS & WARREN. INC.. PlTBLISHERS �'E`� f l \o N r CERTIFIED PLOT PLAN l O C AT 1 O. N S C A L- E _._:3t'- — D Ai T E C E F E R E N C E pap.A/9o;t4o �t LrATE r ri E R E B Y C_ E R T 1 F Y T y 4 T T F+ F 1? i,I et L �r i �• C. fi t n t Y C' WN ON rHI5 P A i s lO TE 1 % h+ t G ROUND f A t T r t A T r r--=" f _ C O N Q R N r s i I" OF Rid Z 0 I^a N G ..B Y - L A V5'S C' E � �i E , 0 dv N i� F ', _,�.� ,,� W H tv r G N S T R u C C g� GEORGE ,I LOW,JR. ` A a J Y A C7 k J I. T '-� 'C1 • I 4 lax _sz s«