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HomeMy WebLinkAbout0245 SCUDDER AVENUE - Health .,245 Scudder:Avenue ll,HyaMis P \' A =F 289 'M3 4 i k 0. Y o COMMONWEALTH OF MASSACHUSETTS vv EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED MAY 1 9 2004 ' TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 245 Scudder Avenue MAR ' Hyannis, M4 02601 PARCEL , _ F Owner's Name: Nancy Vecchione Owner's Address: LOB' Date of Inspection: April 29, 2004 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT l 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: May 3, 2004 The system inspector shall sub a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and.the system owner shall submit the report to'the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments i ****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. i Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 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: 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 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 break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced, obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004. 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 1 1 F OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 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 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 '/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 SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner, occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection ? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ Were all system components, 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 Page 6 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 550 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system (yes or no): n/a [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/INDUSTRUL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components, date installed(if known)and source of information: Installed 6124198-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 r - Page 7 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 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: 5' 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: 4" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 10" Distance from top of scum to top of outlet tee or baffle: 4" Distance from bottom of scum to bottom of outlet tee or baffle: 10" 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.): Tees were present. The tank was 5'below grade. The clean-out cover was 2"below grade. Recommend pumping. GREASE TRAP: None (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 tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Scudder Avenue Hyannis MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 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.): t DISTRIBUTION 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.): 1 was unable to locate the D-box(5'+ below grade). 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.): t 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Scudder Avenue Hyannis, MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-500 gal. leach chambers-per as built card leaching galleries,number: leaching trenches,number, length: 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.): 1 dug down in the stone and the stone was dry and clean. There did not appear to be any signs of failure or backup. 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 hydraul ic'fai lure, level of ponding, condition of vegetation,etc.): 9 I Page 10 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Scudder Avenue Hyannis, AM Owner: Nancy Vecchione Date of Inspection: April 29, 2004 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, g, 410 c, a A Q C o 3 C 0 a� 10 Page 1 1 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 245 Scudder Avenue Hyannis MA Owner: Nancy Vecchione Date of Inspection: April 29, 2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 20' +/- 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: Using a Barnstable topographic map and a water contours map the maps were showing approximately 20'+/-to ground water 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 f TOWN OF BARNSTABLE ✓ 99 LOCATION p SGUG��r /aVL SEWAGE # C)e- 3� VILLAGE 14U 4mil ASSESSOR'S MAP & LOTv2�J 0OC3 INSTALLER'S NAME&.PHONE NO. SEPTIC TANK CAPACITY /0'>'/D .7,LEACHING FACILITY: (type) SOb GA' C �• (size) NO.OF BEDROOMS BUILDER OR OWNER /1AA4,1 !/e-CC10/1t PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility)^� Feet Furnished by ` L/1Sba pn o . Forc-j Q-1 J O C)D J (� n— Cu 13 �a O r TOWN OF BARNS�TABLE , /� , LOCATION SEWAGE # VILLAGE 00YASSESSOR'S MAP & LOT Z"/0 r3 iS INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY ho--f �� LEACHING FACILITY: (type) �'� (size) NO.OF BEDROOMS e BUILDER OR OWNER PERMU DATE: " g COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.,(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ---- 1 f No. rJ U 1 Fee$50 . 00 r, ,.. ;,`,` Entered in computer: THE COMMONWEALTH OF MASSACHUSETTu. Z—/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migoml *pgtem Comaruction Vermit Application for a Permit to Construct( )Repair(xX}Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. 245 Scudder Ave Owner's Name,Address and Tel.No. 7 7 5—6 7 9 5 Assessor'sMap/Parcel Hyannis, MA Nancy Vecchione Fernwood Street _ Hyannis, MA 02601 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. W E Robinson Septic Service PO Box 1089., Centerville, MA 0263 Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder(no Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank a. S-✓ Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic consisting of D-box and three 500cr leach chambers. e /ovC Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oaz of Health. ��Q Signed �� I L - ��/ Dat /n,, Application Approved by �e D Date (o r- T �r LIF NJ Application Disapproved for the following reasons Permit No. _ q 3 `J Date Issued 0 � 2. No. J �,, 0 I •% Fee$5 0.0 0 r !i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:,,,�,� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Z(ppYication for 3Di5pooar *patent Con.5truction Permit Application for a Permit to Construct( )Repair(x)),Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 245 Scudder Ave Owner's Name,Address and Tel.No. 7 7 5_6 7 9 5 Assessor'sMap/Parcel Hyannis, MA Nancy Vecchione Fernwood Street Hyannis, MA 02601 Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No. f W, E binson Septic Service PO,, Ba 1089, Centdrville, MA 0263 Type of Building: a Dwelling No.of Bedrooms 4 Lot Size ^sq. ft. Garbage Grinder(no Other Type of Building 1 T6'4 4en�` _r, Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallo�tS. Plan Date Number of sheets Revision Date Title Size of Septic Tank 9V 1 0!;o Type of S.A.S. Description of Soil sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic consisting of n-hox and three 500g leach chambers. ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this oar f Health /Signed i�r C� � Date `.Q ` Application Approved by d a, �`1 4. ' Date l -- p Ss Application Disapproved for the following reasons Permit No. 5�t� Date Issued ————— --- —° ------------- ----- --- TrHE MONWEAL-TH OF MASSACHUSETTS Vecchione "BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( x )Upgraded( ) Abandoned( )by at 245 Scudder Ave Hyannis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. - c3 _ dated Installer W E Robinson Septic Service Designer The issuance of this permit shall not be construed as a guarantee that the syst function as skrsignad.. Date InspectorNo. Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEATH DIVISION - BARNSTABLE., MASSACHUSETTS Vecchione Mf000ar 6p5tem Construction Permit Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( ) System located at 245 Scudder Ave Hyannis, MA Installer: W E Robinson Septic Service and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply,with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date:_ _ Approved by , l r . '- NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) c 8 I, William E. Robinson. Sr. ,hereby certify that the application for disposal works construction pen-nit signed by me dated concerning the property located at 245 Scudder Avenue, Hyannis, meets all of the following criteria:. * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed- If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: 11::�J z DATE ��— 9— LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). r- 7 � t l " �y TOWN OF BARNSTABLE LOCATION fir' C e, c�i'I''� Q Z� SEWAGE # VILLAGE� / Y ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. "'S '- SEPTIC TANK CAPACITY Z�21 LEACHING FACILITY: (type) C _ (size) s-" NO.OF BEDROOMS e BUILDER OR OWNER �/L—�G C> / O ,'— j= PERMITDATE: G COMPLIANCE DATE: (1, --,2. �� Z Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility.. (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by LO•CAT'ION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS 29 BUILDER OR OWNER DATE PERMIT ISSUED 31-7d_ 71 DATE COMPLIANCE ISSUED 3 �37- 7, I � `O -79 No..........---•--- F��.... �................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... .... ......... Town..... .OF...Barns.t-able-- .......................................... . ppliratinn -fur Diipniittl Works Cnunitrurtinn- Vamit Application is hereby made for,a Permit to Construct. ( ) or Repair (X ) an Individual Sewage Disposal System at: .... .49---Scud er-.Avg-n.ue........................................... ....................................................-............................................ Location-Address or Lot No. .._Carmen.•Vecchione.--------•---•--------------•...._--=-----.------ ----------•Hyannis---._._..... Owner Address a ••.Joseph.P�...Macomber.......Son...Inc..----•__----- •••--.__...Centerville---•-•-----•=---------------••--•-•---------••-••••--- Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ----- ------------------------ W Design Flow--------------------------------------------gallons per person per day. Total daily flow....................-----------------_---.-gallons. . WSeptic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter_---.. ------- Depth.--_-.--:------ x Disposal Trench—No. .................... Width-___---_-..------_-_ Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.-----------------sq. it. z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by........................................................... ... Date....................................... . a Test Pit No. 1________________minutes per inch Depth of "Pest Pit.................... Depth to ground water..-.-.-----.---.--.--.-. �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-----------.------------ ---------------------------------------- --------------------------------------•-----------------•----------------------------------------------------------- O Description of Soil------6-M-d....&...Gr'a e.l....................................................-.......................... x W -•---------------------------•------- ------------ --•--•-------------•---------------------•----------------•----: -------------• ............................................................... Nature of Repairs or Alterations—A swer when �cable--.1-10 J aldlOn.--overflow (Pit-) ,2 -- - � --------------------------------------------------- - ------- -- -------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has / n ssued b thepbrd f alth. Sign ... - QC d` --li'" . --/ ate Application Approved By.._—_. _. _.___ Q ��' ,3-3 ------------------------=---- ------------ Date Application Disapproved for the following reasons------------------------------------------------------------------------------------------------- -----------•---- .............••........--•-•-.--••--•-••-•..-_----------------•••----•-•-••-•.......................•--•-------------•--•--------•-•--------------------------•---------------------------------_----- Da-,e PermitNo......................................................... Issued.....TJ .......17.7� -.................. Date -7S No......... •... FEE...$5...9�0.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. _. ..... T:wm..........OF..13F, Yl_S_table....- Appliratiou -fur Dio,puottl Workii Tomitrurtiou Vrruiit Application is hereby made for a Permit to Construct ( ) or Repair (y, ) an Individual Sewage Disposal System at: 25...Scudd er•_Aye'..un -----------------------------•--------------......---•--•--------------------•-----.....-------- Location.Address or Lot No. Ce,rmen Vecchione •••------•H,���} is----•......................•-----------------------•------•---•---- - ---e ..n Owner Address a ..............s ..h---p.---� �_crmbez----�..5 =1---Inc. ............ ..........Centerville_ --------•--------------.....---..------------------..... - P Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms------------------------------ -------------Expansion Attic ( ) Garbage 'Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity----------._gallons Length---------------- Width................ Diameter------- Depth.__..----------- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------_.__........sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet-------------------- Total leaching area-----.------------sq. it. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..----_-.--------.------ �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-.--.---_--------.-.._. W -------------------------------------------------•-----------------•-------•_--------------------------------------------•-------•--•------------------------ O Description of Soil-----ae-ad...�4--- rT' try 1------------------------------------------- U -------------------------------------------------------------------------------------------------------------------------------------- -------------------------------- W UNature of Repairs or Alterations—Answer when applicable.-!-1!X».. a..l_.T9Ll---O V_e-rf-LOW--..--(Pit)......... _. -. ---- ----• ------ - ----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be&i;issued by the board,of health. . r Sig `�'' �� --'—----------- ----,...................................... ................................ 1 3.3 ?Date Application Approved B ._ - - --- Date Application Disapproved for tlr.e following reasons__________________'.___--__-._ ----------------•--•---•--•-•-----•-•-••--•--•----------------••-•-•-•---•------•-•-•---------------•-----------------------------•---------------------•--•----•---------------------•-----------.----- Date Permit No......................................................... Issued------r�__"_".----2-.--, Zr ......---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH T^!"n ..........0F.B,=,S..ta.b.lE................................................... Tutifirate of 0XImpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (y, ) by....J PnY P....M cOMb�ex-_- ...InQ....... . --••-----------------------•-••••--•-••------•-•---•--------------....-----••-••----••------ at 2�5ScudcerA� en� e Hyannis Installer Vecchione __ i --- _ = ----.....-•---------------------•------------------------ ........-•------••------ has been installed in accordance with the provisions of : icren XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-�t__.-------/_y_71........__. dated...3------T L—...7B__________________ THE ISSUANCE OF THIS CERTINCATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------ J .............................. Inspector----- " THE COMMONWEALTH OF MASSACHUSETTS j 1 BOARD OF HEALTH C7�� T� � OFBr...............................................e -•--......-------- No.------••...�7 FEE �G Bispoiittl urk,q Toniitrurtion Prrmit Permission is hereby granted_jT9.9�Ph P.._.i4aCOraber&, SOTl---I.�1C-'-_---._...-•------------ :...--••---.-.- to Construct ( ) or Repair an Individual Sewage Disposal System at No.245..Scudder-_A.venue-=----H-4Tanni,s---------------- Vec:c'n :enF Street as shown on the application for Disposal Works Constructio�P�.Rnit N .-__:___:--.__..._. Dated-- '-S_': v__ ................ ' -- r -- -------------------------------•--- Board of Hea -------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS I No........ Ficz S .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HF;ALTH 0_3 ............_OF..... .Z ................................. Appliration for Disposal Warks Tonstrurtion thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at, 4g ...................................................................................... y. ........... .. .. .. . .. ....... . ..... Locat . ....... . �6n Address or Lot No. ........ -- --—---- .. .............. ----------- .................................................................................................. O r Address ....... ............... .................................................................................................. Instal I er Address dz�of Building Size Lot............................Sq. feet Dwelling lKNo. of Bedrooms............................................Expansion Attic Garbage Grinder 44 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures ...................................................................................................................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid*capacity............gallons Length................ Width..............._ Diameter_______--______- Depth_...._........_. Disposal Trench—No. .................... Width_....___....___..... Total Length..__..............._ Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter.._......_.......... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit._____._..._......._ Depth to ground water.._._..____..._.._...__. Test Pit No. 2................minutes per inch Depth"I Test Pit.............._..... Depth to ground water........................ P4 0 Description of Soil........ ----- --- W .. ........ ............................................................................................. U ............................................... .......................................................:........ s. -----------------------*----------------------------------------................... .. ................................................. .......................... .. ... t . ...... ............(-!2.-------W------------------------------- ...................... ------- U Natu of Repairs or Iterations r w� appli ble.......A ------- Al .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I'LL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has en ued by theh b oard Valth. Signed- ............ ................................... .. .. .... ---- ---7 Date Application Approved By--....... 7. ...... ...................... . ...... . -1--- —-------------------"Vk j6i ..... .........7------ Application Disapproved for the following�jrjass:------- .. .. ... .....V2.........3 S_ .............. ....... ............ ............................... ........ ... ............ .................................................. .......... -A A ermi0............... ----------- ....................... Mr Date ISSUC'A� - its 4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA_6TH ........... ........OF...... ....................... (Intifiratr of Tilutpliattrr T is Y`��� the Individ Sewage Diqposal S S I TICERTA y�tem constructed or' Repaired by... .......... ................... --------- .... ............................................................. .. ...... ..........................................................................................................4-vt In l at. .....AT.... ................ .....�­L ...... has been installed in accordance with the provisions of 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.........S-8A---------------- dated-....91.7-4r- .................. .THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... . ..................... No ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................... ................ .............0 ........ ............ ...................... Appili;Ettwu g.: uIppli lanstrArtiv Or I irkS Z'' tt Ad','. Application"is'he' reby-made for a Permit to Construct or Repair ­ 'a� Individual 'Sewage Disposal.Sy - ---------- -------- ................ U,j Locati&i'-Addiess or'.Lot l, o. ------------------ ................................... ---------------...... ................... Address, V. .................................................................................................... ...... .......... ........... .........7........................... Buildi x Installer:. % Size"Loi�.�:........:...............Sq. feet` ` j Bedrobrfis.......................................... 1 ­1 . . r�,.. �Xp� 1.4 .? E i�iioh-Aiii�-: of. 'Garbage Grinder 4�­ . Other 'Type'of;_,Building of persons....... e P 1, -Sh 6w rs Cafetefia 0 _,Building ­.. ............... 0ifierfixtures ................................. . .......................................................................................... '7 -alldn peitorv`lki daS� Total ...gallons ,Design,,Flow.................................L............gallons, _'5� .. .. .,r .. Depth...._ ........... t gallons -Length 0iamete' 'S 6arth.................... Width........ ep ic, Tank—'Liq-u-id- L�, ry zLcapaci,y;z1,.. r...............�. is0 No. W . .. . Total lachiizre sqff:D6l.Vh Seepage Pit 1j�No-: . Diameter Depth-bel6win1et.': ., .. ..'Total leaching area . - Z q. ft.stribution it 1)6sinz�tank her Di )ox n sul�i Performed ....................................... by........ .................................................... Ate', Al mutes per inc Per661-atio T6t�'Re ... No. ......m h Depih. of Test Pit................... �If DePth to 9�und,water....' . ... ..................... Test i o- ...............minutes per inch Dept'li"' f� Test Pit. .......... k h dwater........................ 'Pit t j to.,group T ............................. ------Description of-So 0, ............................. .................................................................- ti & .... ............................................. ....................... ..............i........................... ................................... .....................:7...... .......................................... ....................................................................... U, .................................................. ............. . . . .. - - "---- ' v ------.-------------.----- --- iattrie of ipPairs or?Alterations—z,At&wei �---l--e--n--------Q------------------ --- ------- ........I.......!..-.-.............................................. ................................... .... A-: � -- - - ..-.--.... ..... .... ... - - --- - - - - ----- ..... ......0..�. Agreement .............. o ' isp6sal System-.-iniaccordance with The,.undersigned, Agrees to. install the afesc red' ribed Individual Sewage" The undersigned-further the'provisions of Lt agre not to.pld6i.6e system in I. T bfYthe State 8a`niiary_ Code es,'. e' te oi Coni�liance has bee issued bythe boardbf lie"a'lth.operation unti 'A ififica S.1 7"1....................................................................ed �/� ate" Ap ............... l/S` .. ..,pli t on,.A Date ay Al pi0hon0isapproved.fo�r the f6119UR9 reasons pr ........ ... ..................... ............................................................................................................................................ ..................7 Date A io 17n�,,h, ......................................... ;N Daft 4, Issued............. �071117 44 HE COMMONWEALTH OF.IMkSSACHUSETTS n BO ARD OF 'HEALT� OF'..A . .............................. . . ..................................... A 7 CERTIFY, Thff,,,1he,'I fid i'vid,9%,S ewa7e tbl s-posal I.S7 constructed or,Repaired WISJS� 'Tb�" st 1 V.Z: "Z", b ................... ............. ........... Y.................................................. ........................................................................... ........... ................... ........................ ........................................ ....... --- ........................ .................. .... ........ S with The"..State anitdry 'Code�j;i§ described in the dated.. 7................ .the ork�'66n`A'r­u�fi -�.P I "B, appli6iion.fir Disposal.Works, ... ....... . -NOT1E CON''THE ISSUA A 1ft,'CERTIFICATE'.tW4LL STRUED AS'A GUARANTEE THAT,THE NCE?W; THIS �14 I A, v -1, L"FUNCTION�PSATISFA,CTORY SYSTEM, m_40. A-1 . 8�l OW W-1.MEPAXZt-,� - -------- ......6M. M, WIV Ox� �0rii 0. 4, L;Att W ;tna' il q'i % It,St. .....­FAr*l�7**�""'""*"""*",*"*"*I p g W4 -10,r V� I 711_7 _E`COMMONWEAL ...... wag W-1mWWill tH MA SYN- 1HE 6T�BOARD ' OF' AL�' A4 r NO _00 ........ ......... ................................................... .............;............ F ................. ..................... ar 0 r 'IT ermission i t ............................. ....................... s h�reby P 6d'♦ ...... . ...... ...... ...... .............................F Repair an Individual-.,S�'*age i to Construct, sp System a-,,No........................... -ex------------------------ ........................................................................... tree.-A Itt W­it em 0.4 n bn4tW.ipplic­qti6'-n,for Construction -'it`N'Pir:' a�s._s h o-w. ni. ie6AZ�7" 77­ � 7 ......... ................. _41 #"i 6 A ' ' ':oi . ' , � BO'ai,d'of ie'alth V-9 L7 .DATE . . . FORM 126iAi6§b8 ARREN INC, ioiSn & Al� t % � I I � 60 — ir No............ 2...... Fps..-- ... ..... THE COMMONWEALTH OF MASSACHUSETTS ?�QI I I� � �� BOARD OF HEALTH /��................oF.. ., .. ... .............................. Application -fur Dhipailsal Workii Tomitrnrtinn Prrniit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Se age Disposal 1(/'�y-stem at: ..................... .......... __1-- - ------ ..�4�--- ocation•Address or Lot No. ` .- ............ ........ -• ------ - ---------- --•'-.....---------...-------------•--........----.....--•-'----•--.............................-- O er Address nsta er Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria.( ) aOther fixtures ------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow......................._--------------------gallons. WSeptic Tack—Liquid capacity------------gallons Length---------------- Width-------- Diameter_____...-..._-__ Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------.-----sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...--.--.----..--.--.__. �Tq Test Pit No. 2--------------��inutes per inch Depth of Test Pit................... epth t gr and wat .......__ ..... Description o oil_ ° ----- ---- - V ........... no - -- -- -- -- ---- - - - U Nat e of P.epairs or Alte tins—Answer when applicable..� �f2. .. ....�.. _..Q.�.Q__. .. ._J.............. ----------------------------- -------- greement The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has lie, issued by the Joaealth. Sign ze ° 'r ° ----••---•-- 1 `''(. -!._: .•. Date ApplicationApproved By................•-----...----------....-----••-----••-------•--•--•------------....-----•--•.--•-- ........................---------------- Date Application Disapproved for the following reasons:-----•---------•--••---•--------•-----••-------•-----•---.---•--------------------•---------•-----•-----•------- ---------------•-•-•----••--•---•----------------------------••-•-•-•-------------•----•-•-•---------•--•---------------------------------•-•-•• -•--•---•---------'------------•--••---------------•--- Date PermitNo.....................................--•••-------------- Issued........................................................ Date —— _ — ---------------------------------------------------- --------- ---- ---- - ;�� t .. T � I � � � I E j � l� � � � . I r..-. � f P � 'l 1 -.�--�`� J _ . =}-� .� `� �� ..+- No.. S 2 Fim...._.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 74'07�x�, _ - ,may q...............O F.. s /� �.a...7- - V� 4...................:--------. Appliration -fur 4%qpoiiai Workii Towitrurtion Primit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: _-,I- t, ` QM7/,,� ---- ocation•Address or Lot No. j -44 W , O ne Address Installer Address UType of Building Size Lot----------------------------Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building ---- - --------------------- No, of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------•------------------ - - W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-.----------gallons Length________________ Width................ Diameter___._-__._._--- Depth-------.-------. x Disposal Trench—No_ __ ________________ Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. 3 Seepage Pit No--------_---------- Diameter__.-____---_____.__. Depth below inlet-------------------- Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by....... .................................................. ... Date..............--------_-------------- Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..-.--.------.---.------ (� Test Pit No. 2..............Aiinutes per inch Depth of Test Pita__---___________ epth t gr and wat ......-_ _.._/'..--. Description o Soil.- - 11---- -- - —----- v .0 �f x ---------------------------------------------------- ----------------------------- ........................ - - - --------------- -- ----------------- V Na re of Repair or It .'atio, —Answer when applicable. �_._'__'__ ____ ----6.__ ::_ --.�_. -:._3_.._.....-_.. ------------------------------------------------------------------------------------------------------------------------------------------------- greement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance haskbe�n issued by the o4rdlealth. Stgnc(d,/m �/-------•-• ............ -------------------------------- Date ApplicationApproved By------------------------- -----•-•-------------------------------------------------------------- Date Application Disapproved for the following reasons----- ---------•-•-•-----------------------------•-•----••-------•-------------------------------------.--------- ..........................•-••--.•............---.....------------------..----•-••••••-----._.....------.I-•-------------------------•----•-----------------------------------_---.--•-------------.----- Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS t BOARD OF HEALTH .......OF./&, /%Al t....r.................................................. (11rrtifirate of 01,11mVfiaurr T,� -- -`I S OERTIFY,,,,,That t Individual Sewage Disposal Sysfem constructed ( ) or Repaired byZ...ZZL -� �-�- ............................. - -----•---------------•-•-------------------- ------------------•-------.....--------•-•- �- t Installe at �----—- ...4: '- R !A-- has been installed in accordance with visions of Article 1I of T e State Sanitary Code as described in the application for Disposal Works Construction Permit No------------------------------------------ dated-..._-_-_-_-.-__---_-____.--_.---.--•-.-------•_ THE ISSUANCE OF THIS CERTIFICATE SHALE. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............. ._ --_---- Inspector..... __ J -� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... FEE-- ................. 1U rk 411owitturtiop .,rmit Permission is hereby granted__ ___ ,__._ .:. ________ l � .. ____ ________ ____ ! to Consj�ft7 ( ) or Rq)air Ao)°frn�I-ndividual Sew Disposak�em , at No.-------,------/�__>y, ----- --- ^�=�t3 'Street as shown on the application for Disposal Works Construction uVnit .- t ed------------------------------------------ --- ------ - --------- 7 / � • ) — S� Board of Health DATE... F ----------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS \\ 1Y S I I i I � I_ I 50 _ F L -I r. CEgl x CC 4� i C C � � �.,I. 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