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HomeMy WebLinkAbout0075 OXFORD DRIVE - Health 755 Oxford `Drive Cotuit P A = 021 050 lit 1 E i r r it V h I r ' l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I-D Ox d %,t vim. Property Address Owner J Owners2a k, S'l GPO/ e Name information is required for every CO (i1 ! T 17d/o3J/ page. City/I own State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab Inspector: t v key to move your cursor- not use the return key. Name of Inspector _ Company Name 41 Company Address City/Town State �O Zip Code Telephone Nurhb#r / 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. Theiintpectt n was performed based on my training and experience in the proper function and maintenance of slte,E- sewage disposal systems. I am a DEP approved system inspector pursuant to�S.ection 15..340 of� Title 5(310 CMR 15.000). The system: --in Passes ❑ Falls= k ❑ Conditionally Passes • . ❑ Needs Further Evaluation by the Local Approving Authority 3 ` Inspector's Sig ature 4Dat The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30.days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. Isms•1 vio r ele 5 Official Inspection Fortn.Subsurface Sewage System.Page 1 0(17 CommoniNealth of Massachusetts MU�TTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address Owner Owner's Name information is CO 7 required for every / 11,2, page City/Town State Zip Code Date of I ection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) Syste asses: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): 15ins•11/10 Title 5 Official In"clion Forth:Subsurface Sewage Disposal System Page 2 of 17 N Commonwealth of Massachusetts Title o Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name n / information is d r 0'oll required for every page. Cityrrown State Zip Code Date o Ins lion B. Certification (cont.) 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-11110 Title 5 Official Inspection Form:Subsurface Sevsge Disposal System'page 3 of 17 Commonwealth of Massachusett Title .5 Official Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '�S _ COX moo,.� �i�>✓ Property Address l e ©r Owner Owner's Name information is CO 4(-4, 7 �OZ required for every page. Cityfrown State Zip Code Date Ir1sp lion B. Certification (cunt.) 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 ❑ (—a/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System--Page 4 of 17 <L,\ Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 9 S O� /moo/c/ v� Property Address S*il 6:e0r Owner Owners Name information is O4C4 i required for every page. City/Town State Zip Code Date of I pecti n 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: ❑ Ej�' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ l 7 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. ❑ [9"*'/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ L�' 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 ❑ ❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewa/g�ej Disposal System Form- Not for Voluntary Assessments vy / Property Address COC� Owner Owners Name 1 /information is CO —�14, required for every page. CitylTown State Zip Code Date Ins ection 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 ❑ [ ere any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? �❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? �❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has / been determined based on: Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11110 Me 5 Offidal Inspection Form:Subsurface Sevege Disposal System Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G-x ro-rJ Property Address Owner Owner's Name information tion is Ce>4G4t 0 l b ��' /� 1�required for everyO� page. City,Town State Zip Code Date of I spedi n D. System Information Description: / w )410� 6� �X b /D e— Case l,✓ � � s� �_ Number of current residents: Does residence have a garbage grinder? ❑ Yes 0-"No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes a No Seasonal use? Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes Last date of occupancy: 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 Industdal.waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: tsins•1 v10 ra 5 ofricid inspection Forth:subsurface sewage Disposal system-Page 7 of 17 CommonrNealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is e ( Q r /> required for every l— � '� / ..S page. Cityrrown State Zip Code Date of 1p6pect n D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection?, ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sy 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/Altemative 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•11110 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � OTC �o✓'� ��� J Property Address Owner Owners Name information is 0-/t4 , / required for every o page. citylrown State Zip Code Date o Insp ion D. System Information (cont.) Approximate age of all components, date installed (if known) and sou a of i ormation: Were sewage odors detected when arriving at the site? ❑ Yes to — Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;'4--0 El cast iron 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): Depth below grader 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 0 No Dimensions: `� X Sludge depth: t5ins•11/10 TAIe 5 Official Inspedion Form:Subsurface Savage Dispesal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LS Ox Fo�-C! a y`f Property Address Owner Owner's Name /o , /� ©o�-��j information is (_ / / required for every _ page. CitylTown State Zip Code Date of Aspec$on D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness �r Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle JHow were dimensions determined? ° 1 W� e-1 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): q ✓Y CIO a/ !✓1 Good 6✓3�7�0�. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene , ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11I10 Title 5 Official Inspedion Forth:Subsurface Sewage Disposal System-Page 10 of 17 CommontlNealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments Property Address S% C—ec� e Owner Owner's Name information is zo u 1 required for every 4 page, Cityfrown State Zip Code Date of 16spedfon 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 ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Se pe vsye Disposal System•Page 11 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address cl-e 0 Owner Owners Name information is 11 !! 7 n required for every �� '✓ 0,e 3 3 page. City/Town State Zip Code Date of pe ion D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): �n / 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address //�� __ p Owner Owners Name information is required for every page. Cityrrown State Zip Code Date a Insp ion D. System Information (cont.) X w Type: ,✓70 leaching pits number:0 ❑ 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.): c� l ✓is 074�f A c 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•11110 rdi9 5 Official ilnspedan Form:Subsurface Sewage Disposal System-Page 13 0(17 Commonrivealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments /o ©X Fo'-d zl/yt Property Address Owner Owners Name information is required for every page. Cityfrown State Zip Code Date of nspe "on 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.): t5ins•11/10 Title 5Oficial Inspection Form:Subsurface Savage Disposal System•Page 14 of 17 a Commonwealth of Massachusetts Title a Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner'sGe Name / information is coU required for every page. Cityrrown State Zip Code Date of I X /42- ped' n 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 lic water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ rawing attached separately ' 3 11�3 If), 3 � k t5ins•11/10 Title 5 Official Ins pection Form:Subsurface Savage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner S J lJ`e o✓s-Z Owners Name, n information is required for every C"_ 4L4 page. CityTTown State Zip Code Date of I pection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet 30 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.- �l vls f %es)t /qo le ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database -explain: You must describe howyou established t e high ground water elevation: S • s � s O l/� 1 r Vl o L4 N Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Savage Disposal System•Page 16 of 17 I I. commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ''� Owner ST 6I e 0✓ -� Owner s Name (f 7�. information is Z' %17 Qd-6.�,.,r required for every �^ page. Citylrown State Zip Code Date of I spe ion E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked �Insection Summary D (System Failure Criteria Applicable to All Systems) completed System Information-Estimated depth to high groundwater 0--'Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 FAI:FA510 00MMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL EDEPARTMENT OF ENVIRONMENTAL PR .rEALZ H T. W e TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACESEWAGE DISPOSAL SYSTEM FORM r., s PART A MAP CERTIFICATION PARCEL ; 1�) Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 1173rt Owner's Name: MARY FERRACANI Owner's Address: 75 OXFORD DRIVt'COTUIT,MA 02635 Date of Inspection: 10/8/02COPY Name of Inspector: (please print) ,;•,,. .JOI)N GRACI Company Name: ; .SEIC INSPECTIONS Mailing Address: F?O.,BOX•2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270 CERTIFICATION STATEMENT certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: 4 X Passes 4, Conditionally Passes 11 _ Needs Fu t'er Evaluation by the Local Approving Authority Fails ,:. Inspector's Signature: h,.a I {} "y Date: 10/8/02 The system inspector shall s ubm' `a'c'opy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this in tion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner sh ,all,submit.the report to the appropriate regional off ice of the DEP.The original should be sent to the system owner and.copigs sent to the.buyer, if applicable, and the approving authority. Notes and Comments -;)t.h- '_i` SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.. A ****This report only describes c�dqitions at the lime of inspection and snider the contlilions of use ill Ihul Lime.This inspection does not address how tl e,.system,will perform in the future under the same or different conditions of use. r Titla hvznPrtinn Page 2 of I 1 „ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address. 5 OX FORD XFORD DRIVE.COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI 1' Date of Inspection: 10/8/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any informationtwhich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. r 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 replacemen0r,repair;,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)'i Pthe for the following statements. If"not determined" please explain. n/a The septic tank is metal an`Wbver 20.years ord* 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 60is available. ND explain: n/a n/a Observation of sewage backuptor'break dut,'or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled'of'un'even distribution box. System will pass inspection if(with approval of Board of Health): _ broken pipe(s)are replaced '668triictidn is removed _ distribution box is leveled or replaced ND explain: n/a n/a The system required pumping,more'thar 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: n/a { Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t PART A `'r CERTIFICATION(continued) Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI Date of Inspection: 10/8/02 C. Further Evaluation is Required,,by 1h6.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 env:iromnent. 1. System will pass unless Board of Health determines in accordance with 3 it 0 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 fe.ef 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` an er 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 surfacewater supply. _ The system has a septic tanks and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank'.tand SAS,and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SA and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used'to deermmine distance n/a "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 equai fo'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: n/a tt S Page 4 of I I OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRA,CANI Date of Inspection: 10/8/02„ D. System Failure Criteria applicable tof'all systems: You must indicate"yes"or"no"to each of following for alLinspections:- Yes No X Backup of sewage into'facility or'system component due to overloaded or clogged SAS or cesspool X Discharge or ponding.of effluent fo 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 ''/z day flow X Required pumping more tlian 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped n/a. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion.of cesspool or priwyistwithin 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 1 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 yquality analysis. IThis 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 1liat facilitty 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 f6rm.1 (Yes/No)The system fails. l;have.determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.'Th. 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,systeari must serve a facility with a design now of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or°`no"to each of the following: (The following criteria apply to large`systems in addition to the criteria above) yes no _ 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—I WPA)or a mapped Zone 11 of a public water supply well rt: If you have answered"yes"to`ariyquestion 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 L)'sh -0tupgrade the system in accordance with 310 CMR 15.304. The system owner ((I should contact the appropriate regional office of the Department. i� Page 5 of I I '' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART B CHECKLIST Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI Date of Inspection: 10/8/02 Check if the following have been,dondjY,ou must indicate "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 Were any of the system.components pumped out in the previous two weeks X _ Has the system received normal flows in the previous two week period `? X Have large volumes of water been introduced to the system recently or as part of this inspection ? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dweffing inspected for signs of sewage back up? X _ Was the site inspected for.signs of break out? X _ Were all system components,excluding the SAS, located on site ,t Fh`�. •pit X _ Were the septic tank manhW§ 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 ? X _ 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 X _ Existing information. For example;a plan at the Board of Health. X _ Determined in the`�feId (if any of tl e`failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CM 15.302(3)(b)] ; `r 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 15 OXFORD DRIVE COTUIT,MA 02635'M021 P050 L71, Owner: MARY FERRACANI ; Date of Inspection: 10/8/02 t_ FLOW;CONDITIONS RESIDENTIALr'f' FLOW;, Number of bedrooms(design)':`3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.263 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes'or,no): NO Is laundry on a separate sewage system,(yes.or no): NO [if yes separate inspection required] Laundry system inspected(yes'or no,):;NO Seasonal use: (yes or no): NQa,'", Water meter readings, if available(last 2 years usage(gpd)):AJe- Sump pump(yes or no): NO ��- S lr0 oo Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a o.)%.'"1 F Design flow(based on 310 CMR 15.203,):�n/agpd Basis of design flow(seats/persons/sqft,etc.): n/a Grease trap present(yes or no): NO r. 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/use: n/a' , OTHER(describe): n/a " GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no): NO If yes, volume pumped: n/agallons"'-'H'owwas quantity pumped determined? n/a Reason for pumping: n/a ;. r4 ,. TYPE OF SYSTEM X Septic tank,distribution box,,'soil"al sorptibh.system _Single cesspool 4, _Overflow cesspool V ', _Privy _Shared system(yes or no)(if yes, attach previous inspection records, if any) _Innovative/Alternative technology.`_AttaclT a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of thebEP approval Other(describe): n/a : Approximate age of all components,date installed(if known)and source of information: 1993 BY OWNER Were sewage odors detected when arriving at the site(yes or no): NO 1 .fit 6 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: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI Date of Inspection: 10/8/02 ` BUILDING SEWER(locate on site play.)' Depth below grade: 24" Materials of construction:_cast iron _40_PVC other(explain): n/a Distance from private water supply well or suction line: n/a Comments(on condition of joints, venting, evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan)-i Depth below grade: 18" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a "'Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000 GALLONS!, Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 3" 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: 15" How were dimensions determined: MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. GREASE TRAP: _(locate on site plan) Y a . 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 _ r=+ Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a ., V01 , �'yypp `,Y Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI Date of Inspection: 10/8/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) • r Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/a ,,; ' ' Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX: X(if prese0rnust beopened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE Comments(note if box is level and distribEation to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D-BOX IS STRUCTURALLY SOUND. PUMP CHAMBER: _(locate on site p!an) ' 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 E tl` , r t i R . ' Page 9 of I I , n OFFICIAL INSPECTION VORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI Date of Inspection: 10/8/02 SOIL ABSORPTION SYSTEM'(SAS): X (locate on site plan,excavation not required) 1 . If SAS not located explain why.- n/a Type 1000 GAL 6' X 6' leaching pits, number: n/a 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: n/a n/a overflow cesspool, number: n/a n/a inh6vative/alternative system T e/name of technology: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE. PIT HAD 6 OF LIQUID IN IT AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 6" OF LIQUID IN IT. BOTTOM IS AT 9 FT. CESSPOOLS: (cesspool must'be'`puinped as'part of inspection)(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 inflow(yes or no): 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 soi.l,*_signs of,hydraulic failure, level of ponding,condition of vegetation, etc.): n/a S3 Q Page 10 of I I , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C [ ,SYSTEM INFORMATION(continued) Property Address: 75 OXFORD DRIVE COTU IT,MA 02635 M021 P050 L71 Owner: MARY FERRACANI Date of Inspection: 10/8/02 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 I00'feet. Locate where public water supply enters the building. i1 n fL <s 'a t tl^_ 'tip• t f 1(1 Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 75 OXFORD DRIVE COTUIT, MA 02635 M021 P050 L71 Owner: MARY FERRACANI. ,. 1...,• Date of Inspection: 10/8/02 k SITE EXAM • a _Slope _Surface water • . _Check cellar Shallow wells Estimated depth to ground water 12+'feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,'installers-(attach documentation) NO Accessed USGS database-explain: n/a ' s You must describe how you established the:high ground water elevation: HAND AUGER- 12+ FT. ' ?. ' R rr ! q. 4 iA TOWN OF BARNSTABLE LOCATION L D+ -?i O x hoc C Nc,yt SEWAGE # VILLAGE Co4u 7_ ASSESSOR'S MAP & LOT 6 li OSO INSTALLER'S NAME & PHONE NO. -T� ���SCa�� 77►�(Oy SEPTIC TANK CAPACITY 1 000 LEACHING FACILITY:(type) ����^ Q (sue) 000 e,oL 1144,e NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER �01�5 �{ Diu�����•� Cv. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r O No. �?o? F�s......L.. ......_ THE COMMONWEALTH OF MASSACHUSETTS f BOARD OF HEALTH TOWN OF BARNSTABLE Allp iration for Uiipniia1 Works Tono#rnrtiun Prrutit Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: I-U`T -7 t 0)(roAD Die i Vr. Co-t U t rt --.....--- .._................... . .................................................... ----.........------•------•------..._....---•--•-•••-.............•--•-•-----•-•-.............-•-- .V I AX 9N T d r9Y5 /� -- 't No. C ,v7 v, W I Z)R �_S C`,trye ,^„ ILL Address Installer Address Type of Building Size Lot..0?flj_10'V5._._..Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic K) Garbage Grinder ( ) pa,, Other—Type of BuildingWdgp.f M'E.. No. of persons............................ Showers ( ) — Cafeteria ( ) Oa Other fixtures .................................... W - ___.. ---------------- Design Flow----------------------I-`-0.------------gallon per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.I.PeRgallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No----------------_--- Diameter.--................. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) Percolation Test Results Performed by...................... -. Date........................................ a Test Pit No. I... �----minutes per inch Depth of Test Pit-----j ._...._. Depth to ground water-..A�_OA.JE .... (i, Test Pit No. 2..- ....minutes per inch Depth of.Test Pit.....!d.�.._... Depth to ground water... ................-. . C4 ..........--• ......-•- 9-----•--•--•--••-•••••• •• •-•••-_----- Description of Soil-•� "--•/ i� 1 k.-.. .............`�-- .... ✓l�teC� V ------------------------------------ •---------------- ------------------------------------- ----------- •---------------------- •-------- ------------------------------------------------------------------ W UNature of Repairs or Alterations—Answer when applicable................................................................................................ ••• •••-•--•••-•- ----•---------------• Agreement: The undersigned agrees to install the aforedescribed Individ ewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Cod The undersig ther agrees not to place the system in operation until a Certificate of Com is ce has bee d by the b o ealth. Signed ' - --- ---- ----------- ------------------------------ ........................................ f Dace Application Approved B pp pP y 2. Date Application Disapproved for the following reasons' -------------------------------------------------------------------- -------------------------------- ------------------ -- - - -- ----- ------------ ..-- -- ---- ---- ..........--.--- -- -------.....-----------------------------------------............ --------- --------.............................. Permit No. cy Dace 1.2.. -- �v Issued Dare 1— rr � tt No....................a F�a.......1. ....... THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEALTH TOWN OF BARNSTABLE ApplirFatiou for Disposal • orko Toatgtriirtiou Prrutit Application is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal System at: I_UT -71 O Y roAb Dg i Vr. C01 L) /-t ................_...................••••••••-•••-••-••....._......•-•-•••-••....-•••••••••...... •••-•-........_............-••••••--•-••••••-••••--•••......--•••••••.......--•-••................ _V //VC NT t f�tl�fl�✓ ��a,B�YS �v� 3atx° /s. C6Avr;eVk� N .... .. W `✓'v `j� f�C� 5 CV � ✓1�1 �/y1 L t!I- Address Installer Address Q Type of Building 3 Size Lot-__ n .....Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic (AN Garbage Grinder ( ) aOther—Type of BuildingW00,6. M.m.�. No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ........................................arK------------------•:-------------:----------- ---•--'--------- •--.-..------.---- ------------- W Design Flow......................./h o............gallons per p�seii'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--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by............................................. --- Date___._____........._..................__. '-7 � � - /off �--------•---... . ,If O�t/� 14 Test Pit No. 1................minutes per inch Depth of Test Pit___...._..___._..... Depth to ground water-__-_.__:____........... (_, Test Pit No. 2...�_A-.._minutes per inch Depth of Test Pit.....�a.�__._.. Depth to ground water.........../�� . O ��,-••--••.��-- - .......... "...............L............................................. Descri tion of SoiL.4_._.--..��____ x W x ••-•-•---•----•.......-•----------------•'------•-----•-------------•----•-----------•-'-'---------- -•----------------.....----------•---•'-------••'-•-••-----•---------••......-----•-•--.........-- 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 Environmental Coders The undersigned rther agrees not to place the system in operation until a Certificate of Compliance has been-ssued by the boalr' o /health. Signed = /Jc - ''.� - .... ................ .---'--------- - Dare Application Approved B -.-. ..t c .............. ..................................... . /7- Date Application Disapproved for the following reasons- ---------- -- ------------------------ -- ------ - ---------------------- -- ------------------------------------- . . .. ..... .............. .................................. ........... .. ............. ------------------------......---......------ -------- ..................--- -------------- Date Permit No. ....... .2...'...l'l ,a.... Issued ....... ..... .. .. .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CnPrti irate of C�omylinure bY--.......................................................� T IS IS TO CERTIFY, hat the Individual Sewage Disposal System constructed ( �( ) or Repaired ( ) O ------------------- ................. Instal ler-.-..---...........................................--..--...........................................--..-.----------....------ at ...L07 ..-."_V.........O X T_61e.lb.----....7)k.1 U6 tall- C aT o /T................... ............ ............................................. has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------"� --.y6...a`..........- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED.AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 11 }} p DATE.........................1.. /`-........1.. 1 Ins ector .... . { THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq 1� TOWN OF BARNSTABLE No...... l.a:.-.�•-��-- FEE...I��.......... Disposal�Works T'Alm #rm io rrmit Permission is hereby granted.....��--v-...�/�.�SCa/_L _ ••-•--•'--------•---••.......................'-•-••••........... to Construct (X) or Repair ( ) an Individual Sewage Dis osal System at No..4 T...7 ....... XFDi��.._..................................... co 7'lJ �t Street C as shown on the application for Disposal Works Construction Permit No./...`.. a. Dated.......................................... ----••-•-•----••-"'"_ A. ...................................................... ...................................... ���JJJJ Board of Health DATE.............. -- . FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS / f�!�•.:,' _'s i sue•' '�'�r'. :PA 1 T A ;L_ L•gyp\•'�/ 1 ���.F7 -171 A' 6AtzF3A�E GRIrJDE'r� '17 E��w S� i —A I FLOW sEPrI c ra Nl. . 3a. Asa = 4�15 �• ��;'` , o ,' lx IDa4.�AL� �C r E ?o5�4L PIT° l I0ooGal�z ST UE +� 3yJ Ir -15 — � / 1 i Bo'IToM `A - �g'Sr 14- o 5 T o' fi 6 . L 16N �- - `� f3 0 � '�i Cifi � i TOTAL RAIL MY/_=-5wGP'D oL— / L14 Y oLA-nO `QA'TE:.=.' ('! Ii.1 2M►rJ�icfS. . ID , i '` P)2CP 1 IV . :SULLIVAN lylp Wl"T%r` v i9 p�V Yo.�: .. No. 29733 �-v q.Ob op ,TES T g2Z e '-1 TF s PV� wd• 1000 /a/•a �- bKT rN. �N✓. GAL �ao� T ire✓: L3�CK iab 5 rlc 'LEAN} — WiTT TT WA690--7 CeZTITFI® PST" R IJ • - `90 .. go spa� EGA L�% I ��=�-o DATA; 1 - I L• �Z PLAT! ze&-(z&j .lc- 1 ' "CGMFY TEAT Te -t� )ELUNG Lor %0v/ HEzeoN CoM`P!LQ WITA T41tr 51PEL OE `iDA OF`BM2,45748LE .rr4lS F 4 W . ":15 NOr 'UMED oN AN 1447P"aW BE r r w I L �4 Ef 1Gi N EEt?5 Aa�D 5,rzv I LLr-- MAC • 5 T'o.,eiTaBUSN 'vp°P 12:r`! u wel APPLtcQN`(', IT3' ti�(Si�t )VIUDIQ� Ca L .. 1