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HomeMy WebLinkAbout0025 PINE RIDGE ROAD - Health 25 PINE RIDGE R;-v f� I� j` OF B LE LOCATION � l C' SEWAGE# VILLAGE l= t. ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= LEACHING FACILITY: (type) (size). �V NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (H any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �6�CP ELI --j oeet I o G 4A IL D � 14 fir\ r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON.MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE r Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Govemor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 25 PINE RIDGE RD. COTUIT Name of Owner JANET SHANLY Address of Owner: BOX 2074 COTUIT MA.0-2636 Date of Inspection: 6/1199 Name of Inspector:(Please Print)JOHN GRACI I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) �= —1`/ Company Name: n/a Mailing Address: n/a Telephone Number: n/a �If� j AlJ 2 fQ >0 3 1999 CERTIFICATION STATEMENT 40" t% I certify that I have personally inspected the sewage disposal system at this address and that the information r ported beldi t�lyr } urate and complete as of the time of inspection.The inspection was performed based on my training and experience n the proper functidn and maintenance of on-site sewage disposal systems.The system: X Passes The inpection is based on criteria defined In Title Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Further Eval at By the Local Approving Authority performing at the time of the inspection.My Inspection does _ Fails notimply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. Inspector's Signature: Date:6/16/99 The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. 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. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND THEN MAINTAINING EVERY ONE TO TWO YEARS. THE LEACH PIT WS 314 FULL AT THE TIME OF THE INSPECTION. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 25 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1/99 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: 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. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.if"not determined",explain why not. Wa 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. Wit 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 nta 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 9/2198 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1199 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 16.303(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 nla ' t revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 25 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined 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 Wa. 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. 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 II 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 912198 Page 4 of 11 SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 26 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1199 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 BAH, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [t 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. i revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 26 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1/99 FLOW CONDITIONS RESIDENTIAL: Design flOW:-M g.p.d./bedroom Number of bedrooms(design): 3 Number of bedrooms(actual):2 Total DESIGN flow: IU Number of current residents:2 Garbage grinder(yes or no):YES Laundry(separate system)(yes or no): N_Q If yes,separate inspection required Laundry system inspected(yes or no):JLQ Seasonal use(yes or no):JMQ Water meter readings,if available(last two year's usage(gpd): n1a Sump Pump(yes or no): NQ Last date of occupancy: n1a COMMERCIALIINDUSTRIAL Type of establishment: nLa Design flow: n&gpd(Based on 15.203) Basis of design flow: nLa Grease trap present:(yes or no):JM Industrial Waste Holding Tank present:(yes or no): NQ . Non-sanitary waste discharged to the Title 5 system:(yes or no):MQ Water meter readings.if available:Wa Last date of occupancy: n& OTHER: (Describe) Wa Last date of occupancy: D& GENERAL INFORMATION PUMPING RECORDS and source of information: n[a System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nLiL gallons Reason for pumping: n/A TYPE OF SYSTEM n 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: nta APPROXIMATE AGE of all components,date installed(if known)and source of information: 1977 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1/99 BUILDING SEWER: (Locate on site plan) Depth below grade: V 6„ Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) Wa T SEPTIC TANK: X (locate on site plan) Depth below grade: Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ Wa Dimensions: L 8'6"H 6'7"W5'8" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness: Distance from top of scum to top of outlet tee or baffle:Si' Distance from bottom of scum to bottom of outlet tee or baffle: M 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.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS. GREASE TRAP: (locate on site plan) ' Depth below grade: Material of construction:_concrete_ metal_ Fiberglass Polyethylene_other(explain) nla Dimensions: Wit Scum thickness: n& Distance from top of scum to top of outlet tee or baffle:iVa Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: nLa 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 I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:611199 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nta Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nla _ Dimensions: nLa Capacity: nla gallons Design flow: Wa gallons/day Alarm present: N_Q Alarm level:jila- Alarm in working order:Yes—No_: NO Date of previous pumping: n1a Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nta DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert:LIQUID LEVEL WITH BOTTOM OF PIPE Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) DISTRIBUTION BOX IS STRUCTURALLY SOUND PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa r revised 9/2/98 Page 8 of 11 f - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:6/1199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) ' If not located,explain: nta Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: -n& leaching galleries,number: ji& leaching trenches,number,length: n& leaching fields,number,dimensions: nLa overflow cesspool,number: nta Alternative system: nLa Name of Technology: _ala • s Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT WAS 3/4 AT THE TIME OF THE INSPECTION RECOMMEND PUMPING NOW, CESSPOOLS: _ (locate on site plan) Number and configuration: nLa Depth-top of liquid to inlet invert: Wa Depth of solids layer: nLa Depth of scum layer. Wa Dimensions of cesspool: Wa Materials of construction: Wa Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)Wa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nta PRIVY: (locate on site plan) Materials of construction:Wa Dimensions:n& Depth of solids: n/A Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 PINE RIDGE RD.COTUIT 0 P Y Owner: JANET SHANLY Date of Inspection:6l1/99 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) n/a y C do l - . a 4A iL �6 id CA 1� ale �Y revised 9/2/98 Page 10 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 25 PINE RIDGE RD.COTUIT Owner: JANET SHANLY Date of Inspection:611/99 NRCS Report name: n(a Soil Type: nla Typical depth to groundwater: n/A USGS Date website visited: n& Observation Wells checked: NQ Groundwater depth:Shallow _ Moderate Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record X 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) USGS MAPS AND CHARTS AND VISUAL-12+FEET revised 9/2/98 Page 11 of 11 No....... Fizis... . THE CO' MONWEALTH OF MASSACHUSr ETTS� RD,4DK HEALTH _ ® -..... oF........................... � A p irFa#iou for Disposal a7or � f'nflbr�nrtinn rrntit App[1 on is hereby made for a Permit to Construct ( R pair ( ) an Individual Sewage Disposal Syst at -• �. �....�:�.-.• . ` .......................................... ..---• --•- -----.. .......................................... o afo A dress �. or hots o. r[ .Ad7.... Installer Address Type of Building Size^Lot........ ................Sq. feet ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building •__________________________ No. of persons...................... __ _ Showers ( ) — Cafeteria ( ) Other fixtures .. ----- ------------------------------------------------.---•----•-•• W Design Flow............................................gallons per person per day. Total daily1flow_______--_-_-\...........................gallons. GG Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter-___ ........eDepth................ Disposal Trench—'No..................... Width......_............. Total Length................. Total leaching area_.._...............•sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet........ Total leaching ..................sq. ft. Z Other Distribution box (- ) Dosing tank ( ) a Percolation Test Results' .,, Performed by...................................... •------------------------ :--.`------ Dated ---------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--___-_______-_-__..._-- fr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.._......_.........._... 1 O Description of Soil .................................................... x W --•--:•. E--k... UNature of Repairs or Alterations—Answer when applicable._____ Agreement: The undersigned agrees to install the aforedescrtbed Individual Sewage Disposal System in accordance with the provisions of i i ?.: 5 of the State Sanitary C — The undersigned iurti:er agrees not to place the system in operation until a Certificate of Compliance has een iss by of health. Signed ..... l2 :1�•- Date/ Application Approved BY - ............. •----_/Q a< . .... Date Application Disapproved for the following reasons:......................................................................................••--.----.________....._ ..............••---........-----------------•---------------•------------•------......_..--•---......------•...---------------•-------•--------•--•--•---•------•--•----•--•--------•-------••-•-------- Date PermitNo........ --.. ._.......t. ---. Issued-....................................................... Date --' NO.E�; -----—-----— Fmc7...7_7E.�..... THE COMMONWEALTH OF MASSACHUSETTS HEALTH ------- - ----- ------------OF.......................................................................................... A111111ratiou for Dispwial Works !;umitrurfinia Permit A li is hereby made for a Permit to Construct ('0<'Repair an Individual Sewage Disposal pp,I on or System .............................................................................................. .......... a it, dress or Lot lo. L. ...4......................................... .................................. ............................................................ r Address .... ....... .................................................................................................. nstal'fer Address Type of Building Size Lot...............:............Sq. feet Dwelling—No., of.Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( ) Otherfixtures ...................................................................................................................................................... Design Flow............................................gallons per person per day.-Total daily flow............................................gallons. Septic Tank.—Liquid capacity............gallons Length................. Width._.__.______.:_. Diameter..__.._.._..____ Depth.............. Disposal Trench—No..................... Width___.___._.__._._.._. Total Length_._______.______.___ Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.__._...._.._-...... Depth below inlet____.___.__________. Total leaching area..................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit_.________________.. Depth to ground water_._:_.____._.____._..__. 44 Test Pit No. 2................minutes per inch Depth of Test Pit____._._..__.______. Depth to ground water........................ --------------------------------------------------------------------".......*"*......."------- --------"•----------------------------- -----------=­­ 0 Description of Soil------------...........................................................................................................................I.............................. U ......................................................................................................................I..................................................................................... ..................................................... ..................................................?;........... ....I... . .. ............................................ Nature of Repairs or Alterations—Answer when applicable....I ........ ................................ ��A -------- U N_ Ix : !��_ _ 'iZEE------------------ ....... ................................ - Rc� Agree i�nt: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with tlie-provisions of'TTLEIE 5 of the State Sanitary C —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has -een iss d by of health. ....... .................... -----------------Sizned . .............. ........ Date Application Approved By............<:Z77ZZ;?,, ... ............................................. .............. Date Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date Permit No........E5to...... .... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD—O-F HEALTH ..........OF...... ...................................... Tertifir'de of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Di sposal S7.stem constructed or Repaired.Ca�:Izlelb ----------- n - - y ....r� . ................................................................................... Installer ...................................................................................................................... at........ ........... ....... has been installed in accordance with the provisions of 11'ZIE 5 of The State Sanitary Code as,descrjkSd in the .application for Disposal Works Constr�uction Permit dated_,..-_-___ . ..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,CONSTRUED AS A GUA �NTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY.. DATE........................... ...... ........................ . Insp ector....................... ............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ 0 ............................. 7......... iV ............. FEE.... ........ Qufit oustrwtion - A, " Permission��isreby granted. ........I...P....' ...... . r, .................................................................. to Construct or Repair an Individual Sewage.pisposal System ................ t 4 ..... ........m. ......!�!...1Z..... ............I e . ................................................................... y. street 3 as shown on the application for Disposal Works Permit N� --- Dated.......j ? Construction Per -------7.....7—.... ...........................................Board ... ..................... CE Boird of Health DA ...... 9LL.............. A, FORM 1255 1HOSES & WARREN. INC..'PUBLISHERS Ilk 4 TOWN OF.BARNSTABLE LOCATION E ' . SEWAGE # VILLA `"ASSESSOR'S MAP LOT INSTALLER'S NAME Cz PHONE NO,&VV : SEPTIC TANK CAPACITY 1000 -EC ON �.� (size) (r)©O ctAr . . ol NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER �O�fY� 22l DATE PERMIT ISSUED: Y DATE .COUPLIANCE ISSUED- VI J Z L RIANCE GRANTED: Yes No X� r cno i N D