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Home My WebLink About0109 PRUDENCE LANE - Health 109 PRUDENCE LANE$ COTUIT 0,3 LA ...:.:....row.::... _. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad 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 Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 109 PRUDENCE LANE COTUIT C)39 6 Name of Owner MRS FURBER -� Address of Owner: SAME + � Date of Inspection: 8/30/99 Name of Inspector:(Please Print)JOHN GRACI [� 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: n/a p x O Mailing Address: n/a to Jp4 0 �9 Telephone Number: nla Ope Nq 19Q CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below-is t'6!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 The Inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evai ati n By the Local Approving Authority performing at the time of the Inspection.My inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/2/99 The System Inspector shal submit 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 buyer,if applicable,and the approving authority. ' NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFULL LIFE. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 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. 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: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8130/99 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 nLa revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30199 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 nLa. 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 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 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: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 FLOW CONDITIONS RESIDENTIAL: Design flow:-M g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: 22Q Number of current residents:.1 Garbage grinder(yes or no):MQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nta Sump Pump(yes or no): MQ Last date of occupancy: nta COMMERCIAL/INDUSTRIAL Type of establishment: nta Design flow: nta gpd(Based on 15.203) Basis of design flow: Wa Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): MQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: n& OTHER: (Describe) n& Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: nLa System pumped as part of inspection:(yes or no):NO If yes,volume pumped nLa_ gallons Reason for pumping: nta 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& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1980 Sewage odors detected when arriving at the site:'(yes or no): NO revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 BUILDING SEWER: (Locate on site plan) Depth below grade: L'E Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nLa SEPTIC TANK: X (locate on site plan) Depth below grade: i 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): NO nla Dimensions: L 8'6"H 6'7"W 4'10" Sludge depth: 2' 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 bottom of outlet tee or baffle: 1Z 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 TR TUR4 Y SOUND.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) Wa Dimensions: nLa Scum thickness: Wit Distance from top of scum to top of outlet tee or baffle:-La Distance from bottom of scum to bottom of outlet tee or baffle Wa 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.) revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nla Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: Wa Capacity: nLa gallons Design flow: nla gallons/day Alarm present: NQ Alarm level:_n/a_ Alarm in working order:Yes_No_ NQ Date of previous pumping: Wa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:Wa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) W PUMP CHAMBER: MQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): MQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 c Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 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: nLa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: juLa leaching galleries,number: _nLa leaching trenches,number,length: Wa leaching fields,number,dimensions: Wa overflow cesspool,number: Wa Alternative system: n& Name of Technology: -nLA 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 FUNTIONIN PROPERLY-THE PIT HAS NOT HAD MORE THAN 1'OF WATER IN IT CESSPOOLS: (locate on site plan) Number and configuration: n& Depth-top of liquid to inlet invert: Wit Depth of solids layer: n& Depth of scum layer. n& Dimensions of cesspool: n& Materials of construction: n& Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)n& 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:n& Dimensions:n/A Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8130/99 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 4C f St�C e� ec �1nJ o 44�d 4c. 33 N6 revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 109 PRUDENCE LANE COTUIT Owner: MRS FURBER Date of Inspection:8/30/99 NRCS Report name: nta Soil Type: Wa Typical depth to groundwater: n/a USGS Date website visited: nLa Observation Wells checked: No 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 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 revised 9/2/98 Page 11 of 11 1'39CATION SEWAGE PERMIT NO. J09 � �eh c�e _ v l l l A G E .-��- /' /� �` (f /7o/ 1 C,c<vis�,or, sJ C_a7 ,� I N S T A LLER'S NAME i ADDRESS JOHN A. AALTO B:ACKI 110E SERVICE gym, L( L West Barnstable, Mass. .026.63 IUILDEIII OR OWN/ER DATE PERMIT 1 SUED .2_ 2U _ DATE COMPLIANCE ISSUED 'n � 5� !' �+ A �/ �� / ��, . � � � � � /c/-'6 �/ � \ � �� j ��" '�� F4„ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F �-�a�.._............ ...... -----------------------------------------....... D� t l�aal rat Tomitrurtion amit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Li Lo TU Location.Address or Lot-;�Io. O ................................Address nstaller Address Q Type of Building Size Lot%l .9a.!PP .Sq. feet Dwelling—No. of Bedrooms.._...________________________________Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ------------------------------• . W Design Flow............ : ....................... per person per day. Total daily flow......... ��„_______.__.._._._....gallons. WSeptic Tank—Liquid capacity/W. -._gallons Length-------_------ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......J............ Diameter----10---------- Depth below inlets...... ...... Total leaching area A4.7:0.....sq. ft. Z Other Distribution box (k/) Dosing tank ( ) ~' Percolation Test Result Performed by._ "_ ��('. _..C)._.1�` _ ^'�...................... Date........................................ a - Test Pit No. 1...............minutes per inch Depth of Test Pit....1_.Z._--_-___- Depth to ground water.-&�6,V:e- (s, Test Pit"No. 2.......I....minutes per inch Depth of Test Pit....1.�......... Depth to ground water---A?tji,.,51.4 -----------------------------------------•-------•-------•--..... ------•-••----•-•-----•--------•---------------------•---•.-.---------------------- O Description of Soil...... .Z..a-mil= /a��Ht._:# ....rl,----------- ® � ts' '`'' �.... ---------- U W -----•-•------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•--- U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------.................................. ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of' L- T T T•-•. of the State San'ita y Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliancg has een i ued b' the board of health. -- - - --- - - -- - - - Date Z Application Approved By............. ' �/Y = /_/ 1 Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------- -•..................••-------•••-•--•-----•-•------•--•--•---•-•-•---•---•-•-•---•--••••------------•----...•--._.....---•-----•--------•----•----•-••------•••-•••-••---•-------•---------•----...----•- _ Date Permit No.--- ............. Issued---- . vl ....... Date j t � � No.l.. ! THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.... -_ _. Appliration for Uigpoiial Worko Tontitrurtion rrntit Application is hereby made for a Permit to Construct ('" ) or Repair ( ) an Individual Sewage Disposal System at: / -p"�' !; 14 fLOT 1 t'`�`,- Cb A"t�'1Q,!�7.1.... ............ ................................................. .................. .•• .....-• ...---- ....... ocatio -Address or Lot)No. :` _Vl .....--i="--• !N81.--•-•----•------------------ Q.1..... lvt ? 1. _..__..:.. ?..... �? ' ....-- ptiOwner Address .....•.....-•.....................•---•--•^---...-•----............................_._........... ----•-......--•••-------•-----............................. . ..... ._....................... Installer Address d Ty pe of Building rr�''�� Size Lo %3 q!LSq. feet U Dwelling—No. of Bedrooms.....G"%................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type,of Building No. of persons............................ Showers — Cafeteria Q' Other fix res ............................ . W Design Flow...........T_ ,.........................gallons per person per day.. Total daily flow........ .k ,o......................gallons. WSeptic Tank—Liquid capacit/ ...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......I-----_--____-- Diameter---10........... Depth below inlet........(,#....... Total leaching area�k%.77.0......sq. ft. z Other Distribution box (/) Dosing tank ( ) '~ Percolation Test ResulU Performed bye �.`��. --. •lp f ....................... Date........................................ a Test Pit No. l.._... minutes per inch Depth of Test Pitj_.2........... Depth to ground water_.k):e3.AJ �.... (s, Test Pit No. 2..... ___._minutes per inch Depth of Test Pit__V� .._..__... Depth to ground water_, t jLi'P'".. ------------------------------•--------------------------------•-••• •---••---...._--.... ............................•. ----...----.---•-- O Description of Soil '"` �?. E.!a-!�t_.'i`'_u scj j (7rl __." .ra' P_- C D?9 AZ .. ...........................wtr� . R W UNature 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 TLIT p 5 of the State nit y Code— The undersigned further agrees not to place the system in operation until a Certificate of Complian e h een ' sued 'y the board of health. - S --------------------- --�`.... ......`........ ---------------- -- - - - � ate Application Approved By•-•...... - -- /Y........ ,;,,� --- ........................................Application Disapproved for the following reasons:.................. ----------------------------------------•---•...........................Date-------------- ..••--••--•-•-•----••••---.........•-••--•••--••-•------•-•-•-•------•--•------------•-•-•-•------•••----••-•-•---•---------•--••-•---••-••-••-••-•-----•-•--••-----•••---••-••-••-------•--- Date PermitNo---------------------------------------------•----------- Issued...............-•-••----•••---......_----� Date ^-^•---•---- Yes. . i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH • .. Tntifiratr of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed) or Repaired ( ) by---------•-------•--•--•--••----------•--•••-•-•--------------•-------------------- -----------------------------------•-•--•----------•---•--------------------------------•---------------------- Installer' i has been installed in accordance with the provisions of T `iE j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No .._z. ................... dated_...--_-_--_.--.-___--.-__--_-_-._._-_-__-•_-- � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI�FUNCTION SATISFACTORY. i DATE. .... Inspector 61 -`=... .......... ...........................•............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH F. ! -.....�1. o FEE. r .. Dispoml Workii Ouonitrudion rrntit Permissionis hereby granted...............................................---------- --------•-----•------•-------------------•----•---------------.................... to Construct (L-1 or Repair ( ) an Individual Sewage Disposal System i at No. 4-Al f4,>................ Street as shown on the application for Disposal Works Constructio -permit No.................... ate __________... ............................ .... �' -. ----- _.�.. -- - oard of Health DATE....t �r-� ..... -..��-�/.................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 0 O t�ettsT 4 p4hl�•�CALNIJ36t � {4 nj �1•I t�`� Q ��r. E��c�rivr� �� '�' ��p�2�Q` D�s�• goy. � �, lE tcaoo A.L- Co4c to 4"'you f� ?Vc if X f: � Sl�7. e 10 o � -�� 4 o �.. PR v D c15 3$x� Of w -T-0 n1 0 a c E. $NUTN, JR. 1,�za f ' -•�- d� �tisCwr 4 12 46 soc. Wc. A14M f4AK 1 a 4 4Q v t bats + •Cam, A 4 Sep+,t Ta c707 C�-'In 41 A 4-6 SV 6!- -24, o ' �i�r30 1 ��, „+C.t� ►'C' b 1 9A.Ts. Z;ti,A fo lixic� f� C oaf C.oarSE 2 e-P R 4 O A4S X. 140 4tPD = s y { �?CAPAC�IT 4 RP O\/t 9 2 P C-4 P 9 , -TTIO Pp ----�-- $4 L Vic.t�`Ig 'i ; �1` p L7 ` (R i.` �r7 a�✓y {�+. �/ i �� ► ^y:`+ �y le - i�J Q W4-mz CsymoAm-eep �• � +�1[1. _ y �• . . ' .�' rn P' ,OWN OF BARNSTABLE ON b �JJ 1 � E # VILE 'GE ASSESSOR'S MAP &� ® 5� INSTALLER'S NAME&.PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) 1060 NO. OF BEDROOMS o' BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist j within 300 feet of leaching facility) `�— Feet l Furnished by �� ScQC� l�Cc� r 6 `I AA g3