HomeMy WebLinkAbout0262 MARINER CIRCLE - Health 1 �262 ,Mariner Circle.e
Cotuit p
-------_—_ - - - - A = 024 139
III
DATE: 3/1 /02
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PROPERTY ADDRESS: 262 Mariner/ Circle
Cotuit,Mass.
02635
------------------------
On the above date I Y
Inspected the septic system at the above address.
P P
This system consists of the following:
RECEIVED
1 . 1000 gallon septic tank.
2 . 1 -Distribution box. MAR 0 7 2002
3 . 1 -1 00 g llon p ecast leachin pit. 6 'X10 '
based on my nspectlon, I certify the following conditions: TOWN OF BARNSTABLE
4 . This is a title five septic system. ( 78 Code )
HEALTH DEPT.
5 . The septic system is in proper working order
at the present time.
6 . Waste water is 61 " below the invert pipe of the leaching pit.
SIGNATURE:,
Name:-J_�_ Macomber ,Jr
Company: Josejph_P_ Macomber_& Son , Inc .
Address:- Box 66
--------------------
Centerville , Ma . 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachf lelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775.3338 775-6412
COMMONWEALTH OF MASSACHUSETTS
t 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:262 Mariners Circle
Cotuit,Mass.
Owner's Name: Nancy Clough
Owner's Address: gamy
Date of Inspection:
Name of Inspector: (please print) Joseph P.Macomber Jr.
CompanyName:J.P.Macomber & Son Inc.
Mailing Address:gnx 66 rant-t-rvi1 le,
Telephone Number: — 5— 338
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. 1 am a DEP
approved system inspector pursuant t Section 15,340 of Title 5 (310 CMR 15.000). The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation by the Local Approving Authoriry
Fails
Inspector's Signature: Date:
The system inspector shall u it a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of co leting this inspection. If the system is a shared system or has a design Clow 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 7
conditions of use.
Title 5 Inspection Form 6/1 512 000 page I
Page 2 of i 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:262 Mariners Circle
Co ui ,Mass.
Owner: Nancy Clough
Date of Inspection: 3 1 0 2
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. �temPasses.
_t1p have not found any information hich indicates that any of the failure criteria described in 310 CMR
15.303 or in 3 .3 a exist. Any failure criteria not evaluated are indicated below.
Comments:
The septic system is in proper working order at the
present time.
B. System Conditionally Passes:
lt4d 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.
XlO 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:
4 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:
1�� 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 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 262 Mariners Circle
cotuit,mass.
Owner: Nancy Clough
Date of Inspection:
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(l)(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.
40 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
a The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
V2 The system has a septic tank and SAS and the SAS is less than 100 feet but 0 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: 262 Mariners Circle
Cotui.t,Mass.
Owner: Nancy Clouch
Date of Inspection: 3/1 /0 2
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
Y Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or :esspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
/cesspool 6)x Id` (�� 7
squid depth imc.szpoeI is less than 6"below invert or available volume is less than 'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped�.
�y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
�y portion of a:esspool or privy is within a Zone 1 of a public well.
y 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.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
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
th 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
Y g
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system 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 I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 262 Mariners Circle
Cotuit,Mass.
Owner: Nancy Clough
Date of Inspection: 3/1 /C 2
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
-7Pumping 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?
-lam 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,zfccluding the SAS,.located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the b ffles 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.
4/ — 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 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 262 Mariners Circle
Cotuit,Mass.
Owner: Nancy Clough
Date of Inspection: 3/1 /0 2
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): ��
Number of current residents:_ I
Does residence have a garbage grinder(yes or no):�S
Is laundry on a separate sewage system (yes or no):;iD [if yes separate inspection required]
Laundry system inspected(yes or no): S
Seasonal use: (yes or no): VV
Water meter readings, if available(last 2 years usage(gpd))2000=1 58, 000 gallons=432.88 GPD
Sump pump(yes or no):J,�2 , Lea was ound in the water line.
Last date of occupancy: Aevp, 2001 -9, 000 gallons=24. 66 GPD
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): _1f�
Grease trap present(yes or no): A&4
Industrial waste holding tank present(yes or no):/4�
Non-sanitary waste discharged to the Title 5 system(yes or no):.40
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records ,
Source of information: 4+llt>/�i,� ,
Was system pumped as pan of the inspection (yes or no): .( 9
If yes, volume pumped: gallons--How was quantity pumped determined? /L119
Reason for pumping: /
TYV OF SYSTEM
Septic tank,distribution box, soil absorption system
44 Single cesspool
Overflow cesspool
D Privy
W, Shared system(yes or no)(if yes,attach previous inspection records, if any)
Xd Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
,,!Lb Tight tank 4 Attach a copy of the DEP approval
A�U Other(describe): ,&4
Appro mate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 262 Mariners Circle
o ui °,:Mass.
Owner:Nancy Clough
Date of Inspection: 3 1 02
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.):
Joints arJD ar t-i ght _Nn evidence of leakage The system is
vented through the house vents.
SEPTIC TANK: 20ocate on site plan) 1ee0 A'1VW-(1$
rJ
Depth below grade:
Material of construction:�4ncreteAte metal.Oe fiberglass&/4 polyethylene
oother(explain) ,0p
If tank is metal list age: ti10 Is age confirmed by a Certificate of Compliance(yes or no);-,&(attach a copy of
certificate)
Dimensions: %�� '�����yf
Sludge depth:
Distance from top
dge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:Z-'/--,dl
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: ZIkl Is
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):Pum the se tic tcY�)�- . Inlet & outlet tees
ace.1�e an is tructra ly sound and shows
o evidence of ie:akage/
GREASE TRAAI"locate on site plan)
Depth below grader
Material of construction:wconcrete�metal,e fiberglassgypolyethylene,&other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: C/0
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping: AJ4_
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Grease trap i G nnt—preSent.
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: 262 Mariners Circle
Cotuit,Mass.
Owner: Nancy Clough
Date of Inspection: 3/1 /0 2
TIGHT or HOLDING TANK t&d-(tank must be pumped at time of inspection)(locate on site plan)
Depth below-grade: 4-4
Material of construction: _4 4*oncrete A1,j metal�fiberglass.&kp-olyethylene Ae/,4 other(explain):
AIX
Dimensions: Al
Capacity: 64 gallons
Design Flow: W14 gallons/day
Alarm present(yes or no):
Alarm level: ;Vd Alarm in working order(yes or no):
Date of last pumping: _ O�t
Comments(condition of alarm and float switches,etc.):
Tight or holding tanks are not present.
DISTRIBUTION BOX:zz(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 40 ,
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of
leakage into or out of box,etc.):
Distribution box has one lateral.No evidence of solids
carry over.No evidence of leakage into or out of the box
PUMP CHAMBEM�tL(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):5
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Pump chamber is not present.
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 262 Mariners Circle
Cotuit,Mass.
Owner: Nancy Clough
Date of Inspection: 3 1 0 2
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
1 -1000 gallon Are—cast leaching pit. Packed in stone 6 'X10 '
If SAS not located explain why:
Located: See page 10
Typed � 9
leaching pits. number: d 7t 1(}
leaching chambers,number: Q
leaching galleries,number: C�
leaching trenches,number, length: [`2
AR leaching fields, number, dimensions: D
ZF overflow cesspool, number: 0—
,iW
_ innovative/alternative system Type/name of technology:Z 73� '141�el
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
Loamy sand to fine sand.No signs of hydraulic failure or
ponding Soils are dry- Vegetation is normal
CESSPOOLS9, (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: ("j
Depth—top of liquid to inlet invert:
Depth of solids layer: AM
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): &A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Cesspools are not present.
PRI (locate on site plan)
)
Materials of construction:
Dimensions: A,�l
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Privy is not present _
9
Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address;262 Mariners Circle
Cotui ,Mass.
Owper;Nancy Clouqh
Date of lnspectioo; 3/1 /02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or
bcnchma.rks. Locate all wells within 100 feet. Locate where public water supply enters the building.
0
.FTC
to
Page 11 of l 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:262 Mariners Circle
Co uit,Mass.
Owner: Nancy Clough_
Date of Inspection: 3 1 02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water id 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:
_ Checked with local excavators, installers-(attach documentation)
_Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used; Gahrety & Miller Model 12/16/94 , (;round water ahwe --,Pa level
Used: USGS; Ohservatinn wP11 data _ ,TunP 1992
Used. USES; Annual rangPc of grnnnA wat-ar Jawlcax'_= 1999 99—noo—I
Al ate IOp2of Cro n0
Leaching
Pit 14'.cct
Groundwater:` Fee( Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottomq�
of the leaching pit and the adjusted groundwater table is
feet.
` 11
` RnTr.—nt'ts>—.rT' rnrmt•1*TlTrr+m aenre'1r:•.7r+:mrr�"Zrrtm fter6`sa/70'�lRt 9'R .. �.
TOWN OF Barnstable BOARD OF HEALTH
SUI)SURFACR SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION I
,•••Y••t�T•••••t—T.IIT.�.�T TtTT'R.TJ'ITZIrlCi9TSRT7'1'f—•.•I r1tRTf�T1QrTIRf'R71of 7 1<R111 i
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 262 Mariners Circle Cotuit Mass. '
ASSESSORS MAP, BLOCK AND PARCEL # _0,91z -- 1. �
OWNER' s NAME Nancy Clough
PART D - CERTIFICATION I
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAMEJ.P.Macomber & Son Inc,-w
COMPANY ADDRESS Box 66 Centerville,Mass. 02632
Street Town or CSty State LIP
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1578
ri
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true , accurate , and
omplete as of the time of ,inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on
site sewage disposal systems ,
Chec one :
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED* \
The inspection which I have con ircted has found that the system fails to
protect the public health and the environment in accordance with Title
6 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form )
Inspector Signature Date 15_11_d,�
no
copy of this c t.ification must be provided to the OWNER, the BUYER
( Where applicable ) and the 130ARD OF HEAL1'1t.
* If the inspection FAILED, the owner ox"'operator shall u
within one year of the date of the inspection, unless allowed dortrequiredm
otherwise as provided in 3.10 ChjR 16 - 305 .
1
partd .doc
?lam Tv'rrr.�F=BAR�NfSTABL� e . .
T.00ATION � �( /%y�� ��js0` SEWAGE #'
LAGE ASSESSOR'S MAP & LOT
~r 'TALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY &k
LEACHING FACILITY: (type) �`/�'� j (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Lea hing Facility (If any wetlands exist
within 300 feet f le hi cility) Feet
Furnished b
o '..�"-'
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%6
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:,* ,, ,,, .��� b: .0�'`0�;_,�LUt`t,t')e�'' �tJr'• .. e0'�1D1 I I'
TOWN OF BARNSTABLE
LOCATION 1,AX (3O( ACEWAGE #
VILLAGE ASSESSOR'S MAP LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER���C�c /
DATE PERMIT ISSUED:
4�3DATE COZIPLIANCE ISSUED:
` VARIANCE GRANTED: Yes No
A • ,
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IOCAT ON SEWAGE PERMIT N
VILLA
INSTA LLE 'S NAME ,D ADDRESS
BUILDER OR OWN ER
CLPO�e h e--
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED )/_;? ,_ 7 �
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