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Home My WebLink About0057 SUOMI ROAD - Health 57 SUOMI ROAD, HYANNIS A=269-113 � e o 0 0 0 �, o fir\ r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 57 SUOMI RD. HYANNIS D�q - L4 c d Name of Owner ESTATE OF STRINGER � D Address of Owner: C/O JOHN CONATHON 9 PARKER RD.OSTERVILLE MA.02665 'Vc t••CC l Date of Inspection: 6/24/99 rz J U L Z 2 1999 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CM R 15.000) � FA(TMRAR �IE Company Name: n/a 4* Mailing Address: n/a Telephone Number: n/a CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes° code 310 CMR 15.303.My findings are of how the system is Needs Furth r Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity,of the septic system and any of Its components useful life. Inspector's Signature: Date:6/29/99 The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.If the system is a shared system or has a design flow of 10,00d gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOM MEND PUMPING SYSTEM EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: Wa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nta The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty.(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. n!a Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced n& The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6124/99 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, _ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,Method used to determine distance nla (approximation not valid). 3) OTHER i n/a .. - revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped nLa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I'&a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: _ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone It of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up.' X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O;H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) ]t 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. I revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 FLOW CONDITIONS RESIDENTIAL Design flow:-M g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: UR Number of current residents:A Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): N.0 If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):M Water meter readings,if available(last two year's usage(gpd): n1A Sump Pump(yes or no): NO Last date of occupancy: 411199 COM MERCIALIINDUSTRIAL Type of establishment: n& Design flow: n&gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): Na Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ, Water meter readings.if available:NA Last date of occupancy: n& OTHER: (Describe) n/A Last date of occupancy: n/a GENERAL INFORMATION PUMPING RECORDS and source of information: D/A System pumped as part of inspection:(yes or no):MQ If yes,volume pumped n(a- gallons Reason for pumping: n/a TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: NEW SYSTEM WAS INSTALLED IN 1998 Sewage odors detected when arriving at the site:(yes or no). N_Q revised 9/2/98 Page 6 of 11 i i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 BUILDING SEWER: (Locate on site plan) Depth below grade: I Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade:.2& Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nfa j Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 3_' Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 1Z How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nta Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:_nla Distance from bottom of scum to bottom of outlet tee or baffle n(a Date of last pumping: n& Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level.in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wit revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nLa gallons Design flow: nLa gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No_: NO Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:Wa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) ElLa PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) Wa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: oLa Type: leaching pits,number: D/a leaching chambers,number: 1lLa leaching galleries,number: _nLa leaching trenches,number,length: Wa leaching fields,number,dimensions: 6'X20'LEACH FIELD overflow cesspool,number: n& Alternative system: In& Name of Technology: j2& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE SAS IS FUNCTIONING PROPERLY_ CESSPOOLS: _ (locate on site plan) Number and configuration: Wa Depth-top of liquid to inlet invert: In& Depth of solids layer: n& Depth of scum layer. In& Dimensions of cesspool: n& Materials of construction: Wa Indication of groundwater: Wa inflow(cesspool must be pumped as part of inspection)n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) DIA PRIVY: _ (locate on site plan) Materials of construction:n(a Dimensions:n(a Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) WA l revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a v C:) revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 67 SUOMI RD.HYANNIS Owner: ESTATE OF STRINGER Date of Inspection:6/24/99 NRCS Report name: nLa Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: UQ I Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar _ Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 r � TOWN OF BARNSTABLE LOCATION S2 LUOM/' 9d SEWAGE # Va;LAGE Nr/Ahty/.5 jj ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. JOSef 4 19-e- R 4✓*22 SEPTIC TANK CAPACITY !S'qV LEACHING FACILITY: (type) TLEI—" (size) /,V X V X ?_ NO.OF BEDROOMS 3 BUILDER OR OWNER-1,,:-:rY,.�°�r �,relnaAr PERMIT DATE: —3 — 7X COMPLIANCE DATE: Separation Distance Between the: I 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 1 aching fa i i Feet F"shed by �� to G�yw m a G/ i 6 o T T /TOWN OF BARNSTABLE LOCATION '/�� f"G r SEWAGE # V;.LAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK.CAPACITY LEACHING FACILITY: (type) (size). NO. OF BEDROOMS BUILDER OR OWNER 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 leaching facility) Feet Furnished by Z� � N nou) �v`3 p � fit a - �►��✓ew .qre- -..rrr.._,-. .aa-�.:- •- s a h. .-.. •-,..,,..t�.e+• ..�.-ram—�-�.=y... r _.-. ., -�+C .. :. rye' ,. saa.1♦..: .. -. _... ....__.c.. .r. , 4 No. ( / Fee J vi THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: } Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 21pplication for Migoml bpeum Construction V ermit Application for a Permit to Construct( )Repair(e_),<pgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. J"7 54(owl, &"ga Owner's Name,Address and Tel.No. '77S-- el Q0S Hyf4oais Fl�i�(jCNT s'rrihy z!' Assessor's Map/Parcel � �9 115 /5 y? s sR , Installer's Name,Address,and Tel.No. 477— a'j J ' f /� � Designer's Name,Address and Tel.No. 5/y%— 3�( Jos�epl, U� IJ'a'-0l joszlal, �/.G �3<119NvS _ 9/ (f HV1.e,r ow Type of Building: Dwelling No.of Bedrooms Z Lot Size sq. ft. 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 Size of Septic Tank Type of S.A.S. Description of Soil e5's3`i Nature o Repairs or Alterations(Answer when applicable) li/� /XiSTe"o' �'FSSI�oa�s rz/��Li da 6,o/ 1492,rlG r" 5 e_ rp 60 q' �• _-4 Slay 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 thi Board f He lth. Signed ti Date 9—17-- 9cff Application Approved by Date !;—3—9e Application Disapproved for the following reasons Permit No. —/3 Date Issued -3 "3— 1 i. _ s-d No. Fee i �. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes .._.Ruprication for Mio6g;al *pstem Co�ngtruction 30ermit Application for a Permit to Construct( )Repair(e-<pgrade( )Abandon( ) ❑Complete'System O Individual Components Location Address or Lot No. r .�7 .!(/0lf4/ �0.4 Owner's Name,Addres and,Tel.No. t-Iy�NN%s HErbtrT ,S�ir�hq � Assessor's'Map/Parcel � G 9 y7 f7 s owl' cr/ H 4oelS . - Installer's Namlh.Add ss,and Tel.No. 4 77' 003qf Designer's Name,Address-and Tel.No. 4/7 ' °y y 9 JoStp�, vt U,40-005/ ./ost/°ti pt uwr►roS Type of Building: , y. Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) •- Other Type of Building No. of Persons Showers( ) Cafeteria( ) ' Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. ' r Plan Date M Number of sheets Revision Date Title Size of Septic Tapk Type of S.A.S. Description of Soil r Nature Re airs or Alterations(Answer when applicable) Fll /=X1SnAi/ CrsSpoals u�ir'4i 61'j,.a.1 YMV a5to�� /Sda 6 .�r_- TAG Tti*,k LEac �'y Trr- C, ' 40 A 5/ X ki/t 2" F,_-4 Sre,ti•r— 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 ued byth Boar fHe th. Signed -M Date Application Approved by 157 Date !;'3-9e Application Disapproved for the following reasons Permit No. , .,<.. Date Issued 73 -'3- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Complijnce THIS IS TO CERTIFY, hat the On-site Sewage Disposal System Constructed( )Repaired ( ) Upgraded(4-4 Abandoned( )by o3e 4 Q.c 46,4^-0.S at S7 Ja00j/ f?oa *#,W/S has been constructed in ac�r�ce I with the provisions of Title 5 and the for Disposal System Construction Pet No. 9 3 dated'. 3 - r " Installer J05 d d`c 6s4Nro.3 Designer �,Jare_04 de- 64,0wo S The issuance of this rmit 1 n t.be construed as a guarantee that the systewill function as designed. Date Inspector -------- —--- --------------------- — No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mwi-gpogaf *pgtem Construction permit Permission is hereby granted to Construct( )Repair(!_'UPgrade( )Abandon( ) System located at S7 swo si i acsw Hyena i,S' 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 mustbe completed within three years of the date of this f� Date: 3— 3 ^ / Approved by 1019/97 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) S ti hereby certify that the application for disposal works construction permit signed by me dated .3-I - 98 ,concerning the ' property located at / meets all of the y syd � 2o�¢c� following criteria: -- 'There are no wetlands located within 100 feet of the proposed leaching facility There are no private wells within 150 feet of the proposed septic system k There is-no increase in flow and/or change in use proposed �nereare no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will 1>9l 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 Elevation(according to Health Division well map) /94 _ SIGNED: �,� DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert tr' e� 0 0 n s /'i� bad � � • f �k f