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HomeMy WebLinkAbout0100 OAK HILL ROAD - Health 100 OAK HILL RD. , HYANNIS IT S A = 248 064 I _ 1A, CL $ l n J j y t 6 � I o9'18-6tot/ Commonwealth of Massachusetts ol Title 5 Official Inspection Form aSubsurface Sewage Disposal System Form -Not for Voluntary Assessments ©a ire 2ci ram, Property Address II /' �' Owner Owner's Name l� : information is q 4415 V �, aPo l l0 la required for every -- page. Cityiii ovm State Zip Code Date of In pection _4 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 P A. Inspector Enf r anon s'� I3y�8 filling out forms � on the computer, use only the tab 12fr r key to move your Name of inspector cursor-do not , _yy1 o use the return Company Name ,/ / key. �Q J� i u Q Company Address Cityrown o� `8o Y- ` D State / �O�� P Zip Code d r Tele honk-Atumber License Number B. Certification ! certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); i 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;'Passes' sy 1. 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4_ ❑ Fails to a7 !nspect& Signature Date The system inspector shail submit a copy of this inspection -Feport to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This p i inspection does no t address how the system will perform in the future under the same or different conditions of use. ?;qe 5�_a.,rsPe von=c. Scbsurace sewage^:.�socsal Sys'am•Page of t8 'Sinsp.doc•rev.7125.;201e t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r. �% /00 Ou /�rl/ /Qd Property Address C �J Owner Owners Name /j�j /fl information is required for every page. Cityrrown State Zip Code Date of In ection C. Inspection Summary Inspection Summary: Complete 1, 4 3, or 5 and all of 4 and 6. I) System P sses: 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 then"Conditional Pass' section need too ed b replaced or repaired.The system: upon completion o, the replacement or repabe ir, as app y the Board of Health,will pass. Check the box for°yes': °no� or`not determined" (Y, N, ND)for the following statements. If"not determined,- please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic"tank will pass inspection if it is structurally sound; not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. 7 y I I; N ❑ ND (Explain below): i "ine 5 aa,,rspecncn=cr.:UO$LGa:e sevrge sposa System•?aye 2 of 18 tSinsG.3oc•rev.?252016 { 1 Commonwealth of Massachusetts Title 5 Official Inspection Form 3 P, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �D p Rd Property Address Owner Owners Name / information is ��S oa60� �0 a7 required for every � page. CityFFown State Zip Code Date of Ins ection C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or nigh 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 _J Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 limes 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): 1 obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health. ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: e 5;;',5da;,rspe^cn=er:S.;cscAace sewage oisposai system•Page 3 of t8 5insp.doc•rev.7/262018 Commonwealth of Massachusetts p Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /00 0011- A-11 /Qel Property Address Cres5ci Owner Owners Name A,! /j/JJ/ Od 6Ol /�1)nsp?ctjo information is //1required for every page. City/Town State Zip Code Date o C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 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 OCP 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 I`10 _ Backup of sewage into facility or system component due to overloaded or ogged SAS or cesspool _ Discharge or ponding of effluent to the surface of the ground or surface waters F I due to an overloaded or clogged SAS or cesspool Title =G:-:S�OSu,aGe SeWage:DiSPosa:Svsten.page<o:;8 i5in.p.eoc--ey.7262011 8 ti C� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments zoo as 4- *Q Property Address .S S Owner Owner's Name information is required for every page. Cityrown State Zip Code Date of Insp ction C. Inspection Summary (cost.) 4) System Failure Criteria Applicable to All Systems: (cont.) i 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 5' below invert or available volume is less than%day flow —� Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion-of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public water supply u weft_ 1 II 1 Any portion of a cesspool or privy is within 50 feet of a private water supply well. `i 1 6 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.] 1-7 V'/_ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. The system faits. l have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303:therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate erher'yes; or �no-to each of the following, in addition to the questions in Section C.4. Yes No 7 � the system is within 400 feet of a surface drinking water supply 17 time 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 El Area—IWPA)or a mapped Zone It of a public water supply well 5 ids;nsp Cr.Fan:Suosu-ace Sewace D sposal System•pa]e 5 of t8 ;5insp_dx•rev.71262018 Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ /00 Property Addressr-re c SJ cl Owner Owner's Name / 4/ ' 0.?ay /o information is 4 a required for every page. CitylTown State Zip Code Date of I pection C. Inspection Summary (cons.) 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 o mping information was provided by the owner, occupant, or Board of Health ere any of the system components pumped out in the previous two weeks? Q I as 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? i Were as built plans of the system obtained and examined? (if they were not available note as N/A) I Was the facility or dwelling inspected for signs of sewage back up? i — Was the site inspected for signs of break out? J Were all system components, excluding the SAS, located on site? i J 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 een determined based on: Existing information. For example. a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue PP a roximation of distance is unacceptable)(310 CMR 15.302(5)1 ce sewage Disposal syste, ?age 5 of ee SinsR3a'2v.?2520�8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address C'e—tc Owner Owner's Name information is 61 required for every I� page. City/Town State Zip Code Date of Insp ction D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): 'Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /�� tJ4`/ SP fc- AN Lj/ 15 P6C�O� �J OT D Number of current residents: Does residence nave a garbage grinder? Yes No I Does residence have a water treatment unit? ❑ Yes No if yes; discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) I Yes No Laundry system inspected? ❑ Yes No Seasonal use? Water meter readings; if available (last 2 years usage (gpd)): Detail: I ❑ Yes No Sump pump? Last date of occupancy: Date I -_ `c21:rspecor:=c,-..S='-su`ace 5eWa9e:)15PC5a3 Sys;e- peye 7 of 18 ;Sinsp.tloc•rev.726,2018 Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /00 ©Gl,� fir�� 9cl Property Address Cress Owner Owner's Name information is required for every 42 Nib/ �9 oa 6 0/ /Q O� / page. City/Town State Zip Code Date of Insp 'on D. System nforma#ion (cont.) Z. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 1 b.203): Gallons per day(god) 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 occupancyluse: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as par of the inspection? ❑ Yes o if yes, volume pumped: gaiions How was quantity pumped determined? Reason for pumping: G" :-aaj s-_eCZon For:Suosaraoe Sewage:)isposa�system•?age 8 of 18 5insp.00c rev.'262ps8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ccess Owner :Owne;�s Name �� V ` O a information is grPlIff r required for every State Zip Code Date of In ection page. wn. System nformation (cont.) 4. Type of S em: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool I Privy [� Shared system (yes or no) (if yes: attach previous inspection recordsi if any) J InnovativeiAlternative 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 DER approval. Lj Other (describe). Approxim to age of all components: date installed (if known) an/ urc�,Af informal/ / Were sewage odors detected when arriving at the site? �] Yes 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: cast iron �40PVC ❑ other(explain): l Distance from private water supply well or suction line. {eet Comments (on condition of joints. venting, evidence of leakage, etc.): ?age 9 0l i8 3 c2i uc 9scr!ace sewage o1sposa Systen -,fie • t5in5p.doo•rev.726/2018 Commonwealth of Massachusetts e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /00 C� Property Address Owner Owner's Name information is Qi��l f 0P60 /o a�Ily required for every page. City/Town State Zip Code Date of nspectio D. System Information (cons.) 6. Septic Tank (locate on site plan): as Depth below grade: feet Matena ' construction: concrete ❑ metal J fiberglass " polyethylene ❑ other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Ye s No Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle A10 <Sc u r .7 Scum thickness Distance from Lop of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee-or baffle How were dimensions determined? Comments (on pumping recommendations, iniet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Q 0 CpN�ITlO✓� _!tle 5 ao Insp'coc Scosu=ace Sewage Disposal system•Page 10 of to t5insp.doo-rev.712612018 C Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cuss Owner Owner's Name Q� O/ �O information is G a l� i f required for every _O page. City/Town State Zio Code Date of 14pectiorf D. System information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction.- concrete ❑ metal fiberglass i ii 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. fiber lass polyethylene ❑other(explain): 71 concrete !I I metal 9 Dimensions: Capacity: gallons Design flow: galions Per day. 5�e 5�`ca::;spr on For Scosc'ace sewage:)sposai system,.•Page i i of 7a :5i,p.cioc-rev.726,2018 Commonwealth of Massachusetts Title 5 Official Inspection Form jot Subsurface Sewage Disposal System Form -Not for Voluntary Assessments F /0 O ©A IV- Property Address �e ss Owner owners Name /O / information is arwl��--_ (/ required for every State Zip Code Date of In ection page Cityi?own D. System Information (cons.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan : h Depth of liquid level above outiet invert comments (note if box i or out of box s level and trib )ion to outlets equal, any evidence of solids carryover, any evidence of leakage So!I S I Fc-.SeOs.:'ace Sewzae DisPo sal system•?age 12 of 18 TcBe 5 aal:1spenon 5insp.Coc•rev.712&2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /00 OAS , Xd Property Address Owner Owners Name NN/ / ,/� oa6o, /D a information is required for every page. City/Town State Zip Code Date of Ins edon D. SystenT 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: CA 4ri y�� S11 Type: .3 (CWAle c.S m ieachin number: `; g pits 717 ieaching chambers number: 7 11 leaching galleries number: ' leaching trenches number, length: eaching ieids number; dimensions: i I overflow cesspool number: L innovativeialtemative system chnology Type/Hama of te _ ----Se — �9e u�spOSai Sy5[En'P89e 5i,p.roc•rev.'/26r078 Commonwealth of Massachusetts Title 5 Official inspection Form �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t,1"vil Property Address Bess Owner owner's Name information is required for every page. CitylT wn State Zip Code Date of l pectin D. System information (cons.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc_): J! S OT 14, /'Qtwlt�- Gljly� . I 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 1 Yes 17.. No Comments (note condition of soil, signs of hydraulic failure: levei of ponding, condition of vegetation, etc.): -::;e s :tea: =spr_-�o, o,-.-.S�cs�. Sewage Oisaosa'SYs.em.Sege a of 8 SinsP.tloC•n:v.726-201 a_ Commonwealth of Massachusetts Title- 5 Official Inspection Form r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Loo Oak,- da Ad Property Address C✓ess Owner Owners Name information is �� Q,6o/ /O 1 9 .Q required for every Al fy` N page. City/Town State Zip Code Date of specti D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, --ondition of vegetation, etc.): i 'tee tiaa::nseec�on`a :.5'-,s,eace sewage Jrsposa!System•?age 15 of 78 t5insPt�'tec.'1262ot8 l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �V /00 Lea�✓ l� �� �o� Property Address t SS' Owner Owner's NameH-17as4#11-f linformation is " D�6�/ /0required for every ! d page. Cityi rows State Zip Code Date of! pectin D. System Information (cons.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks o enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the bull ' . Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately i 1 ' I I I — 1�,45 /Soo 6,wflo�i j. I go � •-�_ . , - _oft-� - a 5 p"ca -or—'':suOscrFaae se+vage Dspasal system•Page 16 of t8 t5insp.Oce•rev.7/25/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /00 .Oct � �1 Act Property Address Owner Owners Name O�c O information is required for every page. Cityrrown State Zip Code Date of Ins6ection D. System Information (cons.) 15. Site Exam: _ Check Slope Surface water Ji Check ceiiar Shallow wells do Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water eievation: 71 Obtained from system design plans on record if checked; date of design plan reviewed: Date 1 bserved site (abutting properryiobservation hole within 150 feet of SAS) Checked with iioar_d�f Health - explain: A/V —S Checked with local excavators; installers- (attach documentation) Accessed USGS database- explain: You must descr how you as ablished the high ground wager elevation:: a� 1�_J 13 7 OG Jfo Before filing this Inspection Report, please see Report Gompleteness Checklist on next page. 'c...Suos_r"zce Se"age ois?osai System•?age 1.7 0{18 5insp.3oc•:ev.'252078 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address ess Owner Owners Name /�f A 0/ /O a 9 1 e information is ,/`r �n r required for every State Zip Code Date off pection page City(rown E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Te-A."Inspector Information: Complete all fields in this section. Certification: Signed & Dated and 1, 2; 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 ilure 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 Su., .s rac Sewage posal S751em•page tc of t6 'iue 3 t6i,p.00c•rev.726/2056 TOWN OF BARNSTABLE LOCATIONJ�0//� AVID IPA SEWAGE# -�-2— \!.JLLAGE ��j�/1 ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO.022/-C. iPO6,"V f o>d- Z 7.1" 6r 7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) CO-Z 71-Ce' (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: G S� �° COMPLIANCE DATE: Id-/—W 9 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.fee JI Feet Furnished by- x "J No. FARCM N �+ Fee $5 0 . 0 0 HE COMMONWEALT ETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migpool bpgtem Congtruction Permit Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5—1 6 3 4 100 Oak Hill Road, Hyannis David Chisholm, Hyannis Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm.E. Robinson Sr. , Septic Srv. P.O. Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(no) 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 septic system c o n s i s t i ncr of 1500 gal , tank, D—box, and three #330 infiltrators. 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 gu Oo4d Qf Health. Signed Date�d� " _ C/ Application Approved by Date �,o�• Application Disapproved for the following reasons Permit No. Date Issued lin No. �b"•,/ .+C� / Fee $50.00 THE COMMONWEALTH OF MASSACHUSETTS. UBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS . apolication for Migoar *pgtem Construction Permit , Application is hereby made for a Permit to Construct( )or Repair( X)an On-site Sewage Disposal System at: b. d df Location Address or Lot No. Owner's Name,Address and Tel.No. 7 7 5—1 6 3 4 100 Oak Hill Road, Hyannis, --. , David Chisholm, Hyannis , 4; Assessor's Map/Parcel Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. Wm.E. Robinson Sr. , Septic Srv. P.O. Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(no) 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,. a, A. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title 5 septic system consittinq of 1500 gal. tank, D-box, and three #330 infiltratorsa 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 o gf Health. c- Signed DateA6`�y _� Application Approved by � J Date ./A-> V, �71� Application Disapproved for the following reasons Permit No. 7 b ;9 Date Issued Z4^;Z 7-- ,4705, THE COMMONWEALTH OF MASSACHUSETTS z BARNSTABLE, MASSACHUSETTS Certificate of Cony Chisholm fiance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( X)on by Installer Wm.E. Robinson Sr. , Septic Srv. at 100 Oak Hill Rd. , Hyannis has been constructed in accordance with the provisions of Title 5 and the-for Disposal System Construction. ermit No. f�dated � r ^� Date s1�,��f�.?'' Inspector V�l C e THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYS- TEM WILL FUNCTION SATISFACTORY. No. -'- ---.---------------------- Fee 50.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS Chisholm Mi.5pozat *potem Construction Permit Permission is hereby granted to Wm.E. Robinson Sr. , Septic Srv. to construct( )repair( X)an On-site Sewage System located at No.# 1 0 0 Oak Hill Rr9. Hyannii, MA street and as described in the above Application for Disposal System Construction Permit. No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. - Date: ,il � 1� Approved by Board of Health f Q4 CERTMCATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) I,William E. Robinson, Sr.-,hereby certify that the application for disposal works construction permit signed by me dated lJ nc- -1 z concerning the property located at 100 Oak Hill Read,Hyannis meets all of the following criteria: * There are no wetlands within 300 feet of the proposed septic system. * There are no private wells within 150 feet of the proposed septic system. * The obseved groundwater table is 14 feet or greater below the bottom of the leaching facility. • There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. r SIGNED: ZIG-11 1 DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification plot plan,this plan should be submitted). �� � ` P L_- �� 1 _�1 ' 4 r� III - a Commonwealth of Massachusetts Npl/ Executive Office of Environmental Affairs S Department of _° Environmental ProtectionX, WWlam F.Weld , Trudy Coxe Goranor `r Bohr" Arp m Paul Celluoci David B.Strube LL(ioranor CpmtlWorrr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION propertyAddreas- 100 Oak Hill Rd. , Hyannis Address of Owner. David Chisholm Data of inspection:.S,0—//Tp 4 (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6 W.E. Robinson Septic Service P.O. Box 1089 Centerville MA 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _�Paasea _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: A 1 Y Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. U 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A,B. C,or D: A) SYS PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) I One Winter Street a Boston,Massachusetts 02106 a FAX(617)-556-1049 a Telephom(617)292.55M t�Printed on Recycled Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 0 0 Oak Hill Rd. , Hyannis Owner. David Chisholm Date of Inspection: /•�</—�} B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed m the distribution box is due to broken or obstructed pipe(e)or due to a broken,settled or uneven distribution box. The system will pars inspection Health): if(with approval of the Bored of broken pipe(@)are replaced obstruction in removed distribution box is levelled or replaced The system requumed pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the lic health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _, Cesspool or privy is within 50 feet of a.surface water Cesspool or privy is within 50 feet of a bordering vegetated.wetland or a aalt marsh. 8, SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free 3) tfrom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. OEIR (revised 11/03/95) 2 r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropertyAddrem 100 Oak Hill Rd. , Hyannis Owner. David Chisholm Date of Inspection: DI SYSTEM FAILS: determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The beds for determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the Backup of sewage into facility or system component due to an 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 oesspool. Liquid depth in cesspool is less than 6"below invert or available volume is Is"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 Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed:to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE TEM FAILS: e following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply y the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner r operator of any such system shall bring the system and facility into iurll compliance with the groundwater treatment program requiremen of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.. . y` � 3 • (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECMUST PeoperlyAddrew 100 Oak Hill Rd. , Hyannis owner. David Chisholm Date of Impeedow 1/l cl— 1 4 Cbeck if the following have been done: ing information was requested of the owner,occupant,and Board of Health. . one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. b(The facility or dwelling was inspected for signs of sewage back-up. _Z Ae system does not receive non-sanitary or industrial waste flow _�Ae site was inspected for signs of breakout. system components, excluding the Soil Absorption System, have been located on the site. _L,2 a septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge, depth of scum. size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PropertyAddebsm 100 Oak Hill Rd. , Hyannis owner. David Ch ' sholm Date of Inspection: / �`1-� FLOW CONDITIONS REST ENTW: Design flow: �ilons Number of bedrooms: Number of current reeidents:1—t— Garbage grinder(yes or no):-.i-� Laundry connected to system(yes or no):Yc S Seasonal use(yes or no): N O Water meter readings,if available: 1995 - 12 , 500 cubic f t.1996 100400 tihi fi - Last date of occupancy: COMMERCIALANDUSTRIAL: Type of establishment: Design flow:_ allons/day Grease trap present: (yea or no)_ Industrial Wage Holding Tank present: (yes or no)_ Non4anitary waste discharged to the Title 5 system: (yea or no)_ Water meter readings,if available: Lest date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no).,4;" If yes,volume pumped: :L6 gallons Reaso for pumpi& TYPE O 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) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source of information: .140 Sewage odors detected when arriving at the site: (yes or no) /L (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddrew 100 Oak Hill Rd. , Hyannis Owner. David Chisholm Date of Inspection: SEPTIC TANK: (locate on site plan) Depth below �I - Material of conabuction:_concrete_metal_Fl3P_other(e:plaia) Dimensions: /_ 1 Sludge depth. Distance from top of sludge to bottom of outlet tee or baffler scum thickness: 0 Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: (5 _ Comments: (recommendation for pumping,condition of inlet and outlet tees or b ,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) G TRAP: (locate o site plan) Depth be grade: Material o construction:_concrete_metal_FRP_other(explain) Dimens' Scum Som top of scum to top of outlet tee or bafn fie=bottom of scum to bottom of outlet tee or baffle: Comments ( for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence leakage,etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 0 0 Oak Hill Rd. , Hyannis Owner. David Chisholm Date of Inspection: - II TI OR HOLDING TAN&v (bate site plan) Depa �: Material oonstrudion:_concrete_metal_FRP_other(ezplaia) Ca gallons Design sallons/day Alarm Comments (oonditio of inlet tee,condition of alarm and float switches,etcJ DISTRIBUTION BOX-&/ (locate on site plan) Depth of liquid level above outlet invert:_ Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of bos,etc.) PUMPtin :' ER_ (locate n) . Pumps order.(yes or no) Comma(note cf pump chamber,condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) pmperjyAddraw 100 Oak Hill Rd. , Hyannis Owner. David Chisholm Date of Inspection: //—/Y-9 4, SOIL ABSORPTION SYSTEM(SAS): (locate on she plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: kechia8 pits,number: leaching chambers,number_: — 3 3 p C a /' / ��S S Inchon g galleries,number: / leaching trenches,number,length: leeching fields,number,dimensions: overflow cesspool,number• t ra Comments: (note condition of soil of hydraulic failure, level of ponding,condition of vegetation,etc.) 16 CESS LS:_ (locate site plan) Number configuration: Depth 'op f liquid to inlet invert Depth of lids layer. Depth of layer: of cesspool: Materials construction: of groundwater: inflow(cesspool must be pumped as part of inspection) i Comments: ( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc. PRIVY:_ (locate on plan) Materials construction:........ Dimensions: Depth of so Commcnti:( condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) (revised ll/03/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 100 Oak Hill Rd. , Hyannis Owner. David Chisholm Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at beast two permanent references landmarks or bench-ark locate all wells within 100' 71 �IILo r l i J 4 0 I 1 I r -I DEPTH TO GROUNDWATER Depth to rva dwater. `h feet / method of determiaation or approximation: 'Ii lqa it? (revised 11/03/95) 9 TOWN OF BARNSTABLE LOCATION ,() Are �, 7-�� i I je&/ SEWAGE # nr o _ VILLAGE -,/ A ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) ( 6 6 (iz�ie NO. OF BEDROOMS ' PRIVATE WELL OR PUBLIC WATER )-b cum BUILDER OR OWNER C �� l S d.✓� DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:- 1 vZ- `- c� U VARIANCE GRANTED: Yes No �/ i .c 9 `,` 1 3ttt �, . ._: � � i =w, t ' it No.... $30.00 .. ......_....... Fps............._...._...... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALT A TOWN OF BARNSTABLE Commm. Appliration for Uhi n a1 Works T1 J5 0 )an u Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at: d.....[.---...Ii�ranAis.tom............... .................................................................................................. ... �1. L.r or Lot No..... ............... .. L t• s David .... Owner A dress W W.E. Robinson Septic Service P.O. Box 1089 Cen'erville MA 02632 ,-1 ---...7n. ,.... Installer Address Type of Building Size Lot............................Sq: feet Dwelling—No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ---------------------------------------•---•----------•-••--------•--••-----------------------•----------••------•......------........--------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ ...-•-------------------••---•---•--•-------•-------••-•---------•••--------••--•......-----•................................................................O Description of Soil----------sancl,_znd--gr-a.Sze -------------------------------•--------------------------------- x W x ----•------•..........••------•-•--------••---•-•------------------•----•••-•-----------••--------•-----•-------------------•••-----•••-----------••-•---•-----•--•------•---••-•----•-••-•............ U Nature of Repairs or Alterations—Answer when applicable__precast..stme- packed_overflow...................... ----------------------------•---------------------------------------...-------••••---------...•-------•-----••-----••--••-•----•----------••--•------•------------•-----•-------------......--•-------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by bo d of health. Si ned ...= 6- ` I=-----�7--/- - - ApplicationApproved By ... ........................ ... .................'-----........... ......................................... Dare Application Disapproved for the following reasons- ------ ----- ------ ------........----------...--- -- ----...................--- ------------------ ----...--------- ---------------- ------------- Permit No- --- ---------- v ..........-- Issued .........------------.....-- Dare Dare a�-6� , as _ No.. .............. D Fly$....$30.00...._. b I THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE Applutt#aon for DaopoiiFal orki Trinb% .ion mit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ri;i UY9 .,; nrt .........,..,c!,�f?�=-----�-----,�--1�"�.-7--...----••--1�-�r.�-=mom---_�;............... .................................•--..._....------...-------•-------..................._...------- Lo tiou-'Add r s or Lot No. .................. ..........--...................................................................................... Owner Address a W.E. Robinson.Septic.Seryice PvO. Box 1089_Centervlle MA 02632 Installer Address Type of Building Size Lot____ ..__ __...Sq. feet Dwelling—No. of Bedrooms._........3...............................Expansion Attic ( ) Garbage Grinder ( ) PL4Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ------------------------------•. . w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter----.--------....... Depth below inlet.................... Total leaching area..................sq. ft. Z_ Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •-•-••••-•••----------------•••---•-•-••-----••••---•••••....--••-•-•-••.............•-••--.._...---........................................................ 0 Description of Soil.........-�-_n an-d--g-rave7-----------•-•----------------••------------------------------- x �., -••••-•••-•••-----•-•--••-••--•----•--•--•--•-•-•----•-•••--••-•----•----•--•-••-•-•...........•-----•-••---•---••••••••-•---•-•-•-••---••---•---•-••----•---•----•.................•----••-•-•---•..... w UNature of Repairs or Alterations—Answer when applicable---pre-el ast.-!%tanne_moked..nm rf1 mow...................... ------•-••------------------•--------------------------------------------------•---••--------•_.....---••--••---•••-•••-•••-•---••-•--•••••••--••••--•--•--••----•••---•---•--------• -------------- Agreement: �- The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by -•e bo fd of health. Signed ... ......... . ........ . ....---. ................--... .,..... 9i- .:. Date Application Approved By _- ----- ----- ---------- Date Application Disapproved for the following reasons- ------------------------------------------------------------------------- ------- - --------------------------------- ------- ....................................-------------------------------------------------------------------- --------------------------------- Permit No. V Issued Date ------.... . ........J. .....---.-........---'-Dare-------------......................... COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Trez#tft att of (111ontyli xnce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X ) by...... F`- F2n1Zinso --Septic-Set-vice-------------------------------.- Installer at -------1.00-Oak.-Hi11...Rd. Hyannis-MA has been installed in accordance with the provisions of TITLE�)The State n ironmental Code as described in the application for Disposal Works Construction Permit No. r dated ................................................ i --- --- -- THE ISSUANCE OF THIS CERTIFICATE,SHALL NOT BE CONSTRUED,AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAJjCTORyt, -- Inspector -DATE -r /THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a� TOWN OF BARNSTABLE No..�_�................... FEE.ae .MO........ Disposal Workii C�onar ion ami# Permission is hereby granted...... ................................................................... to Construct ( ) or Repair ( X) an Individual Sewage Disposal System atNo........ --••-•--•-•--•-----•--- . •••- .:== - - -r .... Street Y� Q G� as shown on the application for ,isposal Works Construction Permit No� z��• Dated.._��� ! .� ------------------------------;�--a - J � , . ; ?) oard o Health DATE. , •. --••--�--••••-------•--•--••--------•• aY FORM 36508 HOBBS Q WARREN,INC.,PUBLISHERS