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HomeMy WebLinkAbout0033 HIGH STREET - Health ,3 Hig ee h Strt a A = 035 104 I it r� -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL,` ,FFAIRS 45 i.,gi, t DEPARTMENT OF ENVIRONMENTAL PROTECTION -AJ �N 2.0 •s L. i !,� fr�r a. tk� ..•,J �F 1 ��• 0 UN r e , TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ...q,Property Address l'l-d4� - Owner's Name: /'C•944-✓--4;V Owner's Address: po Off /7/ n sT �_ OZG J.� • , Date of Inspection: HAPName of Inspector:(please print) <<J 1Y®/9• Company Name: E'}-S A F'Y`J ►/c PARCEL, Mailing Address: 1aV.1r`-4 PD,94X/7 Z9 LOB- e �9iYDsviGt,��. oZ,SG3 - - Telephone Number: &e> 3619 �ls B��• -Z4�'6 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Pazes onditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's S' i natur • C� - W Date: P g The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. FIGG�w get y � �`J� *Notes and Comments �F�l�/� �f/G�L/L pdC-di � �j?o�►I /J�%d��lr�'oc�x7�v4�17�✓a>� -S� �T pys✓a /7�R ****This report only describes conditions at the time of inspection and under the conditions of use at that J�a time.This inspection does not address how the system,will perform in the future under the same or different conditions of used - PA*,q,,.V/q 4-rx �¢�,6��y ,Clf�n/S �cc� dv�n_ �1^,2�8 -�i=c ��ac <�_u/s�� ei/o?o sr.�— o+ sA�o'�'! �r��srtled-Cjp,fawlyja tle ction orm 6/15/2000 page s Page 2 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property YAddress: S,— Tu�T • .. Owner• Date of Inspection: /— /7—C,5 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D stem Passes: - I have not foun rmation which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. a criteria not evaluated are indicated below. Comments: r System Conditionally Passes: ' One or " mores stem components as described in the"Conditional " Y p do 1 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. er yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. ; The septic tank is me ver'20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or ' n or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as a d by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,no n 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, led or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed J• distribution box is leveled or replaced � 4 O&OVri-4k lain: ce ��v�G� /�s�f D�Y,¢y✓k`�'� 0?G�i '� ��O'� C'c`S.5�'a The system requir more an 4 times a year lue to broken or o tructed pipe(s).The system will pass,inspection if(with approval of the o ealth): broken pipe(s)are replaced obstruction is removed ND explain: ` -- j Cr�C��l,D�lvt✓ �✓ `/�,.� 7Aq t Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: u1 C. r Evaluation is Required by the Board of Health: Conditions exist w i further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or e a nt. 1. System will pass unless Board of Health determines in accorda -th 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect puba,C,n4 Ith,sa nd 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. tern will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fu ing in a manner that protects the public health,safety and environment: _ The system has eptic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water sup1 or to a surface water supply. P Y �' PP .Y _ The system has a septic tank d SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SA d the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the S is less than 100 feet but 50 feet or more from►a private water supply well".Method used to determine ce "This system passes if the well water analysis,performed at a D certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free in pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less th ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this fo N� 3. Other: Page 4 of I 1 ; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: -- �/ Owner• Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No ✓ a&up 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 overl-:7ex;,fir ogged SAS or cesspool M� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or �pesspool _ ✓Li uid depth in cesspool is less than 6"below invert or available volume is less than day flow �tie wired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number imes pumped ✓✓✓���///_ try 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 er supply. y portion of a cesspool or privy is within a Zone 1 of a public well. ✓My 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.] . .4/a (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. All, 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• You mus icate either"yes"or"no"to each of the following: (The followin riteria apply to large systems in addition to the criteria above) , yes no the system is within eet of a surface drinking water supply.. . the system is within 200 feet of a tary to a surface drinking water supply the system is located in a nitrogen sensitive are nterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well s' If you have answered"yes"to any question in Section E the system is consi a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any a system considered a significant threat under Section E or failed under Section D shall upgrade the system in a ordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 00J,fg Date of Inspection: ! /7— 105-- Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes o _ Pumping information was provided by th owner occupant,or Board o`i�yealth Y 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? ✓ ave 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,*M ike SAS,located on site?_ v _ Were the uncovered,opened,and the interior of the tank inspected for the condition o- / f thebaffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? V — 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 15302(3)(b)] rKC-A6J"'2 ci's 5 Page 6 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: r T_ Owner: Q-1AAi Date of Inspection: I—I'7—D FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): A-- Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): P� Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or noj Seasonal use:(yes or no):A Water meter readings,if available(last 2 years usage(gpd)): 12:�01�OD '5­1I4 aer Sump pump(yes or no): A b Last date of occupancy: OMMERCIAL/II�IDUSTRIAL Typ establishment: Design (based on 310 CMR 15.203): gpd - Basis of desi w(seats/persons/sgft,etc.):_ Grease trap present o):_ Industrial waste holding tank p nt(yes or no): Non-sanitary waste discharged to the system(yes or no):— Water meter readings,if available_: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons—How was quantity pumped det rmined? Reason for pumping: /99g C? ��� �- 101MR,4/y TYPE OF SYSTEM Septic tank,distribution box,soil absorption system �_die cesspool - �d S C /2�IS,TU /-I "Overflow cesspool P _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,d to installed(if known)and source of information:. Were sewage odors detected when arriving at the site(yes or o): 6 Page 7 of 1 1 s . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)' Property Address: (lo Owner: Date of Inspection: 4 BUILDING SEWER(locate on site plan) /I - Depth below'grade: 1g0., - XI Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: G�'�/�/4/ -_�YL��✓7 ,O�t/Ji/L�/!c�Iic� Comments Io on condit' n of'o' ( n ups,venting,evidence of leakage,etc.): ! /G All SEPTIC TANK:_(locate on site plan) eS Dept low grade: Material o truction:_concrete_metal_fiberglass polyethylene _other(explain)) If tank is metal list age:_ sage confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: . Distance from top of sludge to bottom of outlet tee or e: 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: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, ctural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): CREASE TRAP:_(locate on site plan) ` Depth below gra Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba e. Distance from bottom of scum to bottom of outlet tee or ba Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle con ' ' n,structural integrity, liquid levels ' as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: -a Date of Inspection: TIG T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra 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.): DIST TION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above out e ' Comments(note if box is level and distributio lets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): /✓/ PUMP-CHAMBER: (locate on site plan) Pumps in working order o): Alarms in working order(yes or no): Comments(note condition of pump chamber,con ' ' umps and appurtenances,etc.): Page 9 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �l Date of Inspection: i-r7-oJ� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) /OSASat located Type i,-feaching pits,number:/ leaching chambers,number. hZllc�� �v l� t��� � leaching galleries,number: � � � � ��1��G�CST leaching trenches,number, length: re ,s,0�6 Z ,7s leaching fields,number,dimensions: /i.✓/�tl-✓d <•/t'� /vim G,de� p� i�„��,�e �j� overflow cesspool,number: innovative/alternative system Type/name of technology: g� Comments(note condition of soil,signs of hydraulic fail. le eI of ponding,damp soil,condition ofvegetation, IVdL ,ecr tc.);- ! ��a'��1'��' tit��egpp CESSPOOLS: (ces pool must be pumped asp of inspection)(locate on Number and configuration: / O+d' ! 'f C'!/" ".G/,E I d�/�'/1(/Lr '� Y"e T� 3 s vW Depth-top of liquid to inlet invert:_ "ve i,✓c�� Z,93 �t/my Depth of solids layer: 617, r ')@"OVTce r- C Depth of scum layer: /Dimensions of cesspool: ���G Materials of construction: Indication of groundwater inflow(yes or no):40 Comm is(no con i ion of sop,si ns of ydr ul ilure,level of ponding,cond' ion of vegetation,a c.). / v vie e4vHC �zs- ..C. 1o24�i v ¢� %��'1 ��S��J�r�'/c2c✓�o�,✓�r�n�wlc!!` yi o�'-�-c�5'v'�� PRIVY: (locate o e an ��d�✓�� �Qs9��lF Materials of cons Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,le onding,condition of vegetation,etc.): " 9 Page 10 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address J J Owner: ' AAJ Date of Inspection: 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. � to � /15 l/E7tT_G-ZCr 1 4w,/p ' 43.tl S i.✓c 6-I'iw 44/D Ao X4 419vr y Y7.c.) 33 �o(p��vgOLnt j V 10 Page I 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: SITE EXAM 6 Slope / Surface water Check cellar Shallow wells 7'a.*r4/6✓4fVzrt-A4J t fe6. .Uorr� / Estimated depth to ground water feet ..i W:kv 16x6f-to,a-- l3 /tom���,tr.✓' �v�� �✓Laavfeic� .—•- � Please indicate(check)all methods used to determine the high ground water elevation: l�loac> 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: C c ed with local excavators,installers-(attac documentation) �Z 110 �Jd�o�i7.p i Accessed USGS database-explain: '1P&ZA 6—) CL ZX1 � You must describe how you established the high ground water elevation: dig 4e4 /1'/7 Garr J a II `� TOWN OF BARNSTABLE LOCATION J3 / �P .5�/ SEWAGE # ^VILLAGE v ASSESSOR'S MAP & LOT —�U J INSTALLER'S NAME&PHONE NO.�M -e, J/'i e J/�o SEPTIC TANK CAPACITY LEACHING FACILITY: ('type) �� (size) NO. OF BEDROOMS 4/ BUILDER OR OWNER h7t -YC C > I C.V PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 29 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 feetpf leaching facility Feet Furnished by v� Z°91-� - W �' 07) 1'. Z ZZ �31 a TO OF BARNSTABLE LOCATION 3t �l �e e SEWAGE # VILLAGE CD ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. , E APACITY Elf' ��l i,��wifi'7�9 = Scat✓c� ENE LEACHING FACILITY: (ty ,x 4041Z W--e (size�o NO. OF BEDROOMS `'`/J"s /N,s�',. Tu�� ; Eby-v✓9 3G/9 OWNER }Lf-/e&Vd1-,94/ C1A1*a gqgvZ-�- /-/7—O S if-;y PERMITDATE: COMPLIANCE1 DATE Separation Distance Between the: � GIB QZ Maximum'Adjusted Groundwater Table and Bottom of Leaching Facility ` Feet 7ACW— Private Water Supply Welland 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 //// r y�.d Feet Furnished by 5�� 64 `r�4/z- T7�S"144�,a mvzx F f sZ b a / No. tl-no Fee AMVesl THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIppiication for 30igpogar *pgtem Cottgtruction Permit Application for a Permit to Construct( , )Repair(11�1- Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel — Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. /Y/ /Z7— Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) \ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss by this Bo e�lt Sig Date�— Application Approved Date Application Disapproved for the following reasons Permit No. O-GO S 'n3 6 Date Issued i TOWN OF BARNSTABLE' LOCATION J SEWAGE# . VILLAGE v ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. dC SEPTIC TANK CAPACITY LEACHING FACILITY: (type) w �y (size) NO.OF BEDROOMS BUILDER OR OWNER . PERM);TDATE: Z —f COMPLIANCE DATE: Separation Distance Between the: �' Feet Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet�f leaching facili , Furnished by 07) a ZZ 31 O`er _G J 1� - �2,o No. Fee, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ppfication for Biopoaf *pgtem Conotructfon Permit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. "� Owner's Name,Address and Tel.No. 3 3 l iy s�' c m�"' J dye le 3 q,� r�►.-� Assessor's Map/Parcel © .3 -Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l i k/y/ T Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil + Nature of Repairs or Alterations(Answer when applicable)Q\-,C k Date-last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by this Bo d eglt Signe / Date Application Approved Date 1 C� Application Disapproved for the following reasons Permit No. QQQ S --03 Ln Date Issued t 0 O _ ———— —————————————— ---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired )Upgraded( ) Abandoned( )�� y �Y t� at 33 ITS has been constructed in accordance with the provision f Title 5 and the for Disposal System Construction Permit No. :Yr 5-03 (v dated / eg,Ao S Installer �=—c- Q i 11 Designer The issuance of this permit shall not be construed as a guarantee that the system will futiction as designed. Date 1-� d Inspector �- ^,r i x No.�/ Q 3 (P Fee_AQ•— THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Diopoof *pg;tem Con5truction Permit Permission is hereby granted to Construct( )Repair( ,,pgrade( )Abandon( ) System located at S'� . ✓ l and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the�te of this Date: _ Approved b