Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0030 FULLERS MARSH ROAD - Health
'30 FULLERS MARSH ROAD, COTUIT A= 006 031 " I i 1 Town of Barnstable Geographic Information System June 7,2017 C 006030 ,�r� r #10 N , IZ "1 N • 006063' ' tt v , 006042 #312 #666 U o#30 #30 6031 # NE 1000E R� P� oosoal #35 006033 #309 OD65 34 i 0D6040 0 #51 DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:006 Parcel:031 117-1 LLJ boundary determination or regulatory Interpretation. Enlargements beyond a scale of Owner:HOWELL,MARK L&PAMELA J Total Assessed Value:$300100 Selected Parcel 1'=100'may not meet established map accuracy standards. The parcel lines on this map are only graphic representations of Assessor's tax parcels.They are not true property Co-Owner. Acreage:0.93999082 acres Abutters boundaries and do not represent accurate relationships to physical features on the map Location'30 FULLERS MARSH ROAD such as building locations. Buffer F` -(� 1 _TOWN O,F�BARNSTABLE \\ LOCATION � '� y&,Q ishyj SEWAGE # VILLAGE CO'�i�� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) \ �� c1VLLWn Q1f (size) NO.OF BEDROOMS BUILDER OR OWNER't�1C PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by S• aQCA pexc.�► . i u � � � � o � ��3$ � S3 � �� � � 0 � � 3� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owners Name information is required for every Cotuit MA 02635 04/12/15 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Mike Hudson use the return Name of Inspector key. Septic-wiz Environmental Services Company Name 31 Midway Dr Company Address Centerville MA 02632 Cityrrown State Zip Code 508-367-5669 DEP SI#4254 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluatlop by the Local Approving Authority 04/22/16 Inspecto Si nature Date The stem 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 to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the condi 'ons of use at that time.This inspection does not address how the system 11 perform 1 fut re under the same or different conditions of use. A t5ins•3/13 Title 5 Official Inspection Form:Subsurfa Sewage Disposal System•Page 1 of 17 A Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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: System in good working condition at time of inspection. 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): , t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ~ 30 Fullers Marsh Rd : Property Address W .+ Frank&Marilyn Doulette Westerhoff Owner Owners Name information is required for every Cotuit MA 02635 04/12/15 page. City/Town , State Zip Code, x Date of Inspection B. Certification (cont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y `,❑ N ❑ ND(Explain below): ❑. obstruction is removed ❑ Y ❑ N ❑ Nb(Explain below): ❑ distribution i'box is leveled or replaced ' ❑ Y ❑ N ❑ ND(Explain below): 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 ❑ Y .-❑ N ❑ ND(Explain below): ❑ obstruction is,,removed ry ' ❑ Y- ❑ N ❑ ND(Explain below): a C) Further Evaluation is Required by the Board of Health: h ❑'Conditions exist which require further evaluation by the Board of Health inorder 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 . x t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ' x Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"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%day flow t5ins-3113 Title 5 Oftidal Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts " - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments ; 30 Fullers Marsh Rd Property Address , Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit ^ ' �MA° 02635 04/12/15 page. Cltyfrown State Zip Code_ Date of Inspection B. Certification'(cont.) Yes No t ❑ ® Required pumping more than'4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:` " ;E 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 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. The system'fails. I have determined that one or more of the above failure ❑ ® F :.y 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: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. F For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D.` - 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 ll 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 e system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•all _ Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. Cityrrown State Zip Code Date of Inspection C. Checklist 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: ® ❑ 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(5)] D. System Information Residential Flow Conditions: 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 GPD t5ins-3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd V Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 3 bedroom house Number of current residents: 0-for sale Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection. ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2013-97 GPD 9 ( Y 9 (9P ))� 2014-97 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: unkownDate 0(n,. - Commercial/Industrial Flow Conditions:. V Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ,.; ❑ Yes ❑, No Non-sanitary waste discharged to the Title 5"system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: BOH, Treatmant Plant Barnstable Was system pumped'as part of the inspection? ❑ Yes ® No If yes,volume pumped: N/A gallons How was quantity pumped determined? N/A Reason for pumping: N/A 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owners Name information is required for every Cotuit MA 02635 04/12/15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: k 42 years old, installed 1973 per Barnstable BOH, inspected in 1996 and passed Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 30" Depth below grade: feet Material of construction:, ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line. N/A feet Comments(on condition of joints,venting,evidence of leakage,etc.): vented thru roof, no leaks Septic Tank(locate on site plan): 17" Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) .. N/A If tank is metal, list age: rears Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No Dimensions: ' 4'10'Wx8'6"Lx5'8"H- 1000 gallon Sludge depth: 4'10"(2"thickness) t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y� 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owners Name information is required for every Cotuit MA 02635 04/12/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 2„ Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? sludge probe, LED snake camera, floodlight,tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Pumping of tank should 1X every 3 years, inlet and outlet baffles in good condition, liquid level normal in relation to outlet invert,tank appears structurally sound and not leaking at time of inspection. fGrease Trap(locate on site plan): V Depth below grade: feet 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: Date t5ins•3/13 Tile 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): r Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): nr J� Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments aY 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owners Name information is required for every Cotuit MA 02635 04/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) N 1 Distribution Box(if present must be opened) (locate on site plan): r 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.): PumpChamber locate on site Ian N A ( plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No*. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located,explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 . 04/12/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1)6'Radius w/2'stone ❑ 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.): med sand, no signs of hydraulic failure, no ponding, damp soil or abnormally lush vegetation, bottom of SAS 11"below grade. (1)6'radius 1000 gallon concrete leach pit w/2'washed stone around. Stain line 44"below invert in. Empty at time of inspection. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 e Commonwealth of Massachusetts Title 5 Official Inspection Forrm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is Cotuit MA 02635 04/12/15 required for every - page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t n Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 't 30 Fullers Marsh Rd Property Address - Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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..Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately '4 R t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 30 Fullers Marsh Rd Property Address Frank&Marilyn Doulette Westerhoff Owner Owner's Name information is required for every Cotuit MA 02635 04/12/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope 3 ® Surface water 1N ® Check cellar ® Shallow wells iV I A, Estimated depth to high ground water: feet. . Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS water resource and topographic maps You must describe how you established the high ground water elevation: Reviewed prior septic inspection. Reviewed USGS topo an water resource maps. Bottom of SAS 11' below grade. Estimated high water at 14. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments g 30 Fullers Marsh Rd - Property Address Frank&Marilyn Doulette Westerhoff Owner Owners Name information is required for every Cotuit MA 02635. 04/12/15 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A,'B, C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 30 Pullers Marsh Rd Cotuit, MA A B Deck 1000 gallon septic tank 1 O 2 O 6'x6' Leach Pit w/ stone around 3 FA3A2 33' Bl 17' 38' B2 21' 53' B3 - 39' x .' � arrr+'#1Y i,-.,'•`� i ��,i�� e�.-�€�� _.�y�zry ��, � `��.sf �y���'3.�1q" Ft'� ► / r - s - 7` ''^ -' 'es-• .sa" �^'_ Execu ve Ofl�ce o Ern o_nrt�entarAff - - Septie_Inspecfor QgPrd `f!!'1�1�� M= P:O:Box 2179- w j � Teahcket,.MAa2536 =_ - 111 �'Qh1 �fE1� � = 5 56468r3. - _� n = l = - - -q. SUBSURFACE SEWRGE DISPOSAL SYSTEM INSPECTION PART-A---- CERTIFICATION - -- d. FULl.L'ts -- t Property Address:--_30 Fuller Marsh Rd.Cotult Address of Owner t 0109196 Date of Inspection:: ,.: :;' � �4.' �. '° (If different) _ Name of Inspector.'John Grad _ Ego. Company Name,Address and Telephone Number: CERTIFICATION STATEMENT "I certify-thaf'I-have,personally:,inspecte'd_the�5ewage disposal systerrrat this address and that the,information-reported below is true,accurate and complete as of the time of inspection'The inspection was performed based on my training and experience i rr q c and maintenance of on-site sewage disposal systems: The system:`: ®� ���� X Passes Conditionals Passes — Y T _ Needs Furityar Evaluation By the Local Approving Authority Fails Inspector's Signature: Date 101919ti ° The System Inspector shall submit a copy of this inspection report to the Approving.Authority within thirty(30).days`of completing this inspections. 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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B.C, or D: . A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES One or more system components need to be replaced or repaired...The system,upon completion of the replacement or repair,passes inspection: 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,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is' imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11115/95) One Winter Street a Boston,.Massachusetts 02108 . FAX(617)556-1049 9 Telephone(617)292-5500 n�Y �r r 5f Cat`' - - �i ' { �Y � •- fi �� �� z �� SC`M. - :3 wF„��,��<—�.-��y-�-a'aa-.:f�'�;�;.�-_+�-,r'•"�.,-F+. ._..a�'�, ""'_ �.��a..�, --� -,s�'x` .4^tr�es - ^''�.`^"�-�s3-as:•n` ?g� : - - SUB.SURFAGE SEWAGE DISPOSAL=SYSTEM INSPECTION:FORM _ t = - - _..�_ —_�. .� � �. .-V �, - CER�IFIEATiOD�co�►�f-ts�le�#�.- _ __ � �-`- -- _ - - _ q PropertytAddress 30.FullerMarshRd Gotult owner: — �gr�},�-98l9919B _ _ c1 . n awage cuR or r akout orb wate�leael ibserued In tk a dlstnbudd bows duasa ab[sZCCe ` settled or:uneverr`_dtstnbution bow Thesystem wiN:pass inspection if_4wdh appxaval of the Board ofiKealth) = _ = broken i e s are replaced __pipe( ) obstruction is removed _ - distribution box is leveled or replaced. _The system required pumping more than four-times a year due to broken or obstructed pipe(s): The — system will pass inspection if(with approval of the Board of Health): broken-pipe(s)are replaced _ t obstruction is removed C] FURTHER EVALUATION IS.REQUIRED BY THE BOARD OF HEALTH: Conditions.exist which require further evaluation by the Board of Health in order to determine if the _ 'system is failing to protect the publicahealtK safety 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 privy is within 5Ci 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 APPROPRIATE)DETERMINES ' THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has aseptic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water.supply. The system has a septic tank and soil absorption system and is within a Zone,1 of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well: _ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,"unless a well water analysis,for coliform bacteria volatile organic compounds indicates that the well is , free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm. 3) OTHER D] SYSTEM FAILS: _ _ I have determined that the system violates one or more of the following failure criteria as defined in . 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be . contacted to determine what will be necessary to correct the failure. t - Backup of sewage in facility or system component due to an 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 cesspool. - SAS is in hydraulic failure. (revised 11/15195)w ..0 .t �' .r.ic+a...2s �. �ae..i'.°F n,y v .: ...:,.0 a.Y=....,d'Yh(sf?♦""`a�:.,mn.... -.. ,.' �:h�.......,. _._—_ _._--_ 4.. ._ —'_- Reg „� "' rz w _ . 'may '•a---�� —� = SUB5IJRFACE SEVAffCGEDLSPO&AL SYSTEOII_INSPECTLON FORM �ontitxeled -- - - - � _ CEi�tF1C'A'Tt01s1,: F�ropertAddTess 3oFuUerMarshRtkCotult - a m `13 sYS EM FAILS(continued) T Static liquid-level in the distribution box above outlet invert due to anoverloaded or clogged :SAS or cesspool Liquid depth in-cesspool is less than 61"below invert or available volume is'less than 112 day'.flow. Required pumping more than 4 times in the.last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,-cesspool or privy'is below the high groundwater;'elevation Any portion of a cesspool or privy is within 100 feet.of a surface water supply,or tributary to a surface water supply.. 21. Any portion of a cesspool or privy is within 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 orprivy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable'water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic,compounds;ammonia nitrogen and nitrate nitrogen: E] LARGE SYSTEM FAILS: a; The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface-drinking watersupply _ 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 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information. t . ,- r• (revised 11I15195], w• 'fi k`' _ Syr _. r , R P• "psi= ,. �"sw` - _:r,;�-, 'r'-` 'x'". �T'-'�3 •c9,•. G :_ -., '` z� y, - --n' a - •n ,r MT x - 17 _ « SUBSUREaCE 5EWi0.GEDlSPOSALSYSTEIN{NSPECTION-FORM = - .---=�GFkE�tS - - - Pro ers Address 30.FuIlerMarshRd Cotill6 - - - � ;f�ate,stf_Insoecticr�101Q9(96-• _ � ; _ . _ � �-- F Check if the following have been one: x Pumping information was requested of the owner,occupant,and Board'of Health. X- None of the system components have been pumped for at least two weeks and the-and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. nlaAs built plans have been obtained and examined. Note if they are not available with N/A X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. „ X The site was inspected for signs of breakout. - X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions, depth of liquid;depth of sludge, depth of scum. - X The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub r Surface Disposal System. _ R1 revlsed.l'.1115195)_„ .` �' t—.. "'`•-s'�•...'--•�"�.��a-•'s^�- .€`::e�i_ �-a�.:Fz" _�.-�S �ems' '� �' �n��e`z"`�— _.` `�'—�""'r -�v-^aa'� � - �`-�� � - Y -SLIBSURFAGE,SEWAGE QISPOSAL.SYSTEM INSP"ECTION K -- �— = _ .S6X&TE1VtF[�FO}�JYIA-TtON�tfl _. w 77 . r _ ProRe0y Address 30 F.ullerMarsh Rd 0RUI y DesigFl flow:-'�o` gallons - ,,, _ 4 �..^�u►ohP.r"a__f._b�dr_os�s: 3' - NumbeF":oPcurrer>t`resldents Garbage_grinder(yes or no.): No Laundry connected to system(yes or no): Yes Seasonal use(yes or no)- Yes Water meter readings,if available: nla Last date of occupancy: summers _ COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:9 gallons/day Grease trap present:(ye''s or no) No :4 Industrial Waste:Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings, if available: nra Last date of occupancy: nra OTHER:(Describe) Na Last date of occupancy: " GENERAL.INFORMATION ; PUMPING RECORDS and source,of information: System has not been pumped in the last two years System pumped as part of inspection:(yes or no)Yes If yes,volume pumped: 1000 gallons Reason for pumping: Maintenance. TYPE OF SYSTEM X Septic tankidistribution. box/soil absorptions system Single cesspool Overflow cesspool y Privy Shared system(yes or no)" ( if yes, attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all components,date installed(if known)and source information: 1973 Sewage odors detected when arriving at the site:(yes or no) Yes -(revised 1.1115195) h' # i Fh -10 r5�"a x w�9 gm .. 411, r - __ 5 - — - - =`'e� '��2'_?� s'^�'.h"�• ?'- - -ter : -. SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION.FORM " m - - _ SYSTEM INFORMATION:,(continued)- -- n gyp:: .;Property Address.'30 Fuller Marsh Rd Cotuit tAL[teE EgO. s e i Date of Inspection 10/09l96 '_'�" """� SVTIC;;--TAN-K X - (locate on site_plan) _ _ Depth below grade Material of construction:X concreate_metat FRP_other(explain) Dimensions: LS"6'-H5'7'W4'10' Sludge depth:4' - Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum-thickness:0 Distance from top of scum to top of outlet tee or baffle:6' ,= Distance form bottom of scum to bottom of outlet tee or baffle: 0 Comments: (recommendation for pumping,condition of inlet and outlet tees or,baffles,depth of liquid level in relation to outlet invert,structuraf integrity,'. evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping system every tWa years for maintenance. GREASE TRAP: (locate on site plan) Depth below grade: nia Material of construction: _concrete_metal_FRP other(explain) Dimensions: n!a Scum thickness:n!a Distance.from top of scum to top of outlet tee or baffle:n!a Distance from bottom of scum to bottom of outlet tee or baffle: n!a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,; evidence of leakage,etc.) Na i (revised.l.1l15I95) ; . 3�,4 yRIM VLSvdl� v-. '� .+n+E,rCyy .G�r:bfi+:C4 : FIN A .. � r7n ..... - +•.5.,., �,_ ir � 4`" ^sa 'tea ..a '-' ,�""'^ •.a-n' ._,' o•,,`-r''' x`tc ---._ .',�.—'-MP�--�--"s`'a� U �1 SUBSURFACE SEY�IAGE DISPOSAG�SYSTEM INSPECTION FORM - - -&` nued}i`= - -- _ 35, --P. _ -_:.. _.._ _ eft__Add Cotult ress 3llerMar , — - - - shAd r;-_ Ego,. _ Qa�e o [aspeati:on t01o919 = - R TIGHT`'OR HQLDING_TANK "- - SWC Depth below grade: nla- ,.Material of construction: concrete metal_FRP_other(explain) Dimensions: Na Capacity: nta' gallons Design flow: n/a gallons/day.- - - Alarm Na level: , Comments: `h of alarm and floats witches etc. - e condition __ r'inlet to ) nla. s. DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n1a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) nla PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) rVa (revised 11115195). r �.�'T��� .�M� ,�,�-�.r.•� "+-«� �3�5-.-�u�_ - �- �.��"-�!!��"x-•- •-s .� 3cr-- =�i. � � _.e< x r � SikBt1#2RACE SEVIfAGE DISPOSAL SXSTEM INSPECTION FORM - �EAk'It�1 --Property Ad�dies_s 3Q Fulter�Marsh-Rd Cotult � - � # � _ , SOICRBSORPTION SYSf W AS-) •- :.—(locate on.site-plan,it possible;excavation not'required„but.may be approximated by non-intrusive methods) S ». -• -If"not deterrhined to tie present;-explaiFl - rda Type. leaching pits, number: 1,000 gallon[eachptt leaching chambers,number:n1a leaching galleries, number;n1a "leaching trenches,number,length: nla leaching fields, number, dimensions:n1a 4 overflow cesspool, number:n1a Comments:(note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation etc.). The leach pit was*npty at the time•ofthe inspection At is structurally.sound:. ; ,.. CESSPOOLS:_ (locate on site plan) Number and configuration, n1a Depth-top of liquid to inlet invert: rda Depth of solids layer: n1a Depth of scum layer: n/a Dimensions of cesspool: n1a Materials of construction: n1a Indication of groundwater: n1a inflow(cesspool,must be pumped as part of inspection) Na Comments:(note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: n1a Dimensions: n1a Depth of solids: n1a Comments:(note condition of soil, signs of hydraulic failure,level of ponding;condition of vegetation,etc.) PrivyComments (revised 11115195) a x . Tl -r Le; •r f < . s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART C _ SYSTEM INFORMATION(conflnued) - Prope S: "30 FuICerMarsh Rd.Cotuft — - — -_ Owner: --Ego - - — Date of lnspectlon:.1=9/96 - SKETCH OF SEWAGE DISPOSAL SYSTEM. - ---- - - — -- -- i velude-tres-to atleas tw-per---n references landmarks or benchmarks- ---locate all wells'within 1D0' - - -` ------- ---- -- ---- --- -- - - - - - -- - - - _ z - Per 6 4 ' of - fTV3 3 Tf a DEPTH TO GROUNDWATER , Depth to groundwater:12 feet method of determination or approximation: USGS Maps and Charts (revised 11/15/95) s r r: ri r No-------- 1............. FRs.. ...r..:/...:_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -. ... rz .- .--..-.OF....i........ ....... ...... ---' , ppliration for Uispnutt1 Workii Tonstrnrtinn Prrulit Application is hereby made for a Permit to Construct (Mor Repair ( ) an In ividual Sewage Disposal SystemVat L ion-Address _ or t o. (�Uwner- Addres W ' Es�6-•'• a -- ----- _l______________________ Instal r Address d Type of Buil i`n� Size Lot_Z:11---3zU_----Sq. feet U Dwelling;!No.No. of Bedrooms----------________..........................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ____________________________ No. of persons........................... Showers ( ) — Cafeteria ( ) P.' Other fixtures ...................................................... Design Flow_ _______________________ ._... _gallons per person per day. Total daily flow__-____________a..11" ------------gallons. WSeptic Tank Liquid capacity --gallons Length________________ Width_-__-_-__-_-____ Dirtmeter_____-_____-____ Depth__--_______-_--- x Disposal Trench—No..................... Width-------- ...------- t�t nth�. _�tal leaching area-----------_------sq. ft. Seepage Pit No,,-,,/............. Diameter_. _- Dep be ow inlet._._._____.____.____ Total leaching area___c _ -'sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-, Percolation Test Results Performed by.......................................................................... Date---------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. Z..............,minutes per inch Depth of Test Pit.................... Depth to ground water----------------_____-_. --- -- ---------------••••-----•--••••--------------•-••-•---------------------------....-----••-• ----------------------••---•---- ODescription of Soil_----p ........................................................................... ------------------------------------------- U .-------------------------------•-•------•----------------------------=-•• ----------------------------------------------------------------------------------------------------------------------------- W UNature 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 Article XI of the State Sanitary Code—The der igned further agrees not to place the system in operation until a Certificate of Complianc s enriss ed b the rd of health. igned--- •C-�------ -•• -•----•---- -- D e Application Approved By............/ ----- - '1- .-- ------ Date Application Disapproved for the following reasons---------------- -------------- ------------------------ -------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued..................... ................................ Date No.. �----•-•---- FuE.-. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............OF.... ................... .Appliration for Biliposal Works Tonfitrurtion Pumit Application is hereby made for a Permit to Construct ( or Repair ( ) an In ividual Sewage Disposal System at• ) - . .. :tax' _.... -- >� ( . �° •-----. -------------------. ------ -- ----- ---- - ---- ---------- --- L tion-Address or Lot No. ' - _ `r Owner Addres W •------f• -----• --"•r ____- •----------•-•-••------•--------•- -------• _ t----------------------- Instali�r Address UType of Buil ing Size Lot. .. ... A P.....Sq. feet �-, Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria. ( ) Q' Other fixtures --------.--- ........................................ W Design Flow......................:� :...___-gallons per person per day. /Total daily flow................ ...62-77-d_-----------gallons. R,' Septic Tnnlc Liquid capacity--V..J_gallons Length................ �Vidth______._...____ Diameter----------------- Depth---------------- Disposal Trench—No_---------------------_Width.................... of£ -Len-fll-________.__tee!_- tal leaching area-___ _.•_--•sq. ft. 3 Seepage Pit No..../.............. Diameter. .....-....____ Dep' :below.uil t......___.-.....____ Total leaching area__ 4�_sq. ft. z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed by........ _............................................................ Date----------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.----__--___--_-_----- . 41 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ------ j -------------- --..............................................................................................----------------------------- ODescription of Soil--------------- - -------------------- --------------------------•---------------- "� U -------------------------------------------------------------------- ...........................................................------------------------------------------------------------ W UNature 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 Article XI of the State Sanitary Code—The u.de>signed further agrees not to place the system in operation until a Certificate of Compliance-h�been.issued by the b©a'rd of health. . 6,�;g ` igned_ ` y .�z---`r-d' c� d" . ----- -------------------------------- Application 'f � f�, D to � Approved BY T� - ' �$-'Q ------------- - - - -� �• Date Application Disapproved for the following reasons-------------------------•------(---------------------------•-•--••------------------•...----------------•---- ..--••-------•---••----------•--•----•-••---------------------------------------------•-----•-------•----------•------•--•-------•------•-••-------•-- ................................................ Date PermitNo.......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF........ ....................`................ Irntifiratr of flu t lift rr S IS TO CERTI , That the Individual Sewage Disposal System constructed ,( ) or Repaired ( ) by--•� -- -- ::-••- -- w .�. Installer f e p at .�" _. ..tom _ -' has been installed iaccordance-with the provisionsof -le XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No........................... J.--. dated:..__ -. - ......_.. THE BSSilANCE OF TEAS CERTIFICATE SHALL NOT BE CONStRUED AS A GUARANTEE THAT THE SYSTEM WILL_FYNCTION SATIS'FACTORY r r DATE----------•-. . -------- Ins ecto--- -- arm- - --•---•--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No....... .....----- FEE... ` Permission is hereby granted'•• .* . _4 4-f�° -------------------------- ---------------------------------- Sy to to Constr t ( or Repair ( ) aIndi 1 S age Disp dal . , •a'. Street as shown on the application for-Disposal Works Construction Permit No__�_ _:_.___._ _ Dated-_-,t`�?:-����______________ - --- ----------------------------- Board'of Health DATE--- M A x - :. FORM 12HOBBS & WARREN. INC.. PUBLISHERS _ Pry-r2-7- o (= t.0 7— O N0T Pl-07T FQ M TH T� C TOWN OF .RAR:NSTARLE i BAHd9TAI1LS, i _ . 16j oo� 9: �� BUILDING '. INSPECTOR 'Fp ypy a`• APPLICATION FOR PERMIT TO V 1 ....... tr TYPE OF CONSTRUCTION V1�Q Sj s ......... ...... ..�... .,t........... i ."ter" ..:........:............: : TO THE. INSPECTOR OF BUILDINGS: The underlsiiggned hereby applies for a permit according tothe following infor ation: LocationU :. :. .:.... ProposedUse .:...:... ......... ......... ......... ...........................:................ ...... ...............S............................................ Zoning District ..::.:. �^-� ' ` ..:.: C (� ' Fire District .... .........................:......... :..:.:.:...............:........ Name of Owner 1v).P } ................... Address-Z.! W.=� P 5T 'r 2..: . ... . . ." - ..... V I a Name of Builder :1 .' /. .:;...!"1t�!1 ........Address � !....�??.. .. '�.:..` Name of Architect .................................... ...:..... :............Address ..........:............:......... ............... :.............. Number of 'Rooms .............:. ..... ......................... ..................:Foundation . Exterior f,. -.. ... ....�.... . ... .............. .. ......... '^ iO� ............ Floors ...�(..: .. .0.....:� .. ......... ......Interior .../- - .....�..� • r_ Heating :..:.:.Plumbing �......................................................' .... ......J. ...� Fireplace ...... ...... ................... ............:::.Approximate Cost Definitive Plan Approved by Planning Board :________ ------_----19------ , ��, Diagram of Lot and Building with Dimensions 1. a � " SUBJECT TO APPROVAL OF BOARD OF HEALTH { .f A� Moo tu IL U .. _ `xCL LI C) < k- �F U LL- C� Wj {� 8on LO � �- j ¢ Q � hereby agree to conform to all the Rules.and Regulations of the Town of Barnsta le regarding the above construction. � � � � k e pNam ..... t .. ........... 10�7 No ...��8�3... Permit for .......one...story............ . ......... single family ................... ......... S. Location ...Fuller Marsh Road i .................................................. cotuit ............................................................................... Owner ............Ma#an Ego............................................. Type of Construction ..........;U949..................... ................................................................................ plot ............................ Lot ......... ............. January 25 73 Permit Granted ..... ...... .............. 9 Date of Inspection 9 Date Completed 7j...........19 I 1 J .PERMM REFUSED .........................I......... 19 A ................................................................................. lJ . ............................................................................... ............................................................................... ................................................................................ Approve.d ...................................... 19 ............................................................................... ...............................................................................