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HomeMy WebLinkAbout0050 BRAMBLEBUSH DRIVE - Health �50 Brag=uiebrush Drive Cotuit A= 040— 089 i� I I f ` TTS COMMONWEALTH OF MASSACHUS E EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 50 Bramblebush Drive Cotuit MA 02635 LS,�_ 2_1 J Owner's Name: Barbara Harrin t• o� Owner's Address: Date of Inspection: December l:2008: Name of Inspector: (Please Print) Janies M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that 1 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 eeds Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: P December 2,.2008 The system.inspector shall subritaopy 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 ****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. LA� izl0b Title.5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 . OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Bramblebush Drive Cotuit MA Owner: Barbara Harrington Date of Inspection: December 1 2008 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: 50 Bramblebush Drive Cotuit MA Owner: Barbara Harrington Date of Inspection: December 1, 2008 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 aseptic 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 colifonn 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Bramblebush Drive Coto, Mm Owner: Barbara Harrington Date of Inspection: December 1, 2008 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 '/z 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 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: . SO Braniblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: December 1, 2008 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: p Y 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Bramblebush Drive Cotuit: MA Owner: Barbara Harrington Date of Inspection: December 1, 2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no):. No [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: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): -_______.gpd 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 infonnation: Unavailable 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 on 419185-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Bramblebush Drive Coto, MA Owner: Barbara.Harrington Date of Inspection: December 1, 2008 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: 18" 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: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10 How were dimensions determined: Measuring stick Comments(on pumping reconnmendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage. 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 reconunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Bramblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: December 1. M08 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.): :' 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.): The D-box was clean and no solids were resent The cover was to 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.): 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: 50 Brarnblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: December 1, M08 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 agQ 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.): The pit was dry. The scum line was approximately 4'up from the bottom There did not appear to be any signs of failure. A video cmnera was used for the inspection 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 hydraulic failure, level of ponding,condition of vegetation,etc.)- 9 f Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued). Property Address: 50 Bramblebush Drive Cotuit, MA . Owner: Barbara Harrinttton Date of Inspection: December 1. 2008 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.' GArAgc Q � (3ACk i � a 3� s 3 3 ag �o 10 J �1 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Braniblebush Drive Cotuit AM Owner: Barbara Harrington Date of Inspection: December 1. 2008 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/- 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 Barnstable toj2ographic and water contours maps the maps were showing approximately 50'+I-.to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection.This report is not a warranty or guarantee that the systent will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic systent which have not been located and inspected. 11 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE. 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �raw,bi�b t-.v51� Property Address: 50 Bramblebush Drive Cotuit, MA 02635 Owner's Name: Barbara Harrington Owner's Address: 8317 Harps Mill Road Raleigh, NC27615 Date of Inspection: September 12, 2007 �-1 e oy o.o%ck 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 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 15.1000). The system: a - ✓ Passes Cond' ' nally Passes cF# Nee _her_Evaluation by the Local Approving.Authority l Failco . ua �tt. c�so Inspector's Signature:. Dater September 24, 2U07, ' r�F The system inspector shall subt i a copy bf tlii inspection report to the Approving Authority(Board of Health or IIEP)within 30 days of complet' g 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 . DER The original should be sent to the system owner and copies sent to the 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 page 1 I N Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Bramblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12:2007 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: SO Bramblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12. 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to detennine 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 C1VII2 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has aseptic 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 50 Br•ainblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12 2007 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 50 Brainblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12, 2007 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)J. 5 Page 6 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 50 Bramblebush.Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [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: Unknown C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based.on 310 CMR 15.203): gpd 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: Unavailable 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 on 419185-per as built card Were sewage odors detected when arriving at the site(yes or no): No ' 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION(continued) Property Address: 50 Bramblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12,2007 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 grader 18" 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: 21' Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" 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: 10." How were dimensions detennined:_ Measuring stick Cotmnents(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 liquid level was even with the outlet invert ^There did not appear to be any signs of leakage 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 i Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: SO Branzblebush Drive Cotuit, MA Owner:. Barbara Harrington Date of Inspection: September 12, 2007 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): Alarn level: Alarm in working order(yes or no): Date of last pumping: Co mments(condition of alarm and float switches,etc.): 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.):. The D-box was broken down structurally. A new D-box was installed(see Permit No. 2007-393). PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarns in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): . r. 8 , w Page 9 of 11 . OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SO Bramblebush Drive Cotuit. MA Owner: Barbara HariinQton Date of Inspection: September 12.2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why:' Type ✓ leaching pits,number: 1-6'x 6'0600 zal.) 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, on,etc.): The pit was dry. The scum line was approxiinately 4'up from the bottom There did not appear to be any si ns of failure. A video_camera was used for the inspection 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): Connnents (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 hydraulic failure,level of ponding, condition of vegetation, etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 50 Brainblebush Drive Cotuit ILIA Owner: Barbara Harrington Date of Inspection: Senteniber 12 2007 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. i A(A L Q 3 � � y as yy 3 �. 10 10 a Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 50 Bramblebush Drive Cotuit, MA Owner: Barbara Harrington Date of Inspection: September 12,'2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/ 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 Barnstable topographic and water contours maps;the maps were showing approximately 50'+/-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been 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 septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 I Town of Barnstable OF 1HE t Regulatory Services y BARNSTABLE Thomas F. Geiler, Director MASS. 1639. Public Health .Division ATFo Nw�" Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. > '~ T N OF BA STABLE LOCATION �� r �05 SEWAGE#aOO N3 1 .VILLAGE ASSESSOR'S MAP&PARCEL no INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY (000 LEACHING FACILITY.(type) X Ca (size) /CW NO.OF BEDROOMS J OWNER PERMIT DATE: Q COMPLIANCE DATE: O 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 �h ^r 1 V � D :X No. . -00 ^ 7 FeeTHE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Yicatiott for ty 5a' *r5tem Cowgtruction Verm t Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ stem Complete Sy stem y ❑Individual Components Location Address or Lot No. �Go (�� Q, �tlSk (, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Cv_U+1 0y0 _eg +3A(�A(4 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G I'2 A RUTAP Os 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(min.required) gpd Design flow provided gpd 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) ®7C ftPAI 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 Certificate of Compliance has been issued by this Board o Health. Signed Date _ Application Approved by Date _ Z 7 7 Application Disapproved by: Date for the following reasons Permit No. 0 3 Date Issued �-oo l - 013 No. _ Fee / vV T ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN-OF-BARNSTABLE, MASSACHUSETTS ZIpplication for Mi5po5al *p!6tem Cow6truction Permit Application fora Permit to Construct Repair Z Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. So 8(/-m e.� sK Owner's Name,Address,and Tel.No. Assessor'sMap/parcel CUru1 "0Ll0 -ago/ IJP4(Ara �Arr1/1 +0(� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Gorton RUM US Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) i Other Type of Building No.of Persons Showers.(- ) Cafeteria( ) Other Fixtures t ` Design Flow(min.required) gpd Design flow provided gpd` Plan Date Number of sheets Revision Date Title f Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) OX CePAI 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 Certificate of Compliance has been issued by this Board o Health.^ O� t3 r Signed Date Application Approved by Date ! 7_0 Application Disapproved by: Date for the following reasons Permit No: Date Issued 7 THE COMMONWEALTH OF MASSACHUSETTS \' BARNSTABLE, MASSACHUSETTS 1`� aox rePAI( %� Certificate of (Compliance 1 THIS IS TO CERTIF ,that the On-site Sewage Disposal System Constructed ( ) Repaired / Upgraded ( ) Abandoned( hby ����^ at 50 6 A M V S rl-3 r I C 0Tu'fi has been constructed inaccordance n w q o with the provisions of Title 5 and the for Disposal System Construction Permit No. 0" d 7 7 3 dated ! 7 7. Installer Designer i #bedrooms Approved desig.-flow gpd �19 *0,rlvlx� The issuance of this permit shallnot/be colnst�ed as a guarantee that the,system will?func�onasdes�igned.Date < f I t � Inspector 'G i If i `\) ------- -------------------- f—"--- FeeTHENO. COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE, MASSACHUSETTS 1=igo5a1 1p5tem C 5trUction Vermtt Permission is hereby granted to Constru t ( ) Repair r ) Upgrade ( ) Abandon ( ) System located at Sd 0-Tv ' � V and as described in the above Application for Disposal System Construction Permit.The applic recognizes his/her duty �V to comply with Title 5 and the following local provisions or special conditions. Provided: Construction m 04completed within three years of the date of thisse> rrit— Date ' t U Approved by No....... .. > q0 _ Fxs........................... tAJ- � THE COMMONWEALTH OF MASSACHUSETTS /`r'1r' BOAR® OF HEALTH ........................OF... lv. ! ! -e......................................... Appliration for Disposal Works Tonstrnrtion Vrrmit Application is hereby made for a Permit to Construct (�_) or Repair ( ) an Individual Sewage Disposal System at: !�P.T.... l............. !F.l!`l� .Pl�S .........1..✓.. .. P -66J 7--•-•----............�..1------------•------•---------------------------------------- Lo lion-Address or L9t No. ...................... �`�'Cf T. r ..... `'- Owner Address -------------------------------------------- ---------- 'rr ..° . .......•....._............................. Installer Address Type of Building Size Lot....P",.S'A4?�......Sq. feet Dwelling—No. of Bedrooms.......3.............. Expansion Attic ( ) Garbage Grinder ( ) �._ No. of persons ................. Showers — Cafeteria p,, Other—Type of Building P�r. __..... p ( ) ( ) P4Other fixtures ......................... ............................................................... W Design Flow.........iP S...........................gallons per person per day. Total daily flow........t�#?........................gallons. WSeptic Tank—Liquid capacity.. 04PO.gallons Length....ej........ Width......5-------- 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 Dist bution Dos aPercolation r1Test Results ) Performed byl A t4 (.._F.ser t P .:T�-�--y�o.�,--- Date_".__Z7_f..t.9.d!_9----_-. a Test Pit No. I......j:P......minutes per inch Depth of Test Pit___!.. ........... Depth to ground water-_ !o!'___.._____- fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' •------------------------------------•----------•-••------••.......•-----------•....---.........---•......................................................... 0 Description of Soil---..�u.6?..... ............... -----------------------------------------------------------------•-----•------------. x �., ------------------------------------........-.......................-------..........---- ----------------------------------------------------------------- --------------------------------------------- W --•----------------------------•-----------------------••---------------------------.......----------------•-----------...-----•------------------•--------.------------....-•----------............-- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLH1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ued by Ile board of health. io�� Signed--- ..................... - -------------•-----•....... -���--�........ ApplicationApproved By.................................. = ` ......................................... _........... Date Application Disapproved for the following reasons---------------••------..._......------------------------------•----------------------------------------.....-- -•-•---------------•-•--•--•-•-•---•---•----•------•-----.....--•-------••----•-------••........•------•- Date PermitNo......................................................... Issued------------------------------ Date - No........ ......... Fss.........................._. THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH " .. ..�sJ........ '--------------OF.. J 1sN...`.�i' , .......................................... Appliratilan for Uiopoo al Works Tonstrurtinn ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: 12.M..I-q..1..._........ !'1`� .1_:b'.Lal a...a61.'/..J..E�. .. .C�j`�Cdr ...............•..... •- .............................................................- Location-Address or Lot No ................. ...G4?ir!"/22._ :?ra!?�cA....- 1. 1I/.7° Ll .. Owner Address . ` ----•-••----------•------------•-----••------ -------•-• .. Installer Address a Type of Dwelling Building Size of Bedrooms...... ..................................Expansion Attic ( ) Size Lot.�3.Garbage Grinder q feet 04 Other—Type of Building Ar6..,crf... ........ No. of persons__....._(................... Showers ( ) — Cafeteria ( ) a Other fixtures .---.....---•-----•-•-•••-...... •-- W Design Flow..•.....:!�_'E..............................gallons per person per day. Total daily flow.........,:, _p........._...•..........__gallons. WSeptic Tank—Liquid capacity./twa-gallons Length._.5......... 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 ( ) f�'<a a Percolation Test Results Performed by__ + �A� _ .c1 :t _---••-- r� ��y_-• Date �.��... _��..z_91._.___-. a Test Pit No. I.....9......minutes per inch Depth of Test Pit.�2'____._... Depth to ground water.LiLct tt C....._.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --•••-•---.•--------•--•--•-••-•-•••-••-•----••-----•••----•---•...••-•-------...--•••-•••.....••----••-----------•---•-••---__...............••--••--•-••-- D Description of Soil----.:i,� _._='a.a 4:...............zee �t ... `' x V W VNature of Repairs or Alterations—Answer when applicable..............................................................................................:. ----------------------------------------------------------•------•-----•--•-------------..........-----•----------------------------•---------------------------•--•-----.._............---•--••----... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by Ae board of health. Signed. :'.. I© /� �'..y..------ Date Application Approved By.. .�l':.. ----•----=................................ -1......: / Date Application Disapproved for the following reasons----------------•--........_........--------------------•---......-----------•----------------------------••••--- ..........................••--------••-•--•-••-•-----•-•.......-••-----••--•--•••.........-•-•-----•...•-.....------•-----•--•------••-••-•••••-•------------•--••-•-•-•-------•---•-••---•--••---•---- QQ Q° Date Permit No.____.....0....l-___�. 4-�.-----.--- Issued___________________ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...W t.�.l....................OF..)et, ................................. Tntifiratr of (SnntpliFanrr THIS IS TO CE IFY, That the Individual Sewage Disposal System constructed (" ) or Repaired ( ) b . / / Installer //+ at---•--...�c•i--••-�.!-•---- =R?a3 _ f"6.� "rw-If .....------'*C t� ------•-----------•---------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary°_Code as described in the application for Disposal Works Construction.Permit No,g../._"..?�_. 'S-.___•- -- dated___.-::___..................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST E® AS A GUARANTEE THAT THE SYSTEM WILL FU CTIO SATISFACTORY. DATE............./. ................•-•--------.....---••- Inspector --•-•• • ---•---. y�___. ��. • ----•---...----•--------•---•--- vJ ... :._... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J........................... ......................................... FEE..:j.i.._........ Disposal Mahn TD anstr ion pamit Permissio is hereby granted..._$f,,tero..-- R� � f ---------------------•---------•---------------.......-•------........................ to Construct? ),.or.Repair�( ) an Individual Sewage Disposal System atNo.----. ......Pr--------1"�.F L'?-L ........................................................................ Street as shown on the application for Disposal `'Corks Construction Permit No..................... Dated..................,........................ Board of Health. V / f� DATE............................. -------- ....--------......... � FORM 1255 A. M. SULKIN, INC.. BOSTON - e e LOCATION �J�-*q SEWAGE PERMIT NO. VILLAGE C®-�,3i INSTALLER'S NAME i ADDRESS oor d U I L D E R OR OWNER DATE PERMIT ISSUED -7 8 4 DAT E COMPL-IANCE ISSUED �- �� r q Q Y i M GFA.�EIzA.L NdT'ES �._ `. -- . (�--Air_. EcE�I'. SNc�ta1�..' A�'W MEc ,:.c. 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