Loading...
HomeMy WebLinkAbout0092 NOBADEER ROAD - Health 92 Nobadeer Road a A+250-142 Hyannis 0 o I I I TOWN OF BARNSTABLE LOCATION SEWAGE # W, LAGE { y0�16;1- 'ASSESSOR'S MAP & LOT /AJ YR S'C ore /J I�3� -ER'S NAME& PHONE NO. o/ ( d C O SEPTIC TANK CAPACITY �£�� ��S"oZC LEACHING FACILITY: (type) (size) NO. OF BEDROOMS -- BUILDER OR OWNER a� ®O� �� y ✓� PERMITDATE: GQNHt E DATE: 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 leaching facility) Feet Furnished by p` NY W `cl, .1> F � Cq M R �y l Commonwealth of Massachusetts o?50—Iqa.. P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments »% 92 Nobadeer Rd ` Property Address , Thomas McCallum Owner Owner's Name information is + required for every Centerville MA 02632 9-12-2019 ' page. City/Town _ State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 61 �tf��� - on the computer, use only the tab Darrell Stone key to move your Name of Inspector , cursor-do not use the return Cape Cod Septic Inspection key. Company Name , P.O. Box 1466 reb Company Address Harwich Ma 02645 City/Town State Zip Code 2�� • '`ti (508) 240-2500 - S14995 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the.inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: .1. ® Passes 2. ❑ Conditionally Passes. 3. ❑ Needs Fu Evaluation b e Local JAp r wing Authority 4. ❑ Fails 9-14-2019 Inspec is Si ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board a 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 Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts ,. l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632' 9-12-2019 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: FQ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"snot determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•!Page 2 of 18 Commonwealth of Massachusetts p Title 5 official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments c % 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 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. e . ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will. pass inspection if(with approval of Board of.Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed , , , ❑ Y ❑ N ❑ ND (Explain below): - . ❑ distribution box is leveled.or replaced ❑ Y ❑ N ❑. ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed '❑ Y ❑ N ❑ ND (Explain below): �t. ii x, 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 - Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 e Commonwealth of Massachusetts Title 5 Official inspection Form V M1 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments c � 92 Nobadeer Rd V Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent.and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool 99 p t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ,F Title 5 official- Inspection Form to Subsurface Sewage Disposal System Form- Not for Voluntary Assessments - c %I 92 Nobadeer Rd u Property Address Thomas McCallum Owner Owner's Name information ati is required for every Centerville MA 02632 9-1 Z-2019 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 1/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E 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 t tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. t; ❑ ® 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.] -i t .e ❑ ® 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 CM 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be - necessary to correct the;failure.' 5) Large Systems: To be considered a large system the system must serve a facility with a -design flow of 10,000 gpd to-15,000 gpd. ,il I,.. - 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 rZone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 I ' I Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . % 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is Centerville MA 02632 9-12-2019 required for every 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? ® ❑ 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 infcrmation. 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)) 15insp.doc-rev.7/2612018 Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts , Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information m 1. Residential Flow Conditions: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom residential dwelling 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment.unit? ❑ Yes Z 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 Seasonaluse? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2018 - 5,500 cu-ft 2017- 5,000 cu ft . Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc a rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: '.5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information ati is every Centerville required for eve MA 02632 9-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system_ ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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 com pone nts,,date installed (if known)and source of information: 1984 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan):, Depth below grade: 20°+/- • feet Material of construction: ❑cast iron ®40 PVC :❑ other(explain): Distance from private water supply well or suction liner feet Comments (on condition of joints, venting, evidence of leakage, etc.): Apparent good condition 15insp.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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is Centerville MA 02632 9-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 6. Septic Tank(locate on site plan): Depth below grade: 14"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 gallon Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1/2 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Concrete outlet tee OK Recommended next maintenance pumping within 1.5 years Recommended maintenance pumping every 2-3 years t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments h• 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete D metal." ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design.Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c Commonwealth of Massachusetts �m Title 5 Official Inspection Form 'T Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is Centerville MA 02632 9-12-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 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 anc,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 ar:d distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Grade to box 38" Cover 21" 1 outlet No scum Normal liquid level No sign of leakage OK condition No sign of failure t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts lip Title 5 Official.-Inspection,i Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .1 - ............ % 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name - information is Centerville MA 02632 9-12-2019 required for every 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: ® leaching pits , number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system t Type/name of technology: A! t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 18 1 Commonwealth of Massachusetts s = ,9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 page. CitylTown 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.): 1 (6x6') pit with stone Grade to pit 32" Cover 21" Bottom 110" Ponding 36" of standing water Staining @8" higher No sign of hydraulic failure 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.): i5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts. 9 Title 5 Official Inspection Form I2 i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is required for every Centerville MA 02632 9-12-2019 page. City/Town State Zip Code Date of Inspection D. System information (cont.) 13. Privy (locate on site plan): Materials of construction: r Dimensions ~ Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): F . i S 1 + t t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts �M1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information is every Centerville required for eve MA 02632 9-12-2019 page. Cityrrown 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 I i REAR i I I G" room oh spa+u,bes 2- f; 3G- 2 - 3 24- Lo i 3G— 28- 2 p -- I i_ J I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M e 92 Nobadeer Rd Property Address Thomas McCallum Owner Owner's Name information ati is every Centerville required for eve MA 02632 9-12-2019 page. CitYgown State Zip Code Date of Inspection D. System Information (cost.) 15. Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4. 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: 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: See below You must describe how you established the high ground water elevation: x Elevations from USGS maps are approximate Property ELV. 68.0 Bottom of SAS ELV. 58.84 G W-E LV. 32.0 Adjustment= 1.2' Al W-247 Zone D 21.47' July 2019 Separation > 4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 k Commonwealth of Massachusetts ?� Title 5 official Inspection Foam � h Subsurface Sewage Disposal System Form - Not for Voluntary a Y Assessments u— 92 Nobadeer Rd Property Address -- Thomas McCallum Owner Owner's Name information is Centerville required for every MA 02632 9-12-2019 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 f5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-PEge 18 of 18 LOCATION 116- �.� ��- SEWAGE PERMIT NO. VILLAGE �Y�- 1 INSTA LLE'R'S NAME i ADDRESS R U I L D E R OR OWNER DA fE P ERMIT I S S U E D DATE COMPLIANCE ISSUED P Tr V I' ts �r f� JI COMMONWEALTH OF MASSACHUSETTS Z F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Y a DEPARTMENT OF ENVIRONMENTAL PROTECTION a o" 350 MAIN STREET WEST YARMOUTH,MA 508-775-2800 TITLE 5 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A ' CERTIFICATION ; MAP 250—PARC 142 Property Address: 921<40BADEER ROAD C— �w CENTERVILLE,MA 02632 S C— Ownner's Name: MOON.MARYJO Owner's Address: 92 NOBADEER ROAD cnl CENTERVILLE,MA 02632 Date of Inspection JUNE 16,2005 Name of Inspector:(please print 1 JAMES D.SEARS Company Name: A&B Canco cz3 M Mailing Address: 350 Main Street We::t Yarmouth,MA 02673 Telephone Number: 508 75.2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the p..oper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ./ Passes _ Conditionally Passes. Needs Further Evaluation by the Local Approving Authority ails Inspector's Signature: Date: The system inspector shall s iit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to'the system owner and copies sent tot he buyer,if applicable,and the approving authority. Notes and Comments 'This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15i2000 1 i Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: JUNE 16,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ./ _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310(MR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer ves,no or not determined(Y,N,ND)in the 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 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. ND explain: _ 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Title 5 Inspection Fortn 6/15/2000 2 A Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: JUNE 16,2005 C. Further Evaluation is Required by the Board of Health:N/A 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 salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the'presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 92 NOBADEER ROAD _ CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: DUNE 16, 2005 D. System Failure Criteria applicable to all systems: N/A 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 ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in pit is less than 6"below invert or available volume is less than''/z 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 N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply - N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.,The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the'system must service a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well. If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 'Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: JUNE 16,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components,.including the SAS,located on site? ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)has been determined based on: Yes No ✓ 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(3Xb)] Title 5 hispection Form 6/15/2000 5 Page 6 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: RUNE 16, 2005 ; FLOW CONDITIONS RESIDENTIAL,/ Number of Bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CTAR 15.203(for example: 110 gpd x#of bedrooms: 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): YES Is laundry on a separate sewage system(yes or no): NO (if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): ` Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: _N/A Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 1986—NEW D-BOX 6/05,PERMIT#2005—278. Were sewage odors detected when arriving at the site(yes or no): NO 4 _ 6 Title 5 Inspection Form 6/15/2000 6 a OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 NOBADEER ROAD CEN;TERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: JUNE 16,2005 BUILDING SEWER(locate on site plan): Depth below grade: 181, Materials of construction: Cast iron ✓ 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK(locate onsite plan): ✓ Depth below grade: 15" Material of construction: concrete metal fiberglass polyethylene _ other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000-GALLON PRE CAST Sludge depth: 3" Distance from top of sludge to the bottom of outlet tee or battle: 27" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum.to bottom of outlet tee or baffle: 16" How were dimensions determined: TAPE&PROBE 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 AT WORKING LEVEKL,INLET TEE—OUTLET BAFFLE. NO SIGN OF OVER LOADING OR LEAKAGE. GREASE TRAP(located on site plan) N/A Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Title 5 Inspection Form 6/15/2000 7- Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: DUNE 16,2005 TIGHT or HOLDING TANK: N/A (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/day Alarm present(yes or no) Alarm level: Alarm in working order(yes or no): Date of last pumping Comments(condition of alarm and float switches,etc.): 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.,): D-BOX IS 16"X 16"—30"BELOW GRADE WITH COVER AT 8",BOX IS NEW-6/05. ONE LINE IN—ONE LINE OUT. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump'chamber,condition of pumps and appurtenances,etc.): ' Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 " Owner: MOON,MARYJO Date of Inspection: JUNE 16, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 leaching chambers,number: leaching galleries,number leaching trenches,number,length leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system-Type/name of technology: r Continents(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) LEACHING IS ONE 1000-GALLON PRECAST PIT WITH COVER AT 3',6"OF WATER IN PIT NO HIGHER STAIN LINE.NO SIGN OF OVER LOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (cesspool must be pumped as part of inspectionX 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 or no): Comments(note condition of soil,signs of hydraulic failure,-level of ponding,condition of vegetation etc.): PRIVY: N/A ('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 5 Inspection Form 6/15/2000 9 r :'',.w....,.:.-+`.^�:.w:.. .,L.arm-.v.�.:.,,...s.w.s...„..u.:.a-...:w:..:,.:,�..:M..a::......,...�......_,._«,......,..r._o...............�. .,.__.. ...,.. ,.. .. Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO ' Date of Inspection: JUNE 16,2005 z 4 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. IP 3-'--r a -3 Spy, y o Title 5 Inspection Form 6/15,2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . 92 NOBADEER ROAD CENTERVILLE,MA 02632 Owner: MOON,MARYJO Date of Inspection: JUNE 16,2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to determine the high.ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: �— Observation 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: TEST HOLE AT 12'NO WATER. TEST HOLE Y BELOW BOTTOM OF PIT. BOTTOM OF PIT AT 9'BELOW GRADE. 9 3 Title 5 Inspection Form 6/15/2000 11 No. c;LM 5 c-:)-` Fee D THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for Ziopom.f bpgtem Cow6truction Permit Application for a Permit to Construct( . )Repair( grade( )Abandon( ) ❑Complete System E4 dtvidual Components Location Address or Lot No� n �® 8� y),V w O�///? Address and Tel.®O N Assess is Map/Paz ely C £yl— A Na 13,131 I Xle �T— Installer's Name,Address,and Tel.No. S6 8' 07 9s0,2 176 O Designer's Name,Address and Tel.No. 350 A- Sr Z4-- Type of Building: Dwelling No.of Bedrooms 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 Nature of Repairs or Alterations(Answer when applicable) 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 ed by this Board of Health. Sign d JDate ' d r Application Approved by Date Application Disapproved for the following reasons Permit No. ')-U© 5 7 Date Issued (�.��R�� ram/ Cr 4 No.. (�� Fee /O THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ,b Yes "t PUBLIC..HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Mi000l *pmem Con6truction Permit Application for a Permit to Construct( )Repair(Alouopgrade( )Abandon( ) ❑Complete System E91111vidual Components Location Address or Lot No �. Owner's Nam Address and Tel.No. AI P" Assessor's az ely C I"v'Q 4) Z �9 f Il/ Installer's Name,Address,and Tel.No. Q p ? 9 S 7410 Designer's Name,Address and Tel.No. w, i 3SO m- 5T w" yWlf !� Type of Building: Dwelling No.of Bedrooms Lot Size. sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) f Other Fixtures I Design Flow gallons per day. Calculated daily flow g g p y y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil ti _ Nature of Repairs or Alterations(Answer when applicable) oX 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 beeq-iss ed by this Board of Health. Signed Date Application Approved by Date (D ' Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( ' "Upgraded( ) Abandoned( )by A Y (!/91i C0 IS-0 IV41/;- 57- 4.4- at r /VQ 8A�11/Ir /P� C f ic•iT has been constructed in accordance with the provisions of Title 5 and the for Dis y sal System Construction Permit No. dated Installer 1tiz.- Designer . The issuance of this,permidshafi not be/construed as a guarantee that the sy t m wtl�fR►nctiott as designed. Date Inspector `�.�� --/"".."` — ����r--- Q .— � -:_ No. �W. 5 0 7 O ----- -------.------Fee— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Diopozat *proem Construction 'Permit Permission is hereby granted to Construct( )Repair( `Upgrade( )Abandon System located at g IV 0 IY,4_2) Z) _ C. F R✓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 ust be completed within three years of the,date of this pie Date:._ o Approved by