HomeMy WebLinkAbout0111 RUDDER ROAD - Health 111 Rudder Rd. MM I
247-181 Hyannis
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COMMONWEALTH OF NLASSACHUSETTS
s EXECUTIVE OFFICE OF,ENVIRONMENTAL AFFAIRS
- ,DEPAR•TMENT OF ENVIRONMENTAL PROTECTI.O _'
RECEN1L,D
FEB 2 4 2004
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM' FORM
PART A
CERTIFICATION
Property Address: / / , MAP 2.T�
Owner's Name: PARCEL ,
Owner's Address: LOTa/
- - - -
Date of Inspection: .
Name of Inspector: please print)
Company Name: Q ,
Mailing Address: (�
in ym
Telep hone^Number: �9*.
CERTIFICATION STATElVMENT� �� 4 I ,
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: /710V
` The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I-Ieaith 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 ofthe
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
t,,._..,,_. ... Notes and Cariimenfs __.....
r "
,....-. ._.. .. .. ....." _• - -• -... ..fit» ..� �.... . ._ ... .,..„. ., .,. ..... ... _f „ ..... .. .. � i r �
****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
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAIT A
CERTIFICATION_(continued)
Property Address:
Owner:
Date of Inspection: ,,� &Z a 0 V
Inspection.Summary: Check A,B,C,D or�E/ALWAYS complete all of Section D.
A. '/System Passes:
V I have not found any information which indicates that anv 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:.
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.
..fit - +'. .. ,.
.?i.1' F,.t,f n �" >a£:%t �t'�...a:,>:ya a��.e...d' S ,. 1: . l�� - i 1+RP+....a .... �;4,. .�•.s .ti , , .,
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain'
The septic tank is metal and over 20 years old" or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with 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 pipes)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times,a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):."
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of]'I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION (continued)
Property Address:
Owner: 9u f
Date of Inspection: ZA 4
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 Vnless 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
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 ]00 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 t 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 coliform
bacteria and volatile organic compodn"ds 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
Page 4 of 1 l
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PANT,A __ .. .. . ... . . ,.
CERTIFICATION(continued)
Property Address: a _
Owner:
Date of Inspection-
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes Nc
_ ✓/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or pond`ing of effluent to the surface of the ground or surfacewaters 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 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
/ of times pumped
V Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ — Any portion of cesspool or privy is within.400 feet of a surface water supply or tributary to a surface
l water supply.
Any portion of a cesspool or privy is within'a'Zone 1 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; fo'r`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.]
(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: VArge 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•
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
Page 5 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B .,
CHECIMIST
Property Address: 4 T
Owner:
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes...: � ..-. : .,,., ::.' � ,�; ., • . . .. •, �, s, ._ a . :. . - -
Pumping.information.was provided by the owner, occupant,or Board of Health
vWere.any of the-system components pumped out in the previous two weeks?
t_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 NIA)
_ Was the facility.or dwelling inspected for.signs of sewage back up
Was the site inspected for signs of break out t
Were all system components, excluding.the SAS, located on site
y _ 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?
v _ 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.
i/_ 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
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SLJI3SITRFACE SEWAGE DISPOSAL SYSTEM:I1o1SI'ECTION FORM
`rPART C
_SYSTEM,INFORMAT'ION
Property Address:
Owner:
Date of Inspection:,: Cl44//, Qon V
/ � FLOW CONDITIONS
RESIDENTIAL✓
Number of bedrooms(design):a. Number of bedrooms (actual): 3
DESIGN flow based on 310 C R 15.203 (for exampl gpd x#of bedrooms):
Number of current residents: %
- a 7
Does residence.have.a garbage grinder(yes or no��-
Is laundry on a separate sewage system (yes or no
.[if yes separate inspection required]
Laundry system inspected(yes or nolAlzr
Seasonal use: (yes.or nVav-&aila)ble
Water meter readings, i (last 2 years usage(gpd)) ®Z-6� 75O ✓ �✓'�/ ao
Sump pump.(yes or no):
Last date of occup
ancy':;
COMMERCIAL/INDUSTRIAL/Id
Type of establishment:
Design flow(based on 310 CMR,15.203):, gpd
Basis of design flow(§eats/persons/sgft,etc.): _..
Grease trap present(yes or no):—
Industrial waste holding tank resent
b P (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:
Was system pumped as part of th inspection(yes or no
If yes, volume pumped: VIVO-
gallons--How was quantity pumped determined?..ti
Reason Tor pumping:
TYPE,OF SYSTEM
eptic tank, distribution box, soil absorption system
—Single cesspool.
_Overflow cesspool
Privy
—Shared system.(yes of no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative.technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach a copyof the DEP,approval
7R ... [ -t t -
-Other(describe):Q7p
proximate age of all components, date installed(if known)and source.of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Paae 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM`INFOItMATI ON,(continued)
Property Address: J
Owner:
Date of Inspection: y?[/,L�/l �I. 7
BUILDING SEWER(locate on site plar)/)t&-
Depth below grade:
Materials of construction:_cast iron _40 PVC_other_ (explain):
Distance from private water supply well or suction line: z
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK: ✓(locate on site plan)
Depth below grade:
Material of construction: ncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list aae:_ Is age.confirmed by a Certificate of Compliance_(yes or no):_(attach a copy of
certificate)
Dimensions: /�.S, k(o ' S -
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined: p 062Z a&K21LZU1 IAV-d
Comments(on pumping recommend tions, Ailet and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert, evidence of leakage,etc.):
GREASE TRAP•111)-(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet te'e`or baffle condition, structural integrity,liquid levels
as related to outlet invert, evidence of leakage, etc.): ,.�=.+•t
7
Page 8 of I I
OFFICIAL INSPECTION,FORM-N1.OT FOR VOLUNTARY. ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART. C.
SYSTEM INFORIYIATION.(continued)
Property Ad ress:
Owner:
Date of Inspection: a A14 /000 y
TIGHT or HOLDING TANK✓tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes.or no):
Date of last pumping:
Comments(condition of alarm and float switches,,etc.):
DISTRIBUTION BOX. ✓(if present,must be opened)(locate,on site plan), t
Deptff 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
lea age into or out of box, etc.):
PUMP CHAMBE`R:/It&(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 appurteriances; etc:� '`' - - .
8
.t
Paae 9 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address:
Owner: 11 /I
Date of Inspection: M
SOIL ABSORPTION SYSTEM (SAS): '(locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:_
leaching chambers, number:
:2eaching galleries, number:
1eaching trenches, number, length: _ �� 'X ` k
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. : '6�
1
Q/7/0 Alp
1,
CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes.or..no):..
Comments(note condition of soil,signs of hvdraulic failure, level of ponding, condition of vegetation,etc.):
PRIVY (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C_
SYSTEM INFO.RMATION(continued)
Property Address: l
Owner:
Date of Inspection: A 000
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.
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10
Paae I 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.0
SYSTEM INFORMATION(continued)
.Property Address: f
Owner: !`
Date of Inspection:XeZui 'a �� T
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water L3—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:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
�'!
11
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: Lot No.
Owner: �� / Od�y� Address: '
Contractor: P' _ Address:_ y//J p /`-
Notes:
STEP 1 Measure depth to water table
to nearest 1/10 ft. .............................................................................. .Date AA/ l 7
month/day/year
STEP .2 Using Water-Level Range Zone
and Index Well Map locate
site and determine: /-
OA Appropriate index well...............................:..../ .�
CWater-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
month/year
STEP 4 Using Table of Water level Adjustments
'for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment ...........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
levelat site (STEP 1) .............................................................................................................. l I IJ
Figure '11--Reproducible computation form.
15
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lTOWN OF BARNSTABLE /
LOCATION l�J U�Q�2 X11 SEWAGE#
VILLAGE 11Vi4i9n is /-->oA �J ASSESSOR'S MAP&LOT. 7- f
INSTALLER'S NAME&PHONE NO.0M �2 SPD7�/C ��s
SEPTIC TANK CAPACITY /SV0 679 „
LEACHING FACILrrY: (type) ;�enr_ (size) a '� m
NO.OF BEDROOMS 3 l
BUILDER OR OWNER Z)OU 1 S
PERMITDATE: f—/� _`l'11, COMPLIANCE DATE: ��' ��_'pz
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 leachin cilityb Feet
Furnished by d`?
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ASSESSORS[NAPNQ�
PARCH. (h - - z m
_.�s�-_�� -^�~^ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppfication for Mioo!6ai *r6tem Con.5tructiou 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.
20'
Inst is Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow J gallons per day. Calculated daily flow _3av gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil M 670 p &A- 12
Nature of Repairs or Alterations(Answer when applicable - 5'e_Q .SQ,97dC -t-X U-&-- o'6GZ_'
Ll
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 Co and not t lace the system in operation until a Certifi-
cate of Compliance has been issued d ea
Signe Date e
Application Approved by
Application Disapproved for the following reasons
Permit No. s' Date Issued
ff - t r'r. .. . - '� v-..%• 'n �.. o'n,n.✓"h-.n�.�wp'�.,',�..�CJ+tfs�-'y,.�`.,,r.,.,,... �. - . ,.-, - .. �X
No. �~ / t�` Fee
THE COMMONWEALTH OF MASSACHUSETTS <
PUBLIC HEALTH DIVISION -{TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Migaal * ,gtem Cougtruction Permit
i
Application is hereby made for a Permit to Construct( )or Rep' to,,( an On-site Sewage Disposal System at:
Location Address or Lot No. Owner�s Name,Address and Tel.No. —7
Let
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Inst is Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ti gallons per day.• alculated,Zil"y a ✓ gallons.
Plan_ Date Number of sheets Revision date"
Title
Description of Soil M 1 0 4-111 0
Nature of Repairs or Alterations(Answer when applicable / +DO ✓e-, f 6C_
Date last inspected:
Agreement:
Tffe 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 Coe and not t lace the system in operation until a Certifi-
cate of Compliance has been issued d ea . _
Signe Date
Application Approved by ,
Application Disapproved for the following reasons 1
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS -
Certificate of Compliance
THIS IS TO CER at th ewage Disposal System installed )or repaired/replaced( )on (�
R-40 by c, v 6-Lt for
as / // u A-1C) 3-Vt,A,Yv c. , "has been construct d in accordance
with the provisions of Title 5 and the for Disposal System Construction P rmit No. dated
Use of this system is conditioned on compliance with the provisionwt forth bel w: 1
No. 7 `" Fee j�
k
THE COMMONWEALTH OF MASSACHUSETTS ,X
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi5pooal *p! tern � 9truction Permit `
Permission is hereby granted to
to construct( )repair(v)an On-site Sewage stem located at v ` C_1Z
S 3 77`.'
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 in st be completed within tw .years of the date below.
Date: ^ ! +TJ ' � Approved b
( 1 &
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CERTIFICATION OF SKETCH AND APPLICA' 'I1 A I.AN
WORKS CONSTRUCTION PERMIT(WITHOUT-DESIGN D P
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i.
hereby certify that the 0011ca bpi poi'� 3tits
constriction permit signed by me dated
property located at /// 40QWF 00` yi
following criteria:
} .� � t1a.y'f3 �y. ��,�•� r�1 yf'i 4"`�"P�ft W-s
Y+ �i' Y .
a There are no wetlands within 3M feet of the proposed ' lc system µ
a There are no private wells within 150 feet of the proposed septic system'
a The observed groundwater table is 14 feet or greater below the botto tl of the leaching&iifty!
a There is no increase in flow and/or change in use proposed "
. �P)
a There are no variances requested or needed. ' " f
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SIGNS bA't�3
LICENSED SEPTIC SYSTEM INSTALLER iN T1IE TOWN OF HARNS'1'ABLL' ... .
[Attach a sketch plan of the proposed system. Also if the licensed Installer:",o/esr3es sy at4
this plan should be submitted]. 4
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