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HomeMy WebLinkAbout0157 WINDSHORE DRIVE - Health 157-Windshore. Drive Hyannis t G r A 270 222 1 0 a I� � o TOWN OF BARNSTABLE V LOCATION �� 1,/AZT JAC°£ 2eP SEWAGE # 200 a VIL AGE A-r`iJluts ASSESSOR'S MAP& LOT �9 INSTALLER'S NAME&PHONE NO. f���P 0 17 7(r 17?o a SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS •_ BUILDER OR OWNER ° A41P L 4 ' PERMITDATE: ©l ) COMPLIANCE DATE: ix 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 DEC/( , 2 a � i 3 o , TOWN OF BAARNSTABLE ON tZ7 � � o-J S� A '6Vl it SEWAGE* I:vc:t���, VILLAGE ASSESSOR'S MAP &LOT X'1® as INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ® LEACHING FACILITY: (type) p tT (size) Cn S il4-l NO.OF BEDROOMS BUILDER OR OWNER Q SATE: Ca `S 4 i COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 f et o leaching facility) � �►� Feet Furnished by ��� f i 29 U� Cis .Z w I TOWN OF BARNSTABLE 60CATION �`s /'�� Sfi�v.P£ � SEWAGE # {. - 2 O ' d2 ASSESSOR'S � a �-'II,b;AGE ASSESSOR S MAP & LOT o� /NS"o£C; INR'S NAME&PHONE NO. SEPTIC TANK CAPACITY £ � /ti S £C'/iO LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR WNER �/v if J-,# 1.4v 5,4,ZC iaN `PER I T DATE: C(9TAPE;E 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 o �, # . o � a� o` O � � n .. �� a . M W ' g .. ,, i �No. �UO 1 rU e� Fee V� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: l�✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for 3Mi!5poga1 *pgtem Comaruction i3ermit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System EAS-dividual Components Location Address or Lot No. 1517 W i N,D S�°°<°L cl)-' Owner's Name,Address and Tel.No. 14 s� Assessor'sMap/Pgeb,, � �,�9 wiAo,� S.A/d"e£ Installer's Name,Address,and Tel.No. 7 7S- A9 00 Designer's Name,Address and Tel.No. Type of Building: 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. Plan Date Number;of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) P e lL 4 C r_ 7D 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 ipyed by this Board of H Ith. Signed Date Application Approved by N"- Date Application Disapproved for the following reasons Permit No. oZ 00 A-V0 R Date Issued it I ' No. dUO? • Fee ✓� / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: i/ ✓ j .1 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01pprication for 33igpo5a1,*pgtem Construction Permit ,� � to Application for a Permit to Construct( )Repair( P' Upgrade( )Abandon( ) ❑Complete System LJ�'tt"dividual Components Location Address or Lot No. 1507 4v l N-D .J1,11"°I ,)-F Owner's Name,Address and Tel.No. rat, 5 BAR/G/1 _ - +. Assessor'sMap/PgeI,:iD / 3"7 Gv�•t�3 S�° �F i Installer's Name,Address,and Tel.No. '9S- 2�i o', Designer's Name,Address and Tel.No. Type of Building: _ 4 l�t�6uS£ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other.' Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures x Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date t Title 1 Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) AQ-,-A, i I Date last inspected: i Agreement: f 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 is Red by this Board of He lth. y Signed Date Application Approved by JAJ Date 9 �� Application Disapproved for the following reasons Permit No. a UU A Date Issued --------------------------------------- i THE COMMONWEALTH OF MASSACHUSETTS € BARNSTABLE, MASSACHUSETTS Certificate of (Compliance 1 THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( Z)-Up'graded( ) Abandoned( )by l Y Q l l9 N fG 3 S° at S lvi�� S/,�•iP£ it" %'`. has been constructed in accordance with the pr sions of Title 5 and the f�f Disposal System Construction Permit No. u 0 Z— Y(J} dated 6' " a ' Installer Designer The issue of this permit shall not be construed as a guarantee that the system will function as des'g/ted. ` f Date (( - Inspector CN n----------------------------------------- a No. P6 0:2 -t/U 7, Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Mf6poal *pztem Construction Permit Permission is hereby granted to Construct( )Repair( -rcipgrade( )Abandon( ) i System located at / 5 7 Gv/"3 5/1cle F 3 iA ,0— i 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:Constru cti n must be completed within three years of the date of this permit. Date: I // 0) Approved by &, + , -p S i i TOWN OF BARNSTABLE f7cj 1�7 cv �� .C£ �� SEWAGE # LOCATION VII LAGS— �/ ASSESSOR'S MAP & LOT a- * — i r C �r7 17 76 07r INSTALLER'S NAME&PHONE NO.., SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER ° PERMITDATE:44�-- -C OMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply W911 and.Leaching Facility (If any,wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by I ro�c� P 1 3 C tY I I i r i 1 - " ZCc,I.cJlp COMMONWEALTH OF N lASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVE® 350 MAIN STREET SEP 2 4 2002 & WEST YARMOUTH,MA O 508 775-2800 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART CERTIFICATION MAP 290 PAR 222 Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner's Name: PARILA,JOE Owner's Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Date of Inspection SEPTEMBER 10,2002 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350 Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority 'Is Inspector's Signature: Date: The system inspector shall submit 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and,under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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: N/A 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. I 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 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 I ND explain: Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 C. Further Evaluation is Required by the Board of Health: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect 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 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: �I The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a 1 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to 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 pit is less than 6"below invert or available volume is less than''/z 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 X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fonn.) 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 Systems: N/A To be considered a large system the system must service 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 11 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 is 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 Check if the following have been done. You must indicate"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 Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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 X 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 FLOW CONDITIONS RESIDENTIAL Number of Bedrooms(design): 2 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 2001 250 CU.FT./2002 434 CU.FT Sump pump(yes or no) NO Last date of occupancy: PRESENT COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,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: 1998 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 X 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 copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: UNKNOWN,NEW DISTRIBUTION BOX SEPTEMBER 10,2002 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 BUILDING SEWER(locate on site plan): X Depth below grade: 6" Materials of construction: Cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: Comments on condition of joints venting,evidence f( J g, e ce o leakage,etc.): SEPTIC TANK(locate onsite plan): X Depth below grade: 8" Material of construction: X 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: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to the bottom of outlet tee or baffle: 28" Scum thickness: I" Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.OUTLET BAFFLE.TANK AND COVERS 8"BELOW GRADE.NOTE: INLET COVER UNDER DECK.NO SIGN OF OVERLOADING SEEN IN TANK. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 TIGHT or HOLDING TANK: N/A (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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.,): DISTRIBUTION BOX IS 16"X16", 14"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS NEW-SEPTEMBER 10,2002 PUMP CHAMBER: N/A (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.): Title 5 Inspection Form 6/15/2000 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 1 leaching chambers,number: 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.) LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER 26"BELOW GRADE.WATER LEVEL AT 28".STAIN LINE AT 30".NO SIGN OF OVERLOADING OR SOLID CARRY OVER. CESSPOOLS: N/A (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: N/A (locate on site plan) Materials of Construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Title 5 Inspection Form 6/15/2000 9 f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. W R file _ II C Jj Title 5 Inspection Form 6/15/2000 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: 157 WINDSHORE DRIVE HYANNIS,MA 02601 Owner: PARILA,JOE Date of Inspection: SEPTEMBER 10,2002 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to no groundwater 12 feet Please indicate(check)all methods used to detennine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: X Observation 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 ground water elevation: HAND DUG TEST HOLE, 12'NO WATER. TEST HOLE 4' BELOW BOTTOM OF PIT. 0,T Title 5 Inspection Form 6/15/2000 11 • COMMONWEALTH OF M•ASS.ACHi`SETTS EXECUTIVE OFFICE OF E?��%IRO'�'�4ENTAL AFF�A6IR�, DEPARTMENT OF ENWIRONME\TAL PMHCTI( N • add.. I' eVC6 ONE 'INTER STREET. BOSTO�. r1A 0=1QS 61 :•.9_-SSC�G C/ Jut t .. 199 n,,-.r..ojAB(E �RLiDY CON2 V17LL1A%?F. ID B STR WELD Sc:rca Gov=c " UF- ARGEO PAU1 CELLUCCI _..__. .. � �_f " �, D4� one Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ Commissions CERTIFICATION LCT_ sl �- . S�e��� .Qt�\ .s, Property Address-, ,S� W •►eAS�o�aR ��. � ji'�ru��` ' 'Address of Owner: Date of Inspection: 6 1 t t J/ct�j n -� Did t 'pf different) Name of Inspector: H_.:-1 i, oE��C�� ` I am a DEP ap roved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name:/±/ ,7 ay��'c En r1•ro.j 0" F — � Mailing Address: R in C_ Telephone Number: rS'G�� Zo CERTIFICATION STATEMENT I ce^.tfy that I have personally inspected the sewage disposal systen. at this address and that the information reported below is true. accurate and comolete as of the time of tnspec:oo-�. The inspection was performed based on my training and experience to the proper:funcion and maintenance o!on-sae sewage disposa: systems. The wstern: .A Passes _ ConcioonaiK Passes 1,eecs Furthe- Eva!uatlon By the local Approving Authorir, Fa.- Inspector's Signature:�./1 W Date: -f;,e Sys:e^ Ins:e:o• sha!• submu a copy of this inspec.on report to the Approving Authority• within thirry (30) days of completing this inspection. If jhe system is a shared 5vstem o• ha= a design flow of 10,000 god or greater, the inspector and the systerr owner shall submit the repo to the appropriate regional office of the Depanment of EnwronmentaT Frotectior.. The orig!na! should be sent to the system ow'ne•. and copes rn: to the buyer, if applicable. and the approving authority. INSPECTIO';SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: ; I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. . COMMENTS: ( V\j { pee_ T2 0.w (ice► TO1 v r' - BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upc 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. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance lattachedl indicating that the tank was installed within twenty (201 years prior to the date of the. inspection; c the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tan' failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. trevCeed a i2sts1) Page 1 of 10 I � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART CERTIFICATION (continued) - "--`- Property Addws: Date of Inspection: BJ SYSTEM CONDITIONALLY PASSES iconunj,°d Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Healthl. Describe observations:. broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets).,The system will pass inspection if twith approval of the Board of Health): broken pipe!si are replaces obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF'HEALTH: ---- Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the iystem is failing to protect the public health, sale N•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prn� is within 50 feet of a surface water Cesspool or pnry is within 50 fee: of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The systern has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributan• 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 supniv 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 fee! but 50 feet or more from a private water supply well, uniess a well water analysis for coliform bacteria and volatile organic compounds indicates th= the well is free from pollution from that facility and the P ty presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) _.OTHER _ _. (raviaad 04/15/!') page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propertv Address: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: have determined that the system %•iolates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans for this determination is identified below. The Board of Health should be contacted to determine what will be necessan• to correct the failure. Yes No Backup of sewage Into facility or system component due to an overloaded or clogged 5A5 or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or.clogged SA5 or cesspool. Static !round level in the distribition boi, above outlet Invert due to an overloaded or clogged SAS or cesspoo;. Liouid depth in cesspool is less than 6" below Invert or available volume is less than 1/2 day flog. Reouired pumping mote than. A times in the last year NOT due to clogged or obstructea pipes . Number ci times pumped _. An.- Aomori of the Soil Absorption SvStem. cesspool or privy is below the high groundwate• eievatioc An. por:cn o'a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply- _ _ An1 porion of a cesspoo' or privy is w ithir. a Zone I of a public well. An% po^,io- e:a cesspool or pri.1• is within 50 feet of a private water supple well Anv por..or. o:a cesspool or privy is less than 100 feet but greater than 50 fe•et from a private water supply well with no acceptable Kate, qualit-, analvsis. li the well has been analyzed to be acceptable. attach copv of well water analvsis for coliiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] URGE SYSTEM FAILS: lou must indicate either -Yes` or "'moo" as to each of the following. The ioliow:ng criteria aop;% to large systems in addition to the criteria above: The system serves a iacilin *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 . 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) -•--°• •-=='' - The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater:treatment program requirements-of 31, CMR.5.00 and 6.00. Please consult the local regional office of the Department for._further.iniormation:--- - --- - (ra,,%Sed SL-13SL-RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: (S' Owner: ' ; t Date of Inspection:J I(e,\ Check if the following have been done: You must indicate either "Yes" or 'No' as to each of the following: Yet No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recentl% or as pan of this inspection.. XAs bull: plans have been oo:ained and examined. Note if they are not available with N,A. _ The fac:li� or d%%elling was inspected for signs o'sewage back-up. X _ The s%-stem does not receive non-sanitan• or industrial waste flow. _ The site %%as tnspectel for signs of breakout. _ All !vsterr. co^iponents. excluding the So![ Aosorpuon System, have been located on the site. r The septic tank manholes were uncovered. opened_ and the interior of the septic tank was tnspeaed for condition of baffies or tees. materra' o• construaton. dimensions, deptn 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. The fac,lit\ o\%ne• tano occupants. if dtf7eren: from owners were provided with information on the proper maintenance of Sub-Surface Disposal Svsterr.. Existing information. Ea Plan at 6.0 H. _ Determined in the field !c an, of the failure criteria related to Part C is at issue, approximation of distance is unacceotabie jI5.302;3f:b1t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Properts Address: Owner: Date of Ihspection:�I i5t9 fj FLOW CONDITION'S RESIDENTIAL: Design floK (5 v.d.lbedroom for S.-'S Number of bedrooms, Number o,current residents* Garbage S-;:der (yes or no!:_Ij Laundry cor—ected to system (yes or no, Seasonal use (yes or no!: , Water meter readings, if available (last two i2 year usage (gpd): h/ Sump Pump (ves or note Lac dare o-occupanc%- R1�eilyr COMMERC i AL'INDL.'STRIAL: Type of establishment Design fio%% ga!ionsida% Grease trap present tees or no_ Indus:rial \taste Holding Tani: presen, ices or no ':on-sanita'1 V,aste discnarge, to the T::ie 5 system i1•es or no \\ater meter readings if a.ailabie Las:pa:e o: o ::.pa-;c. OTHER: .Describe Last caie of occuoanc. GENERAL INFORMATION PUMPING RECORDS and Sour of iormaUor �y T{� au BLS Q e U VL 6 kEm I � i! O s.� System mped as par, of inspection: eves or no._ If yes, volume pumped gallons Reason for pumping TYPE OF SYSTEM _ Septic tankrdistribution box/soil absorption system Single cesspool Ovenlow cesspool Prny _ Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: -�— cl�l ..• i �U✓fit� . Sewage odors detected when arriving at the site. (yes or not =- •• _> '° ••• • ••• • ••• •• (revised 04/23/9'7) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: QPA-e-S Date of Inspection: BUILDING SEWER:`P]A (Locate on site plan) Iv Depth below grade. Material of construction. _cast iron _40 PVC _other (explain, Distance from private water supply well or suction Ir-e Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK: (locate on site pl :,' +I Depth below grade material of construction- -kconcrete _meta _Floe+glass _Polyethylene _othertexplain If tank is metal. Ifs-. ape 1: age conarmed o,. Ce-,.ftca:e o: Compliance _(lres.-Nc Dimensions l�( Sludge depth ' +) Disiance from top o: sivaee to bottom o; ou:ie: tee o, ba-:;e L Scum thickness- I fl j 1 Distance from lop o: scum to top o; outlet tee or bade�_ t Distance from bottom o scurn to boom o,outlet tee e• bah.e Now dimensions were determined IU LlUtA Comments trecommendation for pumping. ,condition o; inlet and outlet te=5 or baffles. depth of liquid level in relation to outlet invert. structural in grrty, evidence of leakage, e: l c.t r, t uv w GREASE TRAP:, (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: —' "trecommendatron for pumping.'condition of i,ilet and outlet tees or baffles, depth of liquid level in relation-te-out4ei4nven-structur-al— - mtegrity, evidence of leakage, etc.: - tr-,-e.d 04/25.'971 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION, FOR.tit PART C I SYSTEM INFORMATION (continued) Proper[% Address: 17 I O%ner: Date of Inspection:/ \( S�Cl e, TIGHT OR HOLDING TANK: (!—IJ Tank must be pumped prior to, or at time, of inspect:oni (locate on site plan, Depth below grade. Material of construction. _concrete _metal _Fiberglass _,Polyethylene _other(explain) Dimensions: Capacir,• gallons Design flo,- galtorsda. Alarm level A:arm :n %:ork:ng orde• — Yes. No Date of previous pumping Comments (condition of inlet tee. condn:or. o- a!a•rr. and float sv•ttches. etc.t DISTRIBUTION BOX: S doca:e on site p-an r�Nv� l Dear a Loud lee•. aoo.e out:e: :n.e— �►�10U�� Comments mote :i leve! and d:str:b,m r. : a ua evidence of solids carryover, ce of leaka� into or out of boa, etc.) bl , -k'CL 1jLCk PUMP CHAMBER: (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.) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION (continued) Property Addr-ss: J�q Owner: Wts Date of Inspection: J_ Vgg� C SOIL ABSORPTION SYSTEM (SAS): S (locate on srte.plan, if possible: exca oion not required, but may be approximated by non-intrusive methodsi If not determined to be present, explain: Type: t It leaching pits. number. taXs �pr-T 1, leaching chambers. number:_ leaching galleries, number: leaching trenches. number,lengih: leaching fields, number, d,rne-isio^s overflow cesspool, number Alternative system Name of Tecnnolog-v Comments mote condition of soil. s!grs of hydraulic failure. levee of ponding, condition of vegetation,— etc.) I 14�1 � CE55POOL5: rj (locate on site plar. Numbe, and coniigura:.on Depth-top of liquid to inlet Inver, Depth of solids lave- Depth of scum layer Dimensions of cesspool Materials of constructior Indication of ground\,vate- inflow tcesspool must oe pumpeC as par, of inspection, Comments: Inote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) - PRIVY:At (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.): - = (r.�:&.,.d 04/25/9,) paqe a at 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued! Propert} ddress: Owner: baR15 Date of Inopection: �65(� SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (locate where public water supply comes into house) dq 1 g _ 30 1 I '>`_ 30 r �� S3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Proper iv Address CS� t 54 Owner:(6Wr�s Date of Inspection: Depth to Groundwater ( Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Cneck with loca! Board o• newt^ Chec:. FE.MA Maps Check pumping records Check local exca,ators installers Use Lcrc Da:a r. n Describe in vcixow-: %%oros no•,% o:: established the High Groundwater Elevation. (Must be completed- r S, ofo9 1C� IfIvIiZIC aKZlf3y�e. 1441v-8 ghrlrUf trev:,i•d :4,25!9 Page 10 of 10 LOCATION SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME & ADDRESS BUILDER OR OWNER rAaQ DATE PERMIT ISSUED - DAT E COMPLIANCE ISSUED O J^�� �f• r � �II ��, (Ail No...........7/ i Fxs. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF lHEALTH _d( .............OF....... Z`r9 Appliration for Moposal Works Cfonstrnr1tion ramit Application is hereby made for a Permit to Construct (/�or Repair ( ) an Individual Sewage Disposal system at .....p _�...1.e? J- t�?11 ................. ............................ .., . ...1!e .................................... ,bpcation-A�ress or Lot Noe Ow �1 Address W ._W....-1.............................. ................................................................................................. Installer Address Type of Building Size Lot.__ ..Sq. feet U Dwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder Other—T e of Building .. No. of persons............................ Showers — Cafeteria dOther fixtures ......,1(�OAI�_e--------------------------------------------------------------- -----------------•---------------------•--------•.----------- 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. l f__ below inle�c. Seepage Pit No `OD. Diameter._ t�� Total leaching areasq. ft. ----------- 2-7 Z Other Distribution box ( ) Dosing tank ( 0�' ��''��� Percolation Test Resuis Performed by......... ._. _- ............. Date.._. ...3a:�7 aTest Pit No. 1. .._, -.....minutes per inch Depth of Test Pit.................... Depth to ground water-__________-_---_----- Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ TC--------- . . ...... ---------------------•-----.---•----•----7.....•. ---•-•- -- t O Description of Soil------..... .........../,..R�_S--r------- .- .-1Z-•------ °; x x -------------------- - -- --------•----•---•---•--•----•---•-•-••------•------•-••--•-------•------••------••-•-...-------•---------•-------•---------------------•-------•--------------------•-•---- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... r a ------------------------------------•--------------•------••---•---------------••--.........-•......----.....---•-••---------------•-------••-----•••---•-----•-------•------•----•-----••-•--......---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.EE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of calt4. t Sig, /% ate Application Approved BY.....---- ----- ------• A. 142 ................................ -•------1 ..-'-�---�-`-�--•-- Date Application Disapproved for the following reasons:................................................................................................................ .....................•---......-----------•----------------•----------......------------...........-------------------------•••------•-----------••--^------ ------......--••------•---------------- PermitNo.................. Issued.._.. _ld 7v -------------------------------------- ..------^------•---...Date...... Date n �79 r ^S .....3 .a2. ...... FEs.....t.+.�...i�0..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c '. � .. .. oF.-.... �l�.!r�1 ....'................................................ App iration for UhiposFal Workii Tom4rur#inn Frrmit Application is hereby,made for a Permit to Construct (Al-or Repair ( ) an Individual Sewage Disposal-.. sy st ....................., �.. ................................................. ` ' ' ` '..................................•. ocation- ress or I,ot No. �..,r-'..................................... Owner Address W --• -� -...... ............................................ ........••-------••••--•-•................_.........- q Installer Address � Type-of Building', _ Size Lot..,C ...Sq. feet U Dwelling-No of Bedrooms._.._ . .............................Expansion Attic, (f ) Garbage Grinder t�-Other—Type of'Building y .__..... No. of persons............. Showers ( ) — Cafeteria ( }- Q' Other fixtures ---- ' ---------------------•----- ----------- Design Flow............................................gallons per person per day. Total daily flow.......... .. ----_----------gallons. W Septic Tank—Liquid capacity............gallons Length-------_----_- Width---------------- Diameter._.'': Depth_._ „..,., . x Disposal Trench No ......_.. Width ...... .... ...�otal Length___.........._..._. Total leaching area.. .__..;�sq ft. Seepage Pit N��i Diameter. .._.��1.. V i bel nl t A_ chin area.. ,�'r �s ft. P !l- lea g q Z Other Distribution box ( ) t~ Dosing t 4 - Sad, ~' Percolation Test ResA Performed by............. .......... ........ ....__._-.---.._..___--......_--- Date.__........._. ......... �:. a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to'ground water........................ Test Pit No. 2 _.._ ._.._._minutes per,. inch Depth of Test P�i,�ty.................... Depth to ground ater........................ • �en ............. O Descriptionof Soil..........._ : .:......... -••-•--- -------- -------- --•--•--- ------ --•---. -----••-------------- •----............................ x W .............................................:------------------ .................................................. .................................................................................. UNature of Repairs or Alterations—Answer when applicable...................z........................................................................... Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI-2 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by t ,e board,of h alt S� � X - 'yi , - :---- /Zia Application Approved BY -- Date Application Disapproved for the following reasons-----------------------------•--------------------------...-•------------------------------------------•..------ .. .. Date Permit No. .'................... -• ----••-- -----_.... Issued • l...-• ? -------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF........... ..................................... Tatifirtttr of Tompliaurr ... R// �;' --- --g-----•---P.......... .....•--------•-----•-----....�.... .. Repaired ( ) by............. ._........_... ........ .Installer, r '--..............._..._...: THIS I O T Y That the Individual Sewage Disposal System constructed or a has been installed in accordance with the provisions of T r r j The State Sanitary��de,is�sujbgl in the application for Disposal Works Construction Permit No......................................... da.ted_...._-__.......... ----_--- ............... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIO SATISFACTORY. D _ fi--DATE---....---- Inspector_:-• --------••-----------•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH / 1" C, 2. .......................OF.....a::..... .... :.. ........_................._............... /V NFEE........................ �nnstnution amit Permission is hereby granted..... ....i ...----•-•---.....--•----- to Con)tryst or p it ( ) an Individual Sewage Disposal System atN 6..........fie ?'� !'� t---•----------- - --...............--------- --- -----------•---------- �" a Street ` A�jI.77 as shown on the application for Disposal Works_ Construction Perm' .. . .......... Dated.......................................... � . ................................................. --------------------------------------- Boar of Health DATE............................... `= r, FORA 12551 HOBBS & WARREN, INC., PUBLISHERS c»~�IGI�I VAI77 a ►..to GAtzg,�E GRI�.to2 `D�.� Tadl L-•( FLow = •I lb.x S + Sso G.P.t7. Sr�nc 33o,. ISo % + 4-95 PoSAL PIT • IJsE IOoo C,AL Pit I_ i t O✓t .om aze.A 4 � -a--. sue. I .o ti 5o y r v TCrrAL 1DESIGFJ :. PAP Ike; I�E!1GOLQTIb�.1,: RATE s; �"I�.I 2M I u�•02 La�Y, -y I , , ,.., � , � f•.,•�� of� t ,f� �t J.i. OF h1 !a 1,1 t 30 f` + f x ' o� RI CHARD yG� /� ALAN 1 too # i A. BAXTER Na V048 •p G f' A l00 Q , E cySTEP SIl IUNAt Ek7-1 TEST rwo ILsoo.s Ij ... , mur4"AP - l.o a n� . . �"gpe I oo� lug :� '�. 9'i,y� t � • { ' i2 SJ$SDI(.J s 4'�PEs IW. G�oL. . `k.•1 �� J ` a { J •, t i �, 'pox EpnC 1411/•' PIT rt J 7 ' ST4064/= r 'GR W1tL /.o CE¢TIFIED PLCo (2 LJ es Sc AL t �I A'T c�tZ — T P2oPoti i PtAL! R�FEIZE►.IGE `'}. :'f � T I-� E-(A T .' T N� D t,V l.''L•.�.t•IJG S Iaaw�.! � s %4 F:Q I mi,4 G0,4APL'-ls W I TIA TWi:, .51 D ..0 AUD :SE'rt3tiCK �CgUteEMG►.�TS :OF THC , '4-0T � � ' .u..; lzc.GIS'rr-_¢6D "WO 5urwayolzs' „TI-1IS aLAW IS UOT BASGID OW AW 0STs`ev1ul..G o it reL)AAr_- r-=%I' TIC- �r er-. .usc0 ra..verceMlN I.Ja-c I�1I,lE5 AI�PL1Ci�.1,.IT' I s