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Home My WebLink About0089 NARROWS WAY - Health 89 Narrows Way Cotuit P >� A = 021 111 I ' I I 'I I SI Y I� I 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Met 89 Narrows Way Property Address Eugene Veto �1 Owner Owners Name v information is cry required for every Cotuit MA 02635 9/29/2016 page. City/Town State Zip Code Date of Inspection ►+is 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 /�Z on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. Ford Septic Services, LLC 01a Company Name P.O. Box 49 Company Address Osterville MA . 02655 City/Town State Zip Code 508-862-9400 S12482 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 CM 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further valuation by the Local Approving Authority 10/4/16 Inspec 's Signature Date The s em inspec or 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 conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of/17 �o VS Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89.Narrows Way Property Address Eugene Veto Owner Owner's Name information is required for every Cotuit MA 02635 9/29/2016 page. City/Town 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes:. ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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 Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Narrows Way Property Address Eugene Veto Owner Owner's Name i information is required for every Cotuit MA 02635 9/29/2016 page. City/Town State Zip Code 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 ❑ ND (Explain below): ❑ distribution 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 ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ` ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 page. Cityffown 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 1/z day flow t5ins•3/13 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 4 of 17 Commonwealth of Massachusetts 4 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Narrows Way M Property Address Eugene Veto Owner Owners Name information is Cotult required for every MA 02635 9/29/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. Ej ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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 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. 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 E E the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form: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 89 Narrows Way Property Address Eugene Veto Owner Owner's Name information is required for every Cotuit MA 02635 9/29/2016 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? Z ❑ 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 p 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. ® a 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): n/a Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official 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 a,•''y 89 Narrows Way Property Address Eugene Veto Owner Owner's Name information is required for every Cotuit MA 02635 9/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: 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: i l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts o- Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ��.. •'" 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every COtult MA 02635 9/29/2016 page. City/Town 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: unknown Was system pumped as part of the inspection? ® Yes ❑ No .If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: maintenance 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 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Narrows Way SVa� Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 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: system installed -unknown date Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 101, Depth below grade: feet Material of construction: ® concrete ❑ metal - ❑fiberglass ❑ polyethylene ❑ other(explain) } If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal. Sludge depth: 2 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts r Title 5 official Ins u pection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 page. City/Town 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 29 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? 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.): There were cement tee's.present. There was no sign of leakage. The tank was pumped for maintenance. Grease Trap (locate on site plan): Depth below grade: n/a 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Offic ial Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 page. City/Town 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.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass. ❑ polyethylene El other(explain): N/a 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 i Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�a• ,•'' 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The D-box was normal. I Pump Chamber(locate on site 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit . MA 02635 9/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2- 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The there was no sign of failure. A camera was used to inspect 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 Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,••'•y 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is CotUlt required for every MA 02635 9/29/2016 page. Cityrrown 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.): 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.): N/a 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 '�• a 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 page. City/Town 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 ab 39 Y3 y t� `{3 y°I (Sins•3113 Title 5 Offcial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is required for every Cotuit MA 02635 9/29/2016 page. City/Town State 'Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 40'+/- 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: Topo and water contours map. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation:. see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3113 ` 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 89 Narrows Way Property Address Eugene Veto Owner Owners Name information is - required for every Cotuit MA 02635 9/29/2016 page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION TITTLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS- SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM #_ _ PART A 1' CERTIFICATION Property Address: 89 Nari,ows Wav Cohdt, MA 02632 Owner's Name: Barbara&Arthur Block • r '- + _ Owner's Address: Date of Inspection: September 1, 2010 Name of Inspector:"(Please Print) lames M. Ford. " Company Name: James M. Ford Mailing Address: P.O.Box 49 OVerville,MA"02655-0049 Telephone Number:. (5081862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal systein at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The in spection ection was performed bas ed on my training and.experience in the prober function and maintenance of on site sewage disposal systems. lam a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:. Passes. Conditionally Passes eds Further Evalua tion on b" the Local Approving y pp. ng Authority ai s Inspector's Signature: . Date: Se teiiiber 13 2. "p O10 The system inspector shall subi i 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not,address how the system will perform in the future under the same or different conditions of use. Title 5 Ins ecti r p o f Form 6/I5/2000 page 1 O �! �o 5 O Page 2 of I 1 -OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Narroivs Way' Cotuit, MA Owner: Barbara&Arthur Block Date of Inspection: September 1: 2010 Inspection Summary: Check_A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any inforination 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: t 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 ie'pail -,as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND) in the for the following statements. If"not determined", please explain: The septic tank is metal and over 20 years old* or..the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or•exfiltration or tank failure is iimninent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A inetal septic tank will pass inspection if it is structurally sound,not leaking and if'a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain` Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required purtiping 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 pipes)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY AS SESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) - Property Address: 89 Narrows Wav Cotuit MA, Owner: Bambara&Arthur Block Date of Inspection: SevteinRer'1 2010 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. I. 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 5.0 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 aseptic 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 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:. Page 4 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Narrows Wav Cotuit, MA Owner: Barbara&Arthur Block Date of Inspection: September 1 2010 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system:c.ornponent 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 invent due to an overloaded or clogged'SAS or cesspool ` ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ 'Any portion of the SAS, cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or,privy is within 100 feet of a surface water supply or tributary to a surface water supply. - ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality.analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No .(Yes/No)The system fails. I have determined that one or:more of the above failure criteria exist as . described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to-correct the failure. E. Large System: To be considered a large system the system must serve a facility-with a design flow of 10,000 gpd to 15,000 gPd You inust indicate either"yes".or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system.is within 200 feet of a tributary to a surface drinking water supply the system.is.located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone lI 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 sliall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of l 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY,ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 89 Narrows 141ay Cotuit MA Owner: Barbara&Arthur Block Date of Inspection: September 1 2010 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 ✓ Wei•e 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 pail 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,inaterial of construction,dimensions; depth of liquid, depth of sludge and depth of scum ? ✓- Was the facility owner(and occupants if different fi-oin 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. ✓ Deternined 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)). i 5. Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO RM PART C SYSTEM INFORMATION Property Address: 89 Narrows Wov Cotuit, MA Owner: Barbara&Arthur Block ; Date of Inspection: September 1 2010 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/A Number of bedrooms(actual): _ 4 per owner DESIGN flow,based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents- 2 Does residence have a garbage grinder(yes or no): Yes B laundry on a.separate sewage system (yes or no): n/a [if yes separate inspection required] Laundiy system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump:(yes or no): No Last date of occupancy: _ Currently 'COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on`310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft;etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION , Pumping Records' Source of information: Unknown Was system pumped as part of the inspection (yes or no:, No If yes, volume pumped:, gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a co py 0 f-the current ur•e nt operation PY p on and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other,(describe): Approximate age of all components, date installed(if known)and source of information: 20 vrs. -per owner Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of _l l OFFICIAL INSPECTION FORM-NOT FOR VO LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89.Narrowi l41av — Cotuit. MA Owner: Barbara&Arthur Block Date of Inspection: September 1 2010 � BUIL DING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance fi-om private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 101, Material of construction: ✓ concrete ._metal _fiberglass _polyethylene other(explain) If tank is metal list age: Is age confirmed by.a Certificate of Compliance(yes or no): (attach a copy of certificate) . Dimensions: 1500 gal. Sludge depth: 2 Distance from top of'sludge to bottom of outlet tee or-baffle: 30" Scum thickness: 2 Distance from top of scull;to top of outlet tee or baffle'. 6" Distance from bottom of scum to bottom of outleftee or baffle:; 10 How were dimensions determined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.). Cement tees were Present. The liquid level was even ivith the outlet invert. There did not appear to be any signs of leaka e. i I GREASE TRAP: None (locate on site plan) Depth below grade, Material of construction: _concrete _metal fiberglass _polyethylene _other (explain): -- Dimensions: . Scum thickness: Distance s ance =fi om top of scum to top of outlet tee`or baffle: � Distance from bottom 0 om of scwn to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): 7. I Page 8 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Narrows Way Cotuit MA Owner: Barbara i&Arthur Block Date of Inspection: September 1, 2010 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection).(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions`: - Capacity: gallons Design Flow: gallons/day Alarin present(yes or no): Alarm level: Alarm in working order(Yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): - DISTRIBUTION.BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even Comments.(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc:): . The D-box was level. No solids iiwe resent. PUMP CHAMBER: Nom. (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): 8 . ' Page 9 of I l OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Narrows PVav Cotuit, MA . Owner: Barbara&Arthur Block Date of Inspection: September 1 2010 SOIL ABSORPTION SYSTEM(SAS):) (locate on site plan,excavation not required) If SAS not located explain why . Type YP ✓ leaching pits,number: 2-6'x 6'(1000 gal)ver as-built card leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number;dimensions: overflow cesspool,number: Innovative/alternative system Type/name.oft echnology: Comments(note condition of soil;,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Pit#.#was dry and clean. There did not avpear to be an)signs otfailure. Used a camera for ins ection.12 . CESSPOOLS: None (cesspool must be pumped as part of,inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer; Depth of sewn layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil, signs of hydraulic failure,level of ponding;condition of vegetation,etc.): PRIVY: Norge (locate.on site plan) Materials of construction: Dimensions: Depth of solids: Commen ts (note co ndition of soil si is of hydraulic lrc failure leve l of ponding ndition of vegetation,etc.). i 9 Page 10 of 11 OF INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C - SYSTEM INFORMATION (continued) Property Address: 89 Narrows YVay Cotuit MA Owner: Barbara&Arthur Block Date of Inspection: September 1 2010 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 buildigg. _ Fro T 1 ly 1 �(D L3 a . 3� y3 y°� e _ S1 3. 10 r., Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) Property Address: 89Narr.ows 91a3; - Cotttit, MA Owner:. Barbara&Arthur Block . Date of Inspection: September 1,2010 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 40+/- 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 propei=ty/obs"ervation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:* ToyoLi avhic and water contours reaps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: .You must describe how you established the high ground water elevation: Using Barnstable t000graphic and ivater contours mays the maps were showing approximately 40'l/ to Qr ound ivater at this site. i This r s e 'rt h po . as been pre axed ortlt or the septic s rstem and components p - r L J po zeros described herein. This septic system has been inspected and passed as of the.date of inspection. This report is not n rvarrono;or gtrarai;tee that the system ivill . function pr operly:in the future. There have been:iqo ivari•araties or•guarantees, either expressed, ivritten or implied, relating to the septic system, the_inspection, this report and/or any components of the septic system which have not been located and ins ected . p it DATE:6/7/02 PROPERTY ADDRESS:_89_Narrows_Way T r�� Cotuit� Mass___ ___________ MAP 02635 PARCEL'. - - ------------------------ LOT On the above date, I ' Inspected the -septic -system at the abov ad ss. This system consists of the following:. 1 . 1-1500 gallon septic tank . To 2 . 1-Distribution box . `�PVO'c- b 3. 2-1000 gallon 2" o precast leaching pits packed in 1 stone , ��ti` 010 Based on my Inspection, I certify the following conditions: 10, 4. This is a title five septic system. ( 78 Code�) 5 . The septic system is in proper working order 1 at the present time . F - 6 . ' Pumped the septic tank at time of ,inspection . Heavy scum & solids layers were present.. 7 . #1 pit is dry #2 pit has wastewater 64" below he invert pipe . SIGNATURE:1, 1 Name: _�_�,_ Macomber_.,J-ram--- Company : Jose & Son , I+nc ' ------ Address: - Box 66 __Cent^e_rv_ille , Ma ,-02632-0066 Phone:___ 508^775-3338_____ THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC, Tanks•Cesspools•Leachflelds Pumped & Installed Town Sewer Connections ' P.O. Box 66 Centerville, MA 02632 0066 775.3338 775.6412 • ` COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION• . Property Address: 89 Narrows Way otuit ,Mass . Owner's Name: Edward Burman Owner's Address:89 Narrows Way Cotuit -Mass . 02635 Date of Inspection: _6/7/o 2 Name of Inspector: (please print) Joseph P.Macomber Jr . Company Name: J.P.Macomber & Son inc . Mailing Address: Box 66 C'.antPrvi 11p Mqcc 02632 Telephone Number: 5 n g_7 7 5-3 3 38— CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: r—_. �1 f 2/asses J Conditionally,Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Dater--��.�- i The system inspector sha ubmit 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. _ Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that t time. This inspection does not address how the system will perform in the future under the same or different,' conditions of use..,r Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Narrows way Cotuit ,mass . Owner: Edward urma,n Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D - -r A. System Passes have not found an information hick indicates that any of the failure criteria described in 310 CMR 15.303 or in 3 5.304 exist. ny failure criteria not evaluated are indicated below. Comments: The septic system is in proper working order at the present time . — B. System Conditionally Passes: One or more system components as described in the"Conditional Pass section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the following statements. if"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. .. ND explain: Au6 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: 4,0 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 I z OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propem• Address; 89 Narrows Way otuit , ass , Owner: Edward Burman Date of Inspection: 6/7/02 C. Further Evaluation is Required by the Board of Health- t/O Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: 4/4 Cesspool or privy is within 50 feet of a surface water Cesspool or privy.is within 50 feet of a bordering vegetated wetland or salt marsh t , 2. Svstem "ill 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: Nd 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. ,&Q The system has a septic tank and SAS and the SAS is within a Zone 1•of a public water supple. The,system has a septic:ank and SAS and the SAS is within 50 feet of a private water supply well. I The system has a septic tank and SAS and the SAS is less than TO feet bu 50 feet or more from a private water supple 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 areytrigeered. A copy of the analysis must be attached to this form. 3. Other. ' v y 3 Page 4 of I I r OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 89 Narrows Way' Cotuit .Mass. Owner: Edward Burman Dateof inspection: 6/7/n? 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 i Discharge or ponding of effluent to the surface of the ground or surface waters due to art overloaded or /clogged SAS or cesspool Static liquid level,n_the dismbution box above out inven due to an overloaded or clogged SAS or cesspool _ iquid dcpth iri cessptwlis less than 6" below invert or available volume is less than ''A day flow _ . _4. Required pumping more than 4,times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped . _ y ponion 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 ater supply. Any portion of a cesspool or privy is within a Zoned of a public well. _ y portion of a cesspool or privy is within 50 feet of a private water supply well. -kz A_ny 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 qualiryanalysis. )Tbis system passes il�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.) (YesNo)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 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 now of 10,000 gpd to 15,000 gpd You must indicate cithcr"yes",or"no" to each of the following: (?lie following criteria apply'to large systems in addition to the criteria above)' yes nod _ / the system is within 400 feet of a surface drinking water supply _ system is within 200 feet of a tributary to a surface drinking water supply �` the located_ _ s system is to a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone 11 of a public water supply well if you have answered "yes to any question in Section E the system is considered a significant threat, or answered yes" in Section D above the large system has failed. The owner or operator of any large system considered a s:gatficant threat under Section E•or failed under Section D shall upgrade the system in accordance with 3 10 CMR 5 304 The system owner should contact the appropriate regional office of the Department. 4 i Page 5 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:89 Narrows Way ' otuit -, ass , Owner: Edward Burman Date of Inspection: 6 7 02 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes N /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 Y _ 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 ? 2 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,-A Iuding 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 ? t� — Was the facility owner(and occupants if different from owner)provided with information on the proper .maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15,302(3)(b)) b Page 6 of I I w i OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 89 Narrows Way Cotuit , ass . Owner: Edward Burman Date of Inspection: 6 7 02 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): Ave Al Number of current residents. Does residence have a garbage grinder(yes or no):L Is laundry on a separate sewage system (yes orno):,fLO '{if yes separate inspection required] Laundry system inspected(yes or no):Le-5 Seasonal use: (yes or no): NZ' 2000-107 ; 000 gallons=293. 15 GPD Water meter readings, if available (fast 2 years usage(gpd)): ' gal lons-569. 87 GPD Sump pump(yes no)- �� Last date of occupancy: ncy:. t " COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CvtR 15.203): AIX gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present (yes or no):Ay Non-sanitary waste discharged to the Title 5 system (yes or no):,gg Water meter readings, if available: Last date of occupancy/use: XIA OTHER(describe): IV?4 GENERAL INFORMATION Pumping Records Source of information: A/1A Was system pumped as pan of the inspection (yes or no): If yes, volume pumped:/60d gallons-- How was quantityypumped determined? Reason for pumping:- Pumped septic tank; Heavy scum & layers were present . T;7OF SYSTEM Septic tank, distribution box, soil absorption system A,ld Single cesspool Overflow cesspool Privy SShared 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 AA Attach a copy of the DEP approval Other(describe): Approximate aee of all CQ mponents,date installed (if known)and source of information: ' iceAY .D.h eW e , Were sewage odors detected when arriving at the site(yes or no): 6 f Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 89 Narrows Way otuTt , ass . Owner: Edward Burman Date of Inspection: - 6 7 0 2 BUILDING SEWER(locate on site plan) Depth below grade: ' oC7 Materials of construction: vocast iron /40 PVC&other(explain): AW Distance from private water supply well or suction line: /6'24 Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight . No evidence of leakage . The system. is vented through - the house vents . SEPTIC TANK: (locate on site plan) I10 fef &s Depth below grade: Material of construction:concrete.vie metal de fiberglass 4 olyethylene ,V�other(explain) 41i4 If tank is metal list age:& is age confirmed by a Certificate of Compliance(yes or no)40 (attach a copy of certificate) Dimensions: Ld �` �'j?`'�, �� s`7�• c Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: —0 Distance from bottom of scum to bottom of outlet tee or baffle: in How were dimensions determined: Pumped at time o'fn s p e c t i o n. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage, etc.): Pump septic tank annually . Garbage disposal is present` Inlet & outlet tees are in nlace .The tank' is structurally sound and shows no evidence of leakage . GREASE TRARt&&(locafe on site plan) Depth below grade:AJi4 Material of construction:,f/Aconcrete4meta W&f lberglassAkpolyethylenW2Lother (explain): 44 Dimensions: Ah Scum thickness: A�,4 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:_ VO Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.):' Grease trap is not present . l Page 8 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 Narrows Way o u -, a.ss . Owner Rdward Burman Date of Inspection: 6 7 02 TIGHT or HOLDING TANK44L (tank must be pumped.at time of inspection)(locate on site plan) Depth below grade: ? Material of construction: &?A_concrete ed meta l f2A—fiberglass polyethylene,4—�other(explain): Dimensions Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: .(14 Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): , Joints appear tight .No evidence of leakage .The system is vented through t e Ouse vents . DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: .et) ' 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 two laterals . No evidence of solids carry over . No evidence of leakage into or out of the box . PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no) tt Alarms in working order(yes or no): Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Pump ,chamber is not present 8 �,I Pate 9 of I I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:89 Narr(bws Way otuit, ass . Owner: Edward Burman Date of Inspection: 6 7 02 SOIL ABSORPTION SYSTEM (SAS): locate oa site plan, excavation not required) 2-1000 gallon precast leaching pits packed in stone . ( 6 X10 ) If SAS not located explain why: Located see page 1.0 XT�y�p�e� •' leaching pits. number: , AAA leaching chambers, number: A2r)leaching galleries, number: ,VO leaching trenches, number,length: D leaching fields, number; dimensions: d A.ID overflow cesspool, number: D " 4 innovative/alternative system Type/name of technology: I C ' > Comments (note condition of soil', signs of hydraulic failure, level of ponding, damp soil, condition of vegeta(ion, etc.): Loamy sand to medium fine sand-. No signs of hydraulic failure or pon ing , of s are dry . Vegetation is—normal . J2 pit has waste water at below the invert pipe . CESSPOOLS(cesspool must be pumped as pan of inspection)(locate on site plan) Number and configuration: , (� Depth—top of liquid to inlet invert: Depth of solids Layer: A� Depth of scum laver. Dimensions of cesspool . Materials of construction; Indication of groundwater inflow(yes or no): k/A ' Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspools are not present . PRIVYOA Le(locate on site plan) ) . Materials of construction: Dimensions: , Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding, conditin of vegetation, etc.): J , Privy is not5present . �.J 9 pagc 10 of 11 OFFICL -L INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continucd) Properry Addre,,,89 Narrows Way B Owocr:Edward Burman as Dlie of Inspcctioo; SKETCH OF SEWACE DISPOSAL SYSTEM PTOvid( s skci<h of the lcwlje disfl withossl Imcm including Ilcs to 81 Icett rwo permancnt rcrcrcnce landmarks or ocncNnuki. Loc'i< IIl:wclll in 100 fcct. LQmc whcrc public watcr supply cntcrs the bvil6ng. r , $`r . i'tjo'1�row 3 /itJa� Co-ryr �" \57,3�� 10 Page I 1 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -SYSTEM INFORMATION (continued) Property Address: 89 Narrows Way otuit , ass. Owner: Edward Burman_ Date of Inspection: 6 7 02 SITE EXAM Slope Surface water { Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check)all methods used to determine the high ground water elevation: ,V6 Obtained from system design plans on record - If checked, date of design plan reviewed: �bscerveclwslite(abuttin roe servation hole within 150 feet of SAS) t ocal Board of Health-explain: Checked with local excavators, installers- (attach documentation) ,21�6Accessed USGS database-explain: h t t p : 11 town , b a r n s t a b l e .ma , us . You must describe how you established the higgh gground water elevation: Used : Gahrety & Miller Model 12/16/94 Ground water elevations above sea level Used ; US servation well data. June 1992 Used : USGS ; Technical btalletin. 92-000-1 Plate #2 January 1992 , Annual ranges of ground water elevations . r un Leaching Pit Idb t,'eet Groundwater. Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom .< Of the leaching pit and the adjusted groundwater table is pZ feet. - e II y Rr.�r•!e—R:rr—.'rr— -srrm:•ntnrm*rr.rrr.rr..r.:•.m-rorr:�ss�n•.r.�rte�ts*+ra'e�sr.ia•cz •�, MOWN OF Barnstable BOARD OF HEALTH SUfiSURFACF .SFWA(;F DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION .•••�•••.�•••. •.•. —T.1 IR�.�TTI.TS TTI•R:1TI TIT TTIT?'I'TTl'.T—t'1 r't1TTt 1P1ttC1—'r1TTF7*JT RTSRRI�ry'1R7 iiR,f -TYPE OR PRINT DEARLY- . PROPERTY INSPECTED STREET ADDRES$ 89 Narrows Way Cotuit ,Mass . ASSESSORS MAP, ,BLOCK AND PARCEL„ # 021-111 OWNER' s NAME Edward Burman PART D - CERTIFICATION Y NAME OF INSPECTOR Joseph P .Macomber 'Jr . COMPANY NAME J. P.Macomber & Son InC'`. COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City Stag LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790- 1578 R CERTIFICATION STATEMENT I certify that I .lave personally inspected the sewage disposaj system at this address and that tlae 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 , Check one : ' System' PASSED , The inspection which I have cond`ucted, has not found any information which. indi.cates that the system fails to adequately protect public healLh or Lhe 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 ' cted has ' found that the system fails to Protect the Public health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , •and . as specifically noted on PART C - FAILURE CRITERIA of this inspection orm , Inspector Signatu Date e copy of this ert,ification must be provided to the OWNER, the BUYER arn where applicable ) and the BOARD OF liEAL'L'll. * If the inspection FAILED, the owner or" 'P* erator shall upgrade ' the eyetem within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CFIR 16 . 305 . partd . doc 'Ca TOWN OF BARNSTABLE LOCATION O 1 n A((OWJ Uj SEWAGE# VILLAGE C 070 ASSESSOR4 MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY rCb LEACHING FACILITY:(type) a I"t l 1 (size) NO.OF BEDROOMS / OWNER (, PERMIT DATE: 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY T�.11,�.[�T I�� J FD( C C1 I 1110 J / � c -Z q.� - '° W _ ` ..[ W i -� � -C �� .� � .. -� TOWN OF BARNSTABLE ~ LOCATION SEWAGE VILLAGE _ ASSESSOR'S MAP''& LOTS INSTALLER'S NAME&.PHONE NO. tAe'�1J SEPTIC TANK CAPACITY A!i9 LEACHING FACILITY: (type) 'S (size) r NO OF BEDROOMS BUILDER OR OWNER`4&iee /S.W� PERMIT DATE: COMPL•LANCE DATE: w, 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 Welland and Leaching Facility (If y w tlands exist within 300 feet g 1 cility) Feet Furnished b (� i OOP 100, ICU J -' TOWN OF BARNSTABLE LOC;AT ON_�q _��yS' C,� SEWAGE # _' e VILLAGE �-- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NOGt' 2 C L A V '3�VA-(C-5()q SEPTIC TANK CAPACITY_ SG LEACHING FACILITY:(type) LOo 0 (size) Q4.L� NO. OF BEDROOMS,3 PRIVATE WELL OR PUBLIC1 WATER BUILDER O4eQWt9ER I wa' 4c17F-CAL:c-i4 :ati-=i— DATE PERMIT ISSUED: 2/7 DATE COMPLIANCE ISSUED_ VARIANCE GRANTED: Yes No GN JJ r i 0 1 Y Fim..............1.....60 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF...........................0F........ .. . ............... HEWTFV F ....... .... ............................ OF........ Appliration for Bhqposal Works Tonstrurtion Prrmit Application Construct (1, on is hereby made for a Permit to Constr or Repair an Individual Sewage Disposal Systemat em,...... ........ ............................................................... -- ---- --- ------------------------- -------------Ecal, .1dress N. ........................................... ...... -_ --- ------- . .......... ................ Owner .... Addr.4 a. ............I ..............................C......4�A................................................. .......... . ................... ......... Installer Address Type of Building Size Lot....Z_____________ ..Sq. feet U Dwelling—No. of Bedrooms------- -------------------- --------Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ................................................................................................................................. ----------------- Design Flow........................5,!�. _gallons per person per day. Total daily flow............................. .....gallons. ---6�i6 W Septic Tank—Liquid capaci . ........gallons Length................ Width....._.__._..___ Diameter................ Depth.....___........ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.........._...__ sq. ft. Seepage Pit No..._._ ........ Diameter.......iD........ Depth below inlet.......&I........ Total leaching area'..... ft. Z Other Distribution box Dosing tank ( ) 6-1-&3 _0 -Percolation Test Results Performed by....5AA 9-. .. .1..I.j....qS................................ Date.... Test Pit No. I......2......minutes per inch Depth of Test Pit........1-3------ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___._........_......... ............................................................................................................................................................. 0 Description of Soil.................... ...................... ---------- ------------------------------------------*------- �4 ---------------------- ........ 4 tM Ian .C65A 41 I , AJ. ......... -----------------------------------*-------------------------------*------ ....................................... �r I .............................................................:.......................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITA 11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in opera ion til er�tif#te of Compliance has,been issued issued�y the b.. :P Of e th. ...................... A0.Signed....... . ..... .. ... .. ............. , -_7 pplica, o _ved By . ..... . ...... ...... . .... ............ ............. ... Date Application Disapproved for the following reasons:_.__....................................................................................................... ...........................................................................................................................7---------------------------------------------------------------------------- Permit No. Z_ ......-------------------- Issued.......' .ZZ.............. ...Date............. Date ENd No................--...... Fims............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH:/ r I � Appliration for Disposal Works Tonstrnr#ion ramit Application is hereby made for a Permit to Construct ( � or Repair ( ) an Individual Sewage Disposal System at t .cl+ .� k +ems i� ✓"`a ac+c. Location ,t dress ' or,Lot No. *tl g� a �.� ." ...... .......... ................................. d -.....[ l.........................................................l+ p t er ° Owner 01, t Address / W � .`...._." ° . * /, ' •.� -- ___ /" ems :... Installer Address Type of Building Size Lot.........#.....t�.........Sq. feet g— ..............Expansion Attic ( ) Garbage Grinder � Dwelling o. o Bedrooms.............................. Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------•----------•--------------.....---------...........--•-------------------- W Design Flow........................ .T.............gallons per person per day. Total daily flow.............................. .__gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width.................... Total Length.................... Total leaching area..........._.__._)_:sq. ft. Seepage Pit No..................... D>ameter........10_...... Depth below inlet........ __.__.. Total leaching area..... ; 'sq. ft. Z Other Distribution box ( ) Dosing tank ( ) o Percolation Test Results Performed by..._` X'. .,_.k_��::.:.................... ... Date....._.�_. � ^~° • . 7 .-Wig••-y 5� Test Pit No. I......�&, .minutes per inch Depth of Test Pit.........1,3..... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•-•--------------------------------------•---------------------•--------------------- --........... •------------ ... -----------Description of Soil...........................................•--- .••---••--••-•-----------•-----•----•------•....•-•-•.........-••••••--...----•••••. . U s = - ' - ` � 'a1'' ------- �-q ---------------------------_-.---- W U Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------•-----------•----••-------------------......----------•-•••-•-----••-•---••-----•----•----•--•---•----•-•--••••-•--•-••---------•-••-•••........----•-••--•-•----........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation u it ertific;�te of Compliance has been issued by the board of health. 11.60 ...� `....` ..... �` `¢'EGG' Signed -- . .1 ___ter... ........_ ...................... ... ... J__._........._._.._ i O Alp icati n proded By......... .... Dac Q � - Dat Application Disapproved for the following reasons:..........................................................................................................--- -•-•--•...............•-••.....•••-•-••------•-...•-••--•-••-•-•--••--•••--••-•--•--•--•---•---.....-•--•--•-•---••--•----•.-•--••-----•••-••-•••-•-•-••---••-•--••••-••....----•-••-••-•-•••--•------- Date r Permit No..... 1-r` h�� .......................................................Zr ... _._. issued-, Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH:,. O F.;........ ........ .................................................................. (9rdif iratr of Toutplinnrr THIS IS TO RTIFY, at the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by........................... - . -.............................................................................................................................. Installer at.._.._ 1l1 4 -------` ...............•--•--------------------------•----------------.... has been installed in accordance with the provisions of T 5 o The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__..V,_ .4�__.__....._ dated._.!'-_moo ' ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........... `" �- el.':F1---•-=................. Inspector -- THE COMMONWEALTH OF MASSACHUSETTS _ BOARD OF HEALTH 17 FEE,/...............�.�,I.. Disposal �pp__nrko/Tonstrnduan rrntit Permission is hereby granted--------...... *kIx-•-*Z._....••. ...----------------------------•-•---------..................................._..-- to Construct ( or Repair ( an Individua ewage D' p ahem at No. ii. �� f �`!►tS.. .. -- --------------------------------•---------------------------------..........------- Street as shown on the application for Disposal Works Construction Permit No�Xf !;�Y Dated..A--r '_0` . .... ..... ..... ••--....------.................._' Board of Health DATE FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS �� 1XS%f -�-�/Y� •;.,Lp�}t .:,% ors b' �7��'-LS ?fig j ' /y /fib �o� H� SAC i_�/ 0 - K TIC- 27 Morn r,:l , • �.,i " �, �,4ynm,{e �l i.: �. , , .,. ..:y' 1. i. ,. • S I '2 f�Al vR�\ i�st, / I 1 li I ' I 0. . - //V. / 15 Z 7tY� 0-2 /i1a7d 7%%;tO i I _ i .. � • -------.___ --• �" ,CT'. Nam/ .. . �-.. � tEE z ,'IF 2 ;. 1 , ..... /RED ` agU A i i6,4 4. / I I 1 PIr �rNe �i f Ol '. UF �AkEY N<,f Pi Tyr RIC3;ARD , d, SULL ANA. BARTER N �f!o. 29733 No.24GC8