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HomeMy WebLinkAbout0170 OLD KINGS ROAD - Health 170 OLD KING ROPPCOTUIT A= JOB NO. B08-04 ` SURVEY NOTE: CONCRETE BOUNDS NOTES I BUFFINGTONI.DWG ON FURLONG WAY HELD FOR 1. LOCUS IS A.M. 22, PARCEL 90 (SHOWN ON MAP 8). LOT LINES SHOWN. 2. BUILDINGS ARE IN FLOOD ZONE C ON FIRM DATED JULY 2, 1992. 3. OFFSETS SHOWN ARE TO THE CORNERBOARDS ON EXISTING BUILDINGS, OR TO FOUNDATION ON NEW CONSTRUCTION. N/F lb CHAMBERLAIN A°` o0 = 10, 00 �'Q -� o 24, S M ¢ > 6 S a ,F+ . 10, � N F ® ; Y 2s..,i:::,:::. ;„ %��� BUCKLEY o .'sn EX/ST ;v l :to H00SE l sz`�' o� 170 LOCATION APPROX. 50•0 .... Q FROM JOHN GRACI 2000 INSPECTION z 3B.6 W 'O�,•� V• O N LOT 94 22 280±S.F. 5� GP . I CERTIFY THAT THE LOCATIONS SHOWN ON THIS PLAN WERE MEASURED IN O THE FIELD ON 4/02/08. AS9UILT PLAN L��AoFM s RICHARD B. & FOR BUFFINGTON R N `�G LOT 94, 170 OLD KINGS ROAD, COTUIT, MA. J d ES Il.LA N 00 a .� ,� APRIL 4, 2008 SCALE: 1"=30' q�yITA10 RONALD I CADILLAC, PLS, RS, P.C. PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN y� D 6 P.O. BOX 258 `/�� WEST YARMOUTH, MA 02873 ©2008 BY R.J. CADILLAC (508) 775-9700 ��. � �1b V qAY 1 1 2400 e� olVq Oir���r'tetF COMMONWEALTH OF MASACHUSETTS ., EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET BOSTON MA 02108(617)292-3500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 170 OLD KING RD. COTUIT, MA 02636 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Address of Owner: 77 PONDFIELD RD.BRONXVILLE NEW YORK 10708 Date of Inspection: 6/4/00 Name of Inspector: JOHN GRACI i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: SEPTIC INSPECTIONS Mailing Address: P.O.BOX 2119 TEATICKET,MA.02636 Telephone Number: 508-664-6813 FAX 608-664-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes _ Conditionally Passes _ Needs Further Evalua' n y the Local Approving Authority _ Fails Inspector's Signature, Date:5/4/00 The System Inspector shall su it a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the•ttyyer,if applicable,and the approving authority. NOTES AND COMMENTS "The Inspection Is based on criteria defined in Title V code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.My inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life." THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS FOR PROPER MAINTENANCE. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 6/4/00 INSPECTION SUMMARY: Check A, B, C, Of D: A. SYSTEM PASSES: X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist,Any failure criteria not evaluated are indicated below. B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the"Conditional Pass"section need to to replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance attached)indicating that the tank was Installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health). . _broken pipe(s)are replaced _obstruction is removed _distribution box is levelled or replaced nLa The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass inspection if (with approval of the Board of Health): _broken pipe(s)are replaced _obstruction is removed revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 6/4/00 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil absorption system and the SAS Is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nla(approximation not valid). 3) OTHER n/a revised 9/2198 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 6/4100 D. SYSTEM FAILS: You must indicate either'Yet"or"No"to each of the following: . I havedetermined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary.to correct the failure. Yes No _ X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, - X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0. - X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - X Any portion of a cesspool or privy is within a Zone I of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well, _ X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No - X the system is within 400 feet of a surface drinking water supply - X the system is within 200 feet of a tributary to a surface drinking water supply - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further Information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner: ROHAN C.O TIM GRIFFIN Date of Inspection: 5/4/00 Check.if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health. X _ None of the system components have been pumped for at least two weeks and=the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been obtained and examined.Note if they are not.available with N/A. X _ The facility or dwelling was inspected for signs of sewage back-up. X _ The system does not receive non-sanitary or industrial waste flow. X _ The site was inspected for signs of breakout. X _ All system components,excluding the Soil Absorption System,have been located on the site. X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X _ Existing information,For example,Plan at B4O,H, X _ Determined in the field(if any of the failure criteria related to Part C is.at issue,approximation of distance is unacceptable)1 5.302(3)(b)] X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 5/4/00 FLOW CONDITIONS RESIDEN?IAL: Design flow: 110 g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual): Total DESIGN flow: 330 gpd Number of current residents:0 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): NO Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage): n/a gpd Sump Pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/iNDUSTRIAL Type of establishment: n/a Design flow: n/a gpd(Based on 15.203) Basis of design flow:nla Grease trap present:(yes or no): NO Industrial Waste Holding Tank present:(yes or no): NO Non-sanitary waste discharged to the Title 5 system:(yes or no):NO Water meter readings.if available: n/a Last date of occupancy:n/a OTHER: (Describe) n/a GENERAL INFORMATION PUMPING RECORDS and source of information: n/a System pumped as part of inspection:(yes or no):NO If yes,volume pumped n/a gallons Reason for pumping:n/a TYPE OF SYSTEM X 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) _ I/A Technology etc.Attach copy of up to date operation and maintenance contract _ Tight Tank Copy of DEP Approval Other:n/a APPROXIMATE AGE of all components,date installed(If known)and source of information: THE SYSTEM IS 20 YERAS OLD Sewage odors detected when arriving at the slte:(yes or no) NO revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 6/4/00 BUILDING SEWER:X (Locate on site plan) Depth below grade: 18" Material of construction: _ cast iron _ 40 Pvc X other(explain) Distance from private water supply well or suction line: n/a Diameter: 0" Comments: (condition of joints,venting,evidence of leakage,etc.) THE SYSTEM HAS TOWN WATER. SEPTIC TANK: X (locate on site plan) Depth below grade: 12" Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other explain: n/a If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO Age: n/a Dimensions: 1000G L 8'6"H 6'7"W 4'10"" Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 33" Scum thickness: 0" 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: n/a How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS. GREASE TRAP: _ (locate on site plan) Depth below grade: n/a Material of construction: —concrete_ metal_ Fiberglass _ Polyethylene_other Explain: n/a Dimensions:n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a Date of last pumping: n/a Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) nla revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 5/4/00 TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other Explain: nla Dimensions: n/a Capacity: n/a gallons Design flow: n/a gallons/day Alarm present: NO Alarm level:N/A Alarm in working order:NO Date of previous pumping: n/a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) n/a DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) n/a PUMP CHAMBER: _ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n/a revised 912/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 514/00 SOIL.ABSORPTION SYSTEM(SAS): g (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: n/a Type: leaching pits,number:(1)1000 GAL 6'X 6' leaching chambers,number: (n/a)n/a leaching galleries,number: (n/a)n/a leaching trenches,number,length: (n/a)n/a leaching fields,number,dimensions: (n/a)n/a overflow cesspool,number: (n/a)n/a Alternative system: n/a Name of Technology: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY,THE SYSTEM SHOWS NO SIGNS OF FAILURE.THE SOIL PIT WAS EMPTY AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 2.5'OF WATER IN IT. CESSPOOLS: _ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer. n/a Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/a revised 9/2198 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 6/4100 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) a qA ►4 A� �a 0 311 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 OLD KING RD. COTUIT, MA 02635 M022 P090 Name of Owner ROHAN C.O TIM GRIFFIN Date of Inspection: 6/4/00 NRCS Report name: n/a Soil Type: n/a Typical depth to groundwater: nla USGS Date website visited: n/a Observation Wells checked: NO Groundwater depth: Shallow_ Moderate_ Deep_ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 10 Feet+ Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) UGSS MAPS AND CHARTS-10+FEET revised 9/2/98 Page 11 of 11 DATE:6/12/98 PROPERTY ADDRESS: •170 ©id Kings Road Cotuit,Mass . 02635 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -1000 gallon precast leaching pit packed in stone. Based bn my Insoactlon, I certify the following conditions: 3 . This is a title five septic system.` ( 78 Code ) 4 . The septic system is - in proper working order dt the present time. SIGNATURE: ' Name:_J_P M_acombe_r Jr... Company: `�• P_Maco►�ber- & Son- ,Inc . -� Ip Address:_-Beac—bb-----=I-- -- Fl JUN Cente as�rvilleLMs__0.2'632 ' 1998 --- -- — `� 'OWNHSAT(y RNSr' DfP1. BLE Phone.•---5a8-77�.3338_------ "• I > ti THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tank&-Ceupools-Leachf lelds . Pumped & Installed Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 77'5-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS - ID EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292.5500 ta'ILLIAPO F.H'ELD TRUDY COX: Govcmor Sccrctar ARGEO PAUL CELLUCCI DAVID B.STRUH Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission PART A CERTIFICATION Property Address: 170 Old KingS Road Cotuit,MasSAddress of Owner: Date of Inspection: 6/12/g 8 (If different) Name of Inspector: Macomber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: BOX 66 Centerville,Mass _ 02632 Telephone Number: r;na7 7 5_3 3 3 8 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: asses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector all submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. Indicate yes,,0o, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/hvww.rnagnot.state.ma.us/dep Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of Inspection:6/1 2/9 8 B) SYSTEM CONDITIONALLY PASSES (continued) &9 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken p)pe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: V l� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: &� Cesspool or privy is within 50 feet of a surface water A)& Cesspool or privy is within 50'feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. TJd The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance ��_(approximation not valid). 3) OTHER adT X/9' (rrvlied 04/25/97) P&ge 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of Inspection: 6/1 2/9 8 D) SYSTEM FAILS: You must indicate ei;!.er "Yes" or "No" as to each of the following: _ I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea the failure. Yes y Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. _d) V4_ Static liquid level in the dis 1bution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in eesspeals is less than 6" below invert or available volume is less than 1/2 day flow. — Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Q LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: (a . The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No, the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/]5/97) Y•y• 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of Inspection: 6/1 2/9 8 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined, Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components,Xuding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles.or tees; material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. —The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)) (zevlsod 04/25/97) P&p• 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO-N FORM PART C SYSTEM INFORMATION Property Address: 170 Old Kings Road Cotuit,Mass. O»ner: Dr. Stephanie Wall Date of Inspection: 6/12/98 FLOW CONDITIONS RESIDENTIAL: Design flo%,. i4b x .d./bedroom for S.A.S. .umber of bedrooms:_] ''umber of current residents:, Carnage gonder.lyes or no)" Laundry connected to system (yes or no).Yes Seasonal use (yes or no).N ,y/J %%ater meter readings, if available (last two (2) year usage (gpd): /1g�� /�i�� �AS= ����b./'/� Sump Pump (yes Or n01:.�[(C L¢�*'f(�I�.QQ��� Last date of occupancy. COMMERCIAUINDUSTRIAL: Type of establishment:_ Design flow: A)A Qallons/day Crease trap present: (yes or no).0 industrial Waste Molding Tank present: (yes or no)�O .Non•sanilary waste discharged to the Title 5 system: ryes or no)" Water meter readings, if available._ 10 Ali Las: date of occupancy:- ALA-OTHER: ;Describe) _ a Last date or occupancy. CE-NERAL INFORMATION PUMPINC RECORDS and source of information: N System pumped as pan of inspection: (yes or no)v If yes. volume pumped: gallons Reason for pumping TYPE O� SYSTEM _� Seplic tank/44irrbv"n7rb*u/soil absorption system ja Single cesspool Overflow cesspool Privy 100 Shared system (yes or no) (if yes, anach previous inspection records, if any) VA Technology etc. Copy of up to date contract( Chher APPROXIMATE ACE of all components, date installed (if known) and source of information:/s �jls4J9/`s d 5—age odors detected when arriving at the site: (yes or no) tr•vs••d 0�/75/91) Y.y• 5 of 10 �l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of Inspection: 6/1 2/9 8 BUILDING SEWER: (Locate on site plan) Depth below grade:95 T 7,444 Material of onstr ion: _cast ir 40 P other (explain) tl we Distance from /rivate wat r supply well or suction line LD Diameter 1� Comments: (condition of joints, venting, evidence of leakage, etc.) Joints appear tight. No signs of 1PakagP Thp GTai- is ventprl thrniigh t_h_e hntlSp vent. SEPTIC TANK:�9R'14 (locate on site plan) �I Depth below grade:/6 Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age,l&�2 Is age confirmed by Certificate of Compliance (Yes/No) q Dimensions: O lep"r /SLY' �U � 6"17 r� Sludge depth: a I 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:. Distance from bottom of scum to bono of outlet to or baffIe:�.G How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Pump tank every 7-3 3Zparc _ Tnl Pt anti ni,tlpt tees arp in =1arp.Liauid level at the outlpt invprt- is gill Thp tank is ctriirJ-iiraa1v sound and shows no cigas of lt3elk-Age. GREASE TRAP:,&,6/e (locate-on site plan) Depth below grade: Material of constructionVAconcretet/A metal VAFiberglass A)APolyethylene 4 other(explain) .yA Dimensions:_ ANI , Scum thickness: Distance from top of scum to top of outlet tee or baffle:A14 Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,-etc.) ease trap is not present. (revised 04/25/97) Peg* 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of inspection:6/1 2/9 6 TIGHT OR HOLDING TANK. we- (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construct ion:A concrete oAmetal414FibergIass,WoIyethylene4,Aother(explain) Dimensions: JJA Capaciry: AJA gallons Design flow: /J R gallons/day Alarm level:_Alarm in working order Yes;sJA No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks are not resent _ DISTRIBUTION BOX:41�0i (locate on site plan) Depth of liquid level above outlet invert: U Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Distribution box is not respn PUMP CHAMBER:¢Yt/t (locate on site plan) Pumps in working order: (Yes or No) A44 Alarms in working order (Yes or No)_,IZ& Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) Pump chamber is not present. (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of Inspection: 6/1 2/9 8 SOIL ABSORPTION SYSTEM (SAS):, (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, n umber,length: 0 leaching fields, number, dimensions:_ overflow cesspool, number: Alternative system: n )� Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Loamy sand to fine sand. No signs of hydraulic failure or ponding. The leaching pit is dry- All vPgPtaH nn is nnrmal _ CESSPOOLS: (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 (cesspool must be pumped as part of inspection) Cesspools are not present Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Cesspools are not present. PRIVY: A1vde, (locate on site plan) Materials of construction:_ iU/9 Dimensions: 'V4 Depth of solids: 40 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) Privies are not present. (revised 04/25/97) Deq• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 170 Old Kings Road Cotuit,Mass. Ovrner: Dr. Stephanie Wall Date of Inspection: 6/1 2/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent refgr6es andmadgs,o�b�r�hmarks locate all wells within It r 1 a t i I I (rov1s,d 04/25/11) 9 of 10 Iv SUBSURFACE SEWAGE DISP. I. SYSTEM INSPECTION FORM I C SYSTEM INFOI: . 'ION (continued) Propeny Address:170 Old Kings Road Cotuit,Mass. Owner: Dr. Stephanie Wall Date of Inspection: 6/1 2/98 I• Depth to Groundwater� Feet Please indicate all the methods used to determine High Groundwater EI(:••a:ion: Obtained from Design Plans on record 4De2,e,m;.ne �itfom bservation hole, baseir4rY simp etc.) local conditions Check with local Board of health Check FEMA Maps heck pumping records heck local excavators, installers use uSGS Data Describe m your own words how you established the High Grounclw,lurElevation. Must be completed) Used water contours map. Gahrety & Miller Model 12/16/94 a•nrnrw.—rti r�r.-n� rn. mr ntsnis-�nasnm�rrr+innr+.r*enrm ersrn�u sse•�rrssrs� rRa.eRsertr•Q.rer•ra-�.-.�r*•--:..t-.r•- 'I'OWN OF Barnstable BOARD OF HEALTH \ SUIISURFACF SEWAGE DISPOSAL ,SYSTEM INSPECTION FORM - PART D •- CERTIFICATION `� �:•••Trl-T•'.'::a—T.tlt^.ern.•arm•nrrrlR:Rsrra+r-.Rne-l.•t�'imr.7arnvrl'n+++a�ao► 'e.r� rsm n7r:rr.*sass-+rrr+rr.r.•.+,ra••r-•r.-�r•—!•� -TYPL OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 170 Old Kings Road Cotuit,Mass. ASSESSORS MAP, BLOCK AND PARCELqb OWNER' s NAME Dr. Stephabie Wall PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.'P.Macomber & Solt 'Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State ZIP COMPANY TELEPHONE ( 508 I 775 - 3338 FAX ( 508 1 790 - 1 578 m A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete 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 : _zSysteui 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 16 - 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 acted has found that the system fails to protect the i-iublic health and the environment in accordance with Title 5 , 310 CMR 16 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date __z� One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF IIEALZ'it. * If the inspection• FAILED, the owner or"" porator shall u d within one year of the date of the inspection , unless allowed ortrequiredm otherwise as provided in 3.10 ChJR 16 , 305 Partd .doc w z S bllf 3y�l THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 2 1 A of the General Laws. Issued by The Department of Environmental Protection. tune H. 199s Acting Dircctc>r of the l) ion of Water Pollution Control TOWN OF BARNSTABLE LOCATION AP SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE N0. SEPTIC TANK CAPACITY IAPO LEACHING FACILITY: (type) A(lo X�'��� �!� t fi (size) / NO. OF BEDROOMS r BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: 99 Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Ol 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 lea f Feet Furnished by J� i cl I� OL /\ r THE COMMONWEALTH OF MASSACHUS TT BOARD O HEAL �� 'r _OF........... ......................... .. 1...............,... .� hrtt#tu,n -for ' ofiai o-rk� (�.an.�trutrtinn rrU* Iit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: 14f z • a --------------- -- --------- •ems -•-------------------------•----...---••----- Loc't Address or Lot No. Owner Address --- ---------•--------------------------- ------------------------------------------------------- Installer Address Type of Buildinn���� Size Lot_______________________.....Sq. feet Dwelling No. of Bedrooms-------- -------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtu es ---------------------------------------------- -­------------------­ Design Flow..................lsr..........._.__._-_- -gallons per person per day. Total daily flow--------- __:.._.__.._.._ ---------- WSeptic Tankk Liquid capacity/j gallons Length---------------- Width-------.-_----- Diameter................ Depth---.--_--_.----- x Disposal Trench—No. .................... Widtli.___________ __-_ nth ._ _____ otal leaching arca_._...._____...__.sq. ft. Seepage Pit No.......]........... Diameter, ,.�ep ow i � 0 1 ching z Other Distribution box ( ) Dosing tank Percolation Test Results Performed bY..........................................................--------------- Date------------------------------------.... a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water..-----__---------.____. L1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... D th to ground water........................ a ------------------------ -----.............................................----------- 0 Description of Soil---------------------------------------------------- --••- --- ----- -- -- - --- ---A----------------------------------------- ----------------- x V ........................•-•----....------------------...----------------------------------------------------------------------------- ------------------------------------------------------------------ W VNature of Repairs or Alterations—Answer when applicable..------------------------------------------------------------------------- ----- ------------. --------------------------------------------------•-•-•-------•-------.-------------------------------•-------•------------------••---------=---------------------------------------------------------­ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article YI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned n, r �� .. 0 .. Application Approved By -f ------ ate Application Disapproved for the following reasons--------------------------------------- ---------------------------------------•-------------•----------------- ---•----•----••----•--------•-----------------------•. ------------------------------------------------------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date y . THE COMMONWEALTH OF MASSACHUSETTS BOARD O HE AL H .........OF:........ .:.. ... ............ - - - , pplirtttion -fear Uiiipuott1 Workii C owitrurtion Vrruiit Application is hereby made for a Permit to Construct ( 400ro epair ( ) an Individual Sewage Disposal System at y .............................................................. Locat' Address or Lot No. Owner Address � Installer Address d Type of Buildi Size Lot____________________________Sq. feet Dwelling r—No. of Bedrooms.___.. ___________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a d ------------------------------------------------------------------------------------------- Desi n -Flow. Mons per person per day. Total daily flow_...._.. _,__:_____ _ .__gallons. W g then fixtu s ----• ••_• g< P P P Y• Y - - ----------- g< Septic "Cank�Liquid capacity. gallons Length................ Width................ Diameter........_-_____ Depth................ xDisposal:•Trench N _____________________ Wi th_ '' n th otal leaching area._ �_11 sq. ft. d , e ow 1 chin trea__w,.�G�____. ft. � Seepage Pit,No _.,_�___:_____ Diameter _ p g< �. z Other Distribution box ( ) Dosing tank aPercolation Test Results ...w Performed bY------------- -------------------------------------------------------------- Date---------------------------------------- f Test Pit i\1o.:'.1__..._.......___minutes per inch Depth of Test Pit..------------------ Depth to ground water-----------------.._---- (� Test Pit No. 2----------------minutes per inch Depth of Test P•t--------------------- D th to ground a' water_- :..______-_. ____-.-. ------•----••------------------- •-•--•---• --•-• ••• -•---•--•--•-----•-••-- --••-••-•-•----•--•--•-••••=--=••--=------•--•-•---•-•--- 0 Description of Soil---------------------------•-•••---•••- = f x r -- W ------------------------ -----=----------------------------------------'------------------------=------------------------------•-•-•---•--•----------•---------...................................... U Nature of Repairs or-Alteratio.'ns—,Answer when applicable..............._...........___________________________---__:.___.__,_._.__------_.___.__---.. ------------------------ == ---------------------------------------------------- ----------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned furtlier agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of-health. igned Ve Application Approved BY--- ' -- -- --- Application Disapproved for the following reasons-----------------=---------- ------ ---------------------------------------------------------------------•-- ----------------------------------------------------------------------------------------------------------------------------------------------------•--•------------------------------------------------ Date Permit No.......................... Issued............ = Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALjJ-i ................. uX J....OF........0.4=L r+ a �............. IvErrtifirttte of IVIAWf aurr THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by............................ --------------------------------- ... has been installed in accordance with the provisVnis of :article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......."_t....�_ZONST ______________ dated------------------------------------------------ THE ISSUANCE'OF THIS CERTIFICATE SHALL NOT BE D AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector--- - ----- ---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT.M-�- ......................................................................... No. FEE........................ �i���,�tt� �rk,� C��tt�tr�rti>Qit �rrttttt -Permission is,hereby granted------------------------------------------------•---•----------------••--•----------------------•--•---------•---------•-----•-•------__•••-- to Construct (r). Repair/ ) an Ij.�ividual Sewage Disposals System /............... Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated.......................................... -------------------------------------------- .......................................................... Board of Health DATE................................................................................ FORM 1255 HOBBS .& WARREN. INC.. PUBLISHERS t; r .x.'; t+ � �- _ • - � ` r �. - yr _ � _ _ .. IFprw�.[ }r _ ,:, e 5:. .I��W -+..�e++��� R+•�. •'AYIr . VM.+�hO'1� .• • .. • /•t. / Rom- w< .. � - '7 d.+' ai .. _ r , v 4 1 J ' _ ` { L ', •,tfi'` f yam,.' r n }.. - � '' ... -. 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