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HomeMy WebLinkAbout0010 OAKVIEW TERRACE - Health 10 Oakview Terrace Hyannis A= 269 - 240 03 e7 r I r III ,'I • i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 Oakview Terrace Hyannis, MA 02601 Owner's Name: Ivett Ortiz Owner's Address: Same Date of Inspection: August 9, 2001 , 1 Name of Inspector:(Please Print) James M. Ford Company Name: James M.Ford - 0\,NtA GBH pEPS Mailing Address: P.O.Box 49 P:260 Osterville,MA 02655-0049 Pa eel:240 Telephone-Number: (508)862-9400 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 proper 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 NeeckFurther Evaluation by the Local Approving Authority Fai Inspector's Signature: Date: August 9, 2001 The system inspector shall submiL 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 to the 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 6/15/2000 page 1 r Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ PART A CERTIFICATION (continued) Property Address: 10 Oakview Terrace Hyannis, MA r Owner: Ivett Ortiz _.. . . .. _. .. Date of Inspection: August 9, 2001 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: .11; 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 yes,no or not determined(Y,N,ND)in the for the following statements. If-"not determined",please 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. ND explain: Observation of sewage backup or breakout 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.brokii 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: f 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Oakview Terrace w. Hyannis, MA Owner: Ivett Ortiz - - Date of Inspection: August 9, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board'of Health(and Public Water Supplier,-if any)determines that the U 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 colifor•n 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: 3 - s . Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Oakview Terrace t i Hyannis, MA Owner: Ivett Ortiz Date of Inspection: August 9, 2001 D. System Failure Criteria applicable to all systems: You must indicate either`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 ciogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ available volume is less than '/Z da flow Liquid depth in cesspool is less than 6 below invert or y q P P _ ✓ 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:11 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. [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.] 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 System: To be considered a large system the system must serve 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 II 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 has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 r Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 Oakview Terrace _ Y� Hyannis, MA Owner: Ivett Ortiz _ Date of Inspection: August 9, 2001 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?(Owner•was not home) ✓ ' _ . 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: 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(3)(b)]. 5 c Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS ;SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . __,SYST=EM,INFORMATION Property Address: 10 Oakview Terrace Hyannis, MA _. Owner: Ivett Ortiz - Date of Inspection: August 9, 2001 FLOW CONDITIONS RESIDENTIAL - Number of bedrooms(design): 3 Number of bedrooms(actual): 3(per owner-rooms not inspected) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 4 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design.flow(seats%persons/sgff,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: Pumped on Sept. 25195 and Sept. 26195-per treatment plant 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) c Tight Tank Attach a copy of the DEP approval Other..:(describe): Approximate age of all components,date installed(if known)and source of information: September 18, 1980-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r - Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace Hyannis, MA _ Owner: Ivett Ortiz Date of Inspection: August 9, 2001 BUILDING SEWER(locate on site plan) Depth below grade: 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 on site plan) Depth below grade: 32" 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 gal. Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: 29".. Scum thickness: 6" - Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 9" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. The outlet cover was 6"below grade. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance rom'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.): 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: 10 Oakview Terrace r• t Hyannis, MA Owner: Ivett Ortiz _ Date of Inspection: August 9, 2001 TIGHT or HOLDING TANK: None (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.): DLSTRIBUTION-BOX: ✓ (if present must be•opened)(locate on-site plan) , Depth of liquid level above outlet invert: -- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-box was located but not dug up There were no signs of failure in the leach pit PUMP CHAMBER: None (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.): 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: 10 Oakview Terrace Hyannis, MA Owner: Ivett Ortiz Date of Inspection: August 9, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 6'x 6'w/1'stone leaching chambers,number: leaching galleries,number: leaching trenches,number,length: J leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system. Type/name of technology:_. _ Comments(note condition of soil,signs-of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had 1'of water on the bottom: 'The scum line was 3'up from'the bottom.. There were no si,nm'of failure.' The cover was 40"below grade. Recommend installing risers. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ti PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace r Hyannis, MA Owner: Ivett Ortiz Date of Inspection: August 9, 2001 Map:269 Parcel.240 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. A er:'A e6s C Al 33 3a- as 3 rq3- 3"l Aq- ' 3Vo 10 Page 11 of i l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace Ilyannis, MA _ Owner: Ivett Ortiz Date of Inspection: August 9, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the leach pit to grade was approximately 10. Using the Barnstable topographic map and the Cape Cod Commission water contours map, the maps were showing approximately 22'+/-to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report. 11 Page 10 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace Hyannis, AM Owner: Ivett Ortiz Date of Inspection: August 9, 2001 Map:269 Parcel.240 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. O Al - 33 O a Ao'- 3y �3a- as 3 jq3- 37 �3- a 6 AN y3• r 10 s uilt Page'1 of 1 u(s 'TOWN OF BARNSTABLL ,. LOCATION/Q �s►�ui P.cJ t rl' SEWAGE # VILLAGE �-. ASSESSOR'S MA S ORS q• Alt,i S P � LOT a•d �'y3 INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 ++i SEPTIC TANK CAPACITY Inner LEACHING FACILITY:(type) 4 i,040 C7 (size) 6,YI D NQ. OF BEDROOMS PRIVATE WELL O UB�,I��ATER BUILDER OR OWNER Gk'(>i'j,J DATE PERMIT ISSUED: 7 DATE COMPLIANCE ISSUED: 7 ` ' 23 VARIANCE GRANTED: Yes No j( i ,_d G_����Q 33` ts' •. rim ', http://issgl2/intranet/propdata/prebuilt.aspx?mappar=269240&seq=1 7/8/2010 ,. �0 9 Commonwealth of Massachusetts n do Executive Office of Environmental Affairs Department ® co JUN 1 6 Q NEnvironmental Protection to 1997 William F.Weld R pgT� Govemor Trudy Coxe 1 Secretory,EOEA David B. Struhs 350 MAIN ST,W. YAR U Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION MAP#269 PAR#240 PROPERTY ADDRESS: 10 Oakview Terrace, Hyannis ADDRESS OF OWNER: DATE OF INSPECTION: June 5, 1997 Quinn, Gilbert NAME OF INSPECTOR James D. Sears COMPANY NAME, ADDRESS AND TELEPHONE NUMBER: A&B CANCO, 350 MAIN STREET, WEST YARMOUTH, MA 02673 (508)775-2800 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 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS Inspector's Signature: Date: June 6, 1997 The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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, or C A] SYSTEM PASSES: X 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: N/A 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 NO). 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 conforming septic tank as approved by the Board of Health. (REVISED 11-03-95) One Winter Street Boston, Massachusetts 02108 Fax(617)556-1049 Phone(617)292-5500 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 B] SYSTEM CONDITIONALLY PASSES (continued) s s Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public 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 salt marsh 2) 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 SAFETY 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 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 bacterial 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. 3) OTHER 2 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined N/A in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. o _ 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 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 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. EJ LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: N/A The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exits: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to 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 or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ r PART B CHECKLIST Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 Check if the following have been done: X Pumping information was requested of the owner, occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the system has not been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection X As built plans have been obtained and examined. Note if they are not available with N/A X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. . e _ 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 FLOW CONDITIONS RESIDENTIAL: Design Flow: 330 gallons Number of bedrooms: 3 Number of current residents: 4 Garbage grinder(yes or no): NO Laundry connected to system (yes or no): YES Seasonal use (yes or no): NO Water meter readings, if available 95 800/96 2,300 Last date occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present:(yes or no) Industrial Waste Holding Tank present:(yes or no) Non-sanitary waste discharge to the Title 5 system:(yes or no) Water meter readings, if available: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of;nspection:(yes or no) NO If yes, volume pumped: gallons Reason for pumping TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes, attach previous inspection recods, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: AGE OF SYSTEM 1980 PERMIT#80-221 NEW PIT ADD 1993 PERMIT# 93-160 Sewage odors detected when arriving at the site:(yes or no) NO 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 SEPTIC TANK:_X_ (locate on site plan) Depth below grade: 30" Material of construction: X concrete metal FRP other(explain) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 11" Comments: (recommendation for pumping, condition of inlet and outlet tees ;or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) TANK AT WORKING LEVEL, INLET& OUTLET BOTH HAVE BAFFLES IN PLACE, BOTH COVERS ON TANK 6" BELOW GRADE GREASE TRAP: N/A (locate on site plan) Depth below grade: Material of construciton: concrete metal FRP 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: Comments: (recommendation for pumping,.condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 TIGHT OR HOLDING TANK:_N/A_ (locate on site plan) Depth below grade: Material of construciton: concrete metal FRP other(explain Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level,above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) D-BOX IS 16" X 21"40" BELOW GRADE, BOX IS NEW, CLEAN & SOLID. ONE LINE IN, TWO LINES OUT. e _ PUMP CHAMBER: NIA (locate on site plan) Pumps in working order:(yes or no) (note condition of pump chamber condition of pumps and appurtenances, etc.) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 SOIL ABSORPTION SYSTEM (SAS):_X_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: o leaching pits, number: 2 leaching chambers, number: leaching galleys, number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number: Comments:(note condition of soil, sic ns of hydraulic failure, level of ponding, condition of vegetation, etc.) PIT(1) IS PRE CAST, 4"WATER, PIT& COVER 42" BELOW GRADE, PIT(2) IS PRE CAST 6"WATER, PIT IS 4' BELOW GRADE, COVER IS 16" BELOW GRADE. CESSPOOLS:_N/A_ (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 cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) 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.) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 10 Oakview Terrace, Hyannis Owner: Quinn, Gilbert Date of Inspection: June 5, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' 3 7 OA/ O � ;2 37 P/T0 ° DEPTH TO GROUNDWATER m 4 Depth to groundwater: feet method of determination or approximation: LOT'S HIGH NO GROUND WATER PROBLEM 9 PERMIT NUMBER DATE COMPLETED BY HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 10 Oakview Terrace, Hyannis Lot No. Owner: Gilbert Quinn Address: Contractor: Address: Notes: Figure 13--Reproducible comutation form. 10 TOWN OF BARNSTABLE LOCATION J® DAkuiQ,4,j %err SEWAGE VILLAGE . __-./,�,�rl, S ASSESSOR'S MAP & LOT . V6 INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY loon LEACHING FACILITYAtype) 4 (size) 6,YO NO. OF BEDROOMS -3 PRIVATE WELL O UB ATER BUILDER OR OWNER cvU o,Jd DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 7 3 VARIANCE GRANTED: Yes No )C _ I W _ / 1 W � Uo � � e l NOJZ" ` :I_Aj Fps.. ?................. ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H EA LT t-O°'^ >>@ Fo TOWN OF BARNSTAB Appliration for Disposal larks Tonstrnr r i sY a Application is hereby made for a Permit to Construct ( ) or Repair (&/jan Individual Sewage Disposal System at: ....je -Ofl K t Lsw a .X.. ..............-------------------------------------- ----.----........................-. Location Address or Lot No. .�u 1v� 46 4—Bet d uS-�►N -----------------I-••----•------------•---••-....-------- ............................... .......---••..........--------•-------....... ..........--------.................__.....---- Owner Addres a .................`.........0��G-�•-------•--...-•---------•--•................. .......:.. 0 ....�R.4.....-- :...... ?.C�. .o©�-+-6............. Installer Address � feet Type of Building Size Lot............................S q. U Dwelling - No. of Bedrooms.._3............. .Ex anion Attic 0-4 Dwelling— ______________________ p ( ) Garbage Grinder ( ) a`4 Other—T e of Building ..._.. No. of persons........................ Showers YP g ---------------------= -----P ---- ( ) — Cafeteria ( ) dOther fixtures .---•---•---•---•-------------------------- -------------•--•--•-----••------•---•-....--------------------------..........---•-- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic 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. .I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_---_____-___-__-. 0-4 f14 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ a' ------------------------------------------------------- ------------------------- ------------- .------ --------------- ------------------------- -----------.----- O Description of Soil.................................................................................................................................................x U ........................ w U Nature of Repairs or Alterations—Answer when applicable. _______ __________ _ f.6©o --- --- -------�..__.--_---- - , �' ! ---- Y - --- ------------ -----. Agreement: The undersigned agrees to install the afored scribed Individual wage Disposal System in accordance with the provisions of TITLE 5 of the State Envir 'nme to Code—Th un signed further agrees not to place the system in operation until a Certificate of Corn nce has` een issued b board of health. Signed -- .... — 6 . ................. ........ ..-- ......----------- ...............................9 3 --........ .-----.. Date ,.. ApplicationApproved By -.................................... -----------------.............................................................--- -------------------- -------------- Dace Application Disapproved for the following reasons-- ---------- -- --------------..........-- . . -------------------- .................................................... ------------------------------- ------------------------------------------- --------------------- -- ------....................................................... --------------------------------------- Date Permit No. ------- t°� -- --------- Issued --....--.. !'`....- " - � 4 --Ark THE COMMONWEALTH OF MASSACHUSETTS a BOARD OF HEALTH TOWN OF BARNSTABLE,,e�/�lild - Applicafim is berthy me for a Permit to Cam nr Rxpak (✓�an Indiwidual Sewage Disposal SYM On 2tv flP� 1-' Y I or '%IFQ, Q 1 Q VD , r. �. 1� h�a �+c Rm. 0. q to o %M 1) 1) Type cE Building Sipe Lot � fed Dwid1ling—No- of Bedrxmins 3 Expansion Attu Garbage Grimm ( � Dflimr—Type of Building No. ofpersons—_ Showers ( � o lu r fixtmes Design vallons per person per day Total da4 1H 94 9 Sqbfic Tank—lL41miu$ ­�tF pncons ff:0qgttb Mrn Di�uunelter >_ »« Dismal Tom—No — Vida Total if�mmQ+ttAn Tel leg area e a EL Seqage Pit Diarneffer Depth lttdow inlet TOW leaching $tt. z Other b33K Dosing tank ( Penmbtion Tent Results performed Date _. Test Pelt No. 1 nttes pm-inch Din of Test lPntt Dew to gated witer. �4 Test Pit No. 2 mmutes per mmrh Depth of Test Pit Depth to "!jr Q.D Nature o�ff..�,,�" �or ' —fiver when w 1 C -o a nti -r,-Hn Akmemenr The undersigned agrees to ins=10 tthe aforedescribed 1ndividual Sewage Dismal Syswm in aonmdanee with the provisions of Tff n.E 5 of dh&Sttatte]Frnvia/nQmu d Code—The u unngned ffmurtthetr agmes not to phWe the nsw in operation until a ttua off Coffiissuedhz4mn issued Uy tthe mm bwrd of hultth_ Sig �, ` \ 9. Appfinuion Approved By Applicanon Dmapproved for the J®Illl®wng raffow Fe-_�tt No- - / � /44"�7 Issued THE CAMMCNOWEALTH OF MASSACHUSETrS BOARD OF HEALTH I TOWN OF BARNSTABLE tertfficab of TES IS TO CERTMY,11=the Individual Sewage Disposal,Systtem construcwd( ))or Repiff ed by . f-)� ` '�,> C_ra lJ C-0 at c�to ,K ► to �) p ►,�t has been installed in aarordanxe with the provisions of THE� ff The Sttatte Environmental Code as a��in dw alxpikattion for Dis�aIl WorksC.onstttrumon Feria No 1 — A415_ d..d �PrISSUANCENOTTHE ISSUANCE OF THIS CEMFICATE SHALL NOT Bf C6NSTI".UED AS A GUARANTEE THAT THE SYSTEM VALL FUNCTION SATIISIFACFORY. 4 DATE Inspecror THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No ✓� ��� TOWN OF BARNSTABLE F= loorks amdrotin Firmit Peron is harrhy granteda Fa n> C t to Consbuctt or R an ff djW Sewage Dismal Syst m at No t0 n A K as shown an the application for Disposal Wo;rHes C -eactkn � 'BBwd i' Of TOWN OF BARNSTABLE LOCATION 0 'r-G/IQa SEWAGE # VILLAGE 14�14 lei tl ASSESSOR'S MAP & LOT a Gcl' ayD INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /OVb LEACHING FACILITY: (type) (size) (X NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by S c. -ri Ur+ o 2 �a - A ` t O Aa� 3y �� ao A3- 3�7 (33- a y A y- y3. to (3q ' f� ,r 2 D� z/ LOCATION S E W A G i5PERMIT NO. VILLAGE I N S T LE '5 ,,� AME i ADDRESS � e o� pv t UILDE R OR OWNER DATE PERMIT ISSUED 7—ay DATE COMPLIANCE ISSUED �—. [�. �� � � J '� � 1�►. � o - I�- ��PrC� '� �. �{ z° ., 3 `�° �� No.. ... ._ - Fps.. ......................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEAL,"TH Appliratinn for Uiiipwi al Workii Tonsirurtiun Prrutit Application is hereby made for a Permit to Construct (V ) or Repair ( ) an Individual Sewage Disposal System at: 7Z�1z ACC ..... - AI)IA n/A/lS / 7> 2 •---------------------------• --------------------------- -------------------------------- -1--7 .............................................. Location-Address or Lot No CA-P,e✓C0;e V ,� 7-y v /93 Zy •vovG�/ rzoAb J-/y,4�✓.v�s •---• --- -•--- ------ -----------• ,�................................... ner Address Installer Address Type of Building Size Lot..`2®9 3_._____Sq. feet U Dwelling—No. of Bedrooms..........-�......:.......... _Expansion Attic ( ) Garbage Grinder (NOS) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ............................... .. Design Flow...............:�.5.__...._........._.gallons per person per day. Total daily flow.........._33 .........._.......gallons. W / ,0 n WSeptic Tank—Liquid capacltyld®�_gallons Length 43--6t,i_..... Width._4_��0h___. Diameter. ..(?...... Depth.,S._ ..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq, ft. Seepage Pit No................... Diameter-______-4� _______ Depth below inlet.... . Total leaching area._20�....sq. ft. Z Other Distribution box ( I ) Dosing tank ( ) `�' Percolation Test Results Performed by..__G_r_. 'Z.:_SNo{z?___________________________________ Date....................................... aTest Pit No. 1.._G._z____minutes per inch Depth of Test Pit...... 2.,..... Depth to-ground water_.AU----E-__----. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-4............... ?� x ••. O Description of Soil ©J. 2 Z-! •�-�'"�-------5�5--1C- --------------- :. ...__.... 2lZ'—/2' MEpivA4 Ce>AIZSE 5A.v/v V •--••-••-•---- -------------------------------•---------------•---------------•-............................................................. W ...................-........................................................................................------...----......------•----------------------------•----•--------•--••......--------•--- UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of"T`T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sid-• --------------•-••--• ................................ M' Da III Application Approved By......Aarl�/O.._.. G -7---------- --- ---------- ------- �`- - u"`�-------- Date Application Disapproved for the following reasons-..........................................-................................................................... •................••••-•-•----••--•-•-•••--••-••-----•---•••••-•-...--••••-•------••--------•--•••-•-....---•----------•--•------------------•••••••-----------------•--- ------•--•-•-•--•--••---- PermitNo...................................................... . Issued.......s&.01_'.. --.---------- No...................._.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH E `16 Wn/ n/ST G OF. � '' Appliratilau for Bhipoiial Works Tomitrur#tuu Prrutit Application is hereby made for a Permit to Construct (�) or Repair ( ) an Individual Sewage Disposal System at: ----- -•--•-••-•---------••-•-•-- LDS`--- --- .......................................... ......... t 3P, G J2�/ t Location- �e55 2v57" �`�-�'3 Iy.9n�Dv6 �... . Ny..... ... W _.' y . ... ...... .............. • caner .•---. Address a -•-----•............. Installer Address d Type of Building Size Lot....JZ--O-.. --.9-. ........Sq. feet U Dwelling No. of Bedrooms.......... .............................Expansion Attic ( ) Garbage Grinder (NO) Other—.'Type of Building No. of persons............................ Showers — Cafeteria a' Other fixtures .-----------•--•-------••---------•-•-- . -• ------ W Design,Flow................51�_....................gallons per person per day. Total daily flow..........3��-�-_-......................gallons. WSeptic Tank—Liquid capacity](70-Gallons'' Length.e__6_. ___ Width__4._10___. Diameter.--- ------ Depth_S_:A..... x Disposal Trench—No. .................... Width-------------------- Total Length......_............. Total leaching area....................sq. ft. Seepa6e Pit No......I............ Diameter........ ........ Depth below inlet.....C.......... Total leaching area... QQ....sq. ft. z Other bistribution box ( i ) Dosing tank ( ) `" Percolation Test Results Performed by G....!�� �c.............................................. Date........................................ Test Pit No. 1___``'_ ___-minutes per inch Depth of Test Pit......4 ,..... Depth to ground water..N4)��___..... ` Test Pit N3. 2................minutes per inch Depth of Test Pit.................... to ground waterAW4bY'*Z741?w ------------------- A .. --_---••-----•---------. ... ....-.t.......................................... Description of Soll --- ' 2, / ' M4,17ACl yr COA/SSE S�ir�/4> ......... ------------------------------•-• --•..... --------•••------•--• . -•-------------...--------------------------•--•-- W •--•-•-•-------------------------------------------••--•-•------------•----••-------------------••-----•------------------------• -------------•-•-----•------•--••-----•--•--•-•-----------------.... U Nature of Repairs or,Alterations—Answer when applicable--------------------------------------------------------------------------7.__...__.........._.. ................................... ................................................................................................ ....................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of y y 7"_,E 5 of the State Sanitary Code—The undersigned"furilwr agrees not to place the-system in operation until w.'Certificate of Compliance has been issued by the board of health. -...... F.. Da Application Approved BY --- 4�44 ---------------•----.--•- . -- " Dt�"�,'......--•-•- Date Application Disapproved for the following reasons-..................................................... ........................................... 17 •--'-".................•--------•-••-------•-------------,-------•---•-----M-�-------------------- �4 Date 71 PermitNo......................................................... Issued------..........--•----- .. --•-- •. •------- Date , t THE COMMONWEALTHIOF MASSACHUSETTS BOARD OF HEALTH To WA/ � ev ST4 63 Z_6 (1r -Iifirab of Tamixliaurr TH 19C7 .CE F at the Individual Sewage Disposal System constructed4�o__rRepaired ( ) M by F --- I r, Installer ► /� * �(j *1. has been installed in accordance with the provisions of T 5 of The State Sanitary Code as de cr'bed in the application for Disposal Works Construction Permit No. .._.... ........... dated..... .................. - THIE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEW WILL FUNCTION SAJISFACTORY. DATE.......... .. ................................................ Inspector........--..................................b....................................... P THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........7-�WN...............OF...... rrt? a ................................... ja No._ FEE.__......---�----- u��t1 u � tiuu rruti� Permission is herebyranted.----- i F'`g 1 f' to Construc (�or R it )�.an In 'v' ual Sewage _s osal System u at No.., �' 7 / 1Lr.,�a. �/� -- Street as shown on the application for Disposal Works Construction Per : ' No Dated...., '' _F_.......... ............. - Board of Healt DATE. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS . r - - • • i cam` �: - - A `~ - L�`?"�#irt . Y • - j ""�"" " � . J�':�' " -�N .iL'"��s.pt+•i„,IZ7�e:{T'df"[ltJ. Z •f4.. - �.. ...�, �� . Vf ` •L-+-+>rd '/r• d rfa••• ...•- e+.+,w.i_ ,;.ice.•,.^...., 1 ",''� h i - _ F .'t.'• - �7+. N.. ` ♦,. .`��,"y`[y" . _ __ t.• ap 17 srA n?S 7M�T . ' /3 u/4_01/vG S E7-L3ACk-_ CA L E �/ Q .. s F/20NT_ %Q Si Dom' /0 70.-E A . . P2c� o SED • . . BE_DlZOOiv1S SE P T/C 5 y5 Te_A1 CONS 7-/2 LAG T/ON SHAt L. 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