HomeMy WebLinkAbout0104 PITCHER'S WAY - Health 104 PITCHER'S-WAY, HYANNIS
A/289 060.002
o
�r
L ® CATION SEWAGE PERMIT NO.
VILLAGE
INS TA LLER'S NAME & ADDRESS
LI-V 5 7- a
BUILDER ®R AWME
DATE PERMIT ISSUED
DATE C0 PLIAMCE ISSUED ���
i
I `;
h
� `eo
�� - � � �
•, � � �
`^ `� (� � I
�'
�\
y i
V
No......--.._�? Fina........ .-/...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
- .. ... ....................OF......-,.1.. ....................
ApplirFation for Uispuual Works ( omitrurtinu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Systemat --...� ..............................................................
Locat' n-Ad ress � or Lot No...
. .._
el Own �—, �/,� / Address
a ...................- ----- _..._.._...--•--- .._...
InsKner Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms________________________________ _____Expansion A is ( ) Garbage Grinder ( )
U
Other—T e of Building No. of persons_._____.__ .......... Showers — Cafeteria
a' Other fixtures _________________________
-------------------------------------------- -._._...._.__..__......__..
W Design Flow............................................gallons per person per day. Total daily flow..._............ . __(3...........gallons.
WSeptic Tank—Liquid capacity„A allons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_.-.........._//___j--.sq. ft.
Seepage Pit No____________ ____ Diameter.................... Depth below inlet....._.............. Total leaching area��__�p_7---sq. ft.
Z Other Distribution box ( ) Dosing tan",.,) L
`~ Percolation Test Results Performed b Date__________
y -� = `ice
Test Pit No. i f inutes per inch Depth of Test Pit____________________ Depth to ground water........................
(s, Test Pit No. 2_�_7V`minutes per inch Depth of Test Pit____________________ Depth to ground water_______________________-
---------------------------•-------••---.._..---••-----__-----
0 Description of Soil.....i�. ------- ..... ---••--•---•--•----•-•--•---•-----------•-•-----••-•••--•=-•-•--•-----•-••--••-----•-_-----
x
V -----------
-----------------------------------------------------------------------------------------
•-------------------------------------------------------------------------------------
••----•-----
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
--------------------•---•-------------------•--------------------•----------------------------------------------------------•••---•---.-------------------------------------------------...-------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL4: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has 4issbyte rd e.alth.Signed--. -- ---- ------ -----------------------•---•-•------•--
-•-•----------------------------
Application Approved By.---•------ -•- • •-•-----•------••-•------...•-•---•---- �.. ............
Date
Application Disapproved for the following reasons:.....................................................................................---------------------•----
•-------------•--•--------...-••-.._-------...---•••----•-•-----•------------••------.......•••------_....
Date
PermitNo......................................................... Issued_.......................................................
Date
No....... . � . -' _ Fes$...... ............_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
is� _
Appliration for Bispaoal Works Towitrartion Famit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: �,
- --
--•.Lo:ation-.Addr ss r Lot No.
• �-�'�% 11..gl - .............
W �/Y
Address
Ow r .�✓ C/ ........................... ..........................................
Insta er Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................. _----Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............................ No. of persons.....__ _ Showers — Cafeteria
Gi Other fixtures -------------------------------- -
Design Flow............................................gallons per person per day. Total daily flow.............3..3_..Q_...........gallons.
WSeptic Tank—Liquid capacity/WCgallons 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... 4.5_r..sq. ft.
Z Other Distribution box ( ) Dosing tank
'-' Percolation Test Results Performed by--------- l z..-�-=. __ Date.......
Test Pit No. k.1A.-minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs, Test Pit No. 2..........If 'minutes per inch Depth of Test Pit.................... Depth to ground water_._________-___---_____.
P ------•-----------------------------------------------•---•---------------•----•-------•.....--.............................................................
0 Description of Soil:.....::: :..:..
x / (v U/c G
U -•------------------•• ------------ .------------------------------------------------------
..----------- -•------------------------ -
W -•-------------------- --•-•-------------...._....---------.........................-•----.........----•----...------.._....__._....----.........-----•----••--•--•......•••-- .....................
U Nature of Repairs or Alterations—Answer when applicable.._____.........................................................................................
-------------------------------------------•-------•----•------------------------------...---.-•....-•-•----•-----------•----------•------••--••••••--••--•------••---•---•--------------------•-•-.----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1Z 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss bWerd ealth.Signed ....�( -r....,
DES,
Application Approved By--------- ---------------••-----------------................',��'...f------....---
Date
Application Disapproved for the following reasons:-------•---•------------••---•-----------------•----•-------•--•----•----------------------------------:....._..
--------•-•--•---••--•-•--••---------------------------------------------------------------------
Date
PermitNo..........................---------------------......... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trr ifirab of Toutphattrr
THIS IS TO CERTIFY, hat the I dividu Sewa e Disposal System constructed l�Yor Repaired ( )
C y�,�� ` .,g•
I�nstaller
at. ....................-�.r.-�..---• - ✓-------- ------` � '
has been installed in accordance with the provisions of IrTLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___. ` __.eC7',el.._..... dated_ __..._.____....................
THE ISSUA CE F THIS CERTIFICATE SHALL NOT BE CONSTRUE A GUARANTEE THAT THE
SYSTEM, 19dlIL /FU'f ON SATISFACTORY.
DATE �' ----------------------•-------••-•------.--------. Inspector ------.....-•----•----•-----------------------•--•........._....--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.........................y_...._._.._........_...................................... :k C�
r
No. � FEE........l--f�.........
RoporsttlI
rri9ti
Permission is hereby granted---- `r?; ��........ `-'1 .. tn knl...........................................
to Construct) or Re ) an Individual Sewage Dis osal System
at - •--•--------•-------------------------------
Street
as shown on the applicati for Disposal Works Construction- Permit No..VABoard
.`___. Dated4.........................................
.. : .. _------------------------- ----
of Health
DATE.. ��-�c --•------ -------•--•-----------•---•................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
„.yN$•;- ^'v}':x.J..hvf.!' .;.: 4Cr: - .».:'w.,; R. r N ...
/ i FOl.J D`
Lo T �
your r=; w4 no�J o7. 2 5.
IL F-
O 5, 14o s.F”��e'r AI.1D
o �--_.• _
N LOT
� m
32 . F 119
r
q�q NOTE:rrhs AVCA N
Is NOT-ro Be 0 is= Q
n,QRxfl w 1TMOUT.F1L1Q6 ,
Pea\NenAf.104 /1GT ,pp LO T
Z
U t� ti
T.
Imo .
IL
1` 'S£STIIotg
j(k O F MA S
/ S
3.i3D¢An ? t1dE'L v ;! .. ORSE U)
�N�IL�IIJb� Q � � �w I No.10951�0
I �I�1�.5 pe Q o FND E�' P�v
11 Io1,5 I. JsEr
FSSIONM �a
�\I DAYE A I ro40
Ei]CaE SiDEwAL4.
�T ti
10,00+� 'S•F.
�� .c---"-•` INM:Rb"•s .•� 9 aMr= PAVEMENT
OD vjI D7TE_l " I Q pK.HAN� 'fy�,oe eo V,j Q�
F Qb�1T
LEGEND MI OF
r EXISTING SPOT ELEVATION . Ox0 CERTIFIED` PLOT PLAN-
EXISTING CONTOUR ---- 0 ---- Le=%T" F
FINISHED SPOT ELEVATION [Q ] t-IYANFJIS
FINISHED CONTOUR - 0
Id ,
APPROVED BOARD OF' HEALTH Sao sua�`° S� ��� ��A L9a
� k�VISE�:o'10283
DATE AGENT. SCALE= 40 .DATES .12' Vq 1
LDREDGE ENGINEERING CO. IN CLIENT �I�K��AS 1 CERTIFY THAT THE PROPOSED
LETERE REGISTERED JOB. NO. 9 I i ! o BUILDING SHOWN .ON :THIS _PLAN
' IL LAND. CONFORMS' TO THE ZONING LAWS
DR.BY J
NEER SURVEYOR OF BARNSTA E , ASS.
?.F 2 MAIN STREET CH. BY= AAM
HYANNIS, MASS. 12.�lggi
SHEET, -;1 OF �- DATE,. R LARD SURVEYOR
.Ij 2 ri
Ul
Do
Q , 111 J W Q W• ' p p ac (. I r p &
� � Z � A h
'Vo �+ o � W hWW
tj
Uk Ci
� 000 k yti � Jn v O
IrjQ� �4 -. . 0
w � � 2 _I 0
Nt
w 00
0 � `\ ^
c,aw W h � � 3 .� Q
to 0
W � � rs
o-F\ XX � h JW ; 0 w t0
10
In00
g
1' %ZKQ � � G� srrs ®Cl
Ilk
yy
u �
N o20 4 Fv Ulc� — cr L z
p= Q 6i ai dr >6 ¢ Z��'l 07
�
• 2 k � �.h Irk-
4i
2k
,� W atiao k ti '' a ? w a
v r;;sE�iS
� � a\p � V Ira
w �Z
Q. I p2•p Wy �` Q b OC � VQ V H
Qh h . w
ASSESSORS my NOa
�4� �. PAR L1 1u/�, 0
THE COMMONWEALTH%OF MASS (d
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpplication for Mi!5pool *p!tem eomgtruction Vermtt
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer' Name,Address,and Tel.No. 3(0 2� 3 49(o ® Designer's Name,Address and Tel.No.
up M O R
3, 4- e-,C.F je t3e4,1/
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ko,,_ ®Y,
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 ' 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th B and of He h.
Signed Date 3
Application Approved by 4P
Application Disapproved for the following reasons
Permit No.,7 �6 `�l Date Issued
———————————-- ---
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance `
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( or repaired/replaced(f__<on
by M,--,e/AJ for 'D
as has been constructe in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit 70 f dated
Use of this system is conditioned on compliance with the provisions set fo below:
No.
THE COM'MO! NWEALTH OF MASSACHUSETTS
ti PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplicatiaft" or XDt9;pogaY *pgtem Con.5truction Permit
Application is hereby made for a Permit to Construct/( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Installer s Name,Address,and Tel.No. 3 4o(o O Designer's Namq,Address and Tel.No.
5 S.q r c. F (3�"?�1/ t
Type of Building: ,
Dwelling No.of Bedrooms -3 Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title '
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Aye R 4 G e 3 a x
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 o , i 5 of the Environmental Code and not to place the system in operation until a Certifi-
,cate of.Compliance has been,issue by thIs B and of He th.
Signed 1 V'. "� Date V �.S
Application Approved by V_13e
Application Disapproved for the=following,reasons ; s;
Permit No.,7iV�'��fGf j Date Issued
1
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
THIS IS TO CERTIFY,that the On-side fSewage Disposal System installed( or re aired/replaced onI /5 f
by for�D f
as has been constructe in accordance
with the provisions of Title 5 and the for Disposai System Construction Permit 7®f dated
Use of this system is conditioned on compliance with the provisions set f elow:
i
No. 7— • Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwtgpogal *p!5tem Conttruction Permit
Permission is hereby granted tov •C! r
to construct( )repair( Gin On-site Sewage System located at /V
K
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction
must be completed within two of the date below.
Date: -4 r' �"_ `�S Approved
i
outh 0
hore
uruey
Consultants, Inc. CZ
` r
Registered Land Surveyors
& Civil Engineers �
r 1 j.
August 10, 1995 99,� �
Board of Health ,
Barnstable Town Offices
367 Main Street
Hyannis,MA 02601
Re: SEPTIC INSPECTION: - 104 Pitcher's Way, (Lot F), Hyannis, MA
Former Owner: Daniel Beaton - Currently owned by FNMA (Bank)
Dear Board Members:
South Shore Survey Consultants, Inc. recently completed a Subsurface Sewage
Disposal System Inspection in your Town and we enclose a copy of our Inspection Report
in accordance with the State Environmental Code Title V,301 CMR, 15.300 thru 15.303.
As per the requirements of TITLE V, Section 15.340, the individuals listed below
have been approved as Certified Department of Environmental Protection System
Inspectors:
Henry T. Nover,P.E. Mark D. Casey, C.S.I.
William P. Sylvia,P.L.S., C.S.I. Charles Fortier, C.S.I.
Please acknowledge receipt of this report by signing a copy of this letter and
returning same to this office. Your kind attention to this request is appreciated.
Sincerely,
Mark D. Casey, C.S.I.
MDC/df
Enc.
Acknowledgement of Receipt of Report: AN 14
Date:
167 R Summer Street o Kingston, MA 02364 e (617) 582-2185
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
Water Pollution Control Technical Assistance and Training Sections
William F.Weld
Gamma
Trudy Coxe
Secrelmy,EOEA % ��
Thomas B. Powers j
Actingm er Acting Comieaion e
1 jj!�
,y
03/09/9.5 �, _ L93
ATTN: Mark D. Caseyto
a �
South Shore Survey Consultants, Inc. y 'j,
167 R Summer St.
Kingston, MA 02364-
Dear Mark D. Casey,
I am pleased to inform you that you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310 CMR 15.340. The passing grade for
the exam was 39/52 or 75%. Your grade was 90%.
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15.340 .
You will receive a System Inspector certificate at a later date.
If you have any futher questions, please write to me at the following
address:
Kimball Simpson
D.E.P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very much for your time and consideration in this matter.
Sincerely,
Kimball T. Simpson,
DEP Training Center Director
(371
Route 20 • Millbury, MA 01527 • FAX 508-755-9253 • Telephone 508-756-7281
r;
i
,t T
UB URF'ri,Cr SWAFA WA GIC JI SPOI MI
!l�I��FrTlJl�l
This Subsurface Sewage Disposal System Inspection
Has Been Performed In Accordance With The State
Environmental Code " TITLE V
301 CMR 15.300 thru 15.303
March 1995
By :
outh
hore
urvey
Consultants, Inc.
Registered Land Surveyors
& Civil Engineers
167 R Summer Street • Kingston, MA 02364
(617) 934-7553
(617) 582-2185
FAX (617) 582-2239
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of Property:
Owner's Name: v, c,�f92/l�/ /!�?/l�L�
Date of Inspection:
FART A
CHECKLIST
Check if the following have been done:
—Zpumping information was requested of the owner, occupant, and Board of Health.
__�/None 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.
The facility or dwelling was inspected for signs of sewage back-up.
�he site was inspected for signs of breakout.
P g
,ZA11 system components, excluding the SAS, have been located on the site.
�heseptic tank manholes were uncovered, opened, and the interior of the septic
P P P
,tank was inspected for condition of baffles or tees, material of construction,
dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the SAS on the site has been determined based on existing
information or approximated by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with
information on the proper maintenance of SSDS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential:
number of bedrooms
number of current residents
Ile garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated.flow:
Water met pr readings, if available:/gf/6;
/ 1j :5-- Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
y /4 "Ile
System pumped as part of inspection, yes or no
If yes,volume pumped
Reason for pumping:
Type�q 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. Source of information:
�� Sewage odors detected when arriving at the site, yes or no
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
f SYSTEM INFORMATION continued
SEPTIC TANK: 1�
(locate on site plan)
Depth below grade:
Material of construction: Zconcrete metal FRP other(explain)
Dimensions: __ �•(��,/�( 0 3"Wb llwlP7ef�
J/
J? sludge depth distance from top of sludge to bottom of outlet tee or baffle
scum thickness
Ji 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,
recjVnmendations or re irs etc.
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 box, recommendations for re airs, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
r SYSTEM INFORMATION continued
PUMP CHAMBER:
(locate on site plan)
pumps in working order, yes or no
Comments:
(Note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc.)
SOIL ABSORPTION SYSTEM (SAS): v
(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:
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number,dimensions
overflow cesspool, number
Comments:
(Note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
recommy�ndations for maintenance or replie, etc.)
I
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
f SYSTEM INFORMATION continued
CESSPOOLS (locate on site plan): 1-0/1t1'
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 (cesspool must be pumped
as part of inspection)
Comments:
(Note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,
recommendations for maintenance or repairs,etc.)
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(Note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
recommendations or repairs, etc.)
DEPTH OF GROUNDWATER
depth to groundwater IIA- 91 !��IW4 411
Method of determination or approximation:
P �- � v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
T.vK
3
y �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' FAILURE CRITERIA
Indicate yes, no, or not determined (Y,N, or ND). Describe basis of determination
in all instances. (If "not determined", explain why not).
// Backup of sewage into facility?
/!' Discharge or ponding of effluent to the surface of the ground or surface waters?
Static liquid level in the distribution box above outlet invert?
�iJ'p�SS�G
Liquid depth in cesspool <6" below invert or available volume <1/2 day flow?
Required pumping 4 times or more in the last year?
Number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial infiltration?
substantial enfiltration? tank failure imminent?
/ Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
/V within 50 feet of a surface water?
within 100 feet of a surface water supply or tributary to a surface water supply?
within a Zone I of a public well?
Zwithin 50 feet of a bordering vegetated wetland or salt marsh (cesspools and
privies only,091 the SAS)?
/`within 50 feet of a private water supply I well?
A�less than 100 feet but greater than 50 feet from a rivate water supplywell with
P
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.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
f CERTIFICATION
Name of Inspector: jg,��,,(J
Company Name: South Shore Survey Consultants, Inc.
Company Address: 167R Summer Street,Kingston, MA 02364
Certification Statement:
1 certify that I have personally inspected the sewage disposal system at this address and
that the information reported is true, accurate and complete as of the time of inspection.
The inspection was performed and any recommendations regarding upgrade, maintenance
and repair are consistent with my training and experience in the proper function and
maintenance of on-site sewage disposal systems.
Check one:
I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303. Any
failure criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
I have determined that the system fails to protect public health and the environment
as defined in 310 CMR 15.303. The basis for this determination is provided in the
FAILURE CRITERIA section his form.
q,.
Inspector's Signature:��
Date:
Original to system owner
Copies to:
Buyer(if applicable)
Approving Authority
LOCUS ADDRESS: i,
9/19/2019 ShowAsbuil t(1700X 2800)
LOCATION 'dy SEWAGE PERMIT NO.
,fir,` F3--/6/
VILL''AAGE !
7�H�ww"S
INSTALLER'S NAME IS ADDRESS
i,v ST rr
BUILDER OR OWNIF
DATE .PERMIT ISSUED i7F�
DATE COMPLIANCE ISSUED/6
w ,Cor F
https://itsq Idb.to\&n.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=289060002&sq=1 111