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HomeMy WebLinkAbout0382 SANTUIT ROAD - Health 3.82 Santuit Road, Cotuit A= 020— 115 —002 r.� I TOWN OF BARNSTABLE LOCATION VILLAGE Cc3 u\,-r- ASSESSOR'S MAP&PARCEL INSTAE-LER'S NAME&PHONE NO. �� .e-l�OC�✓1 y1,�(I �a G i'�7�1 SEPTIC TANK CAPACITY I'5_0 0 LEACHING FACILITY:(type) .,OoU'df f>501'S (size) NO.OF BEDROOMS OWNER sa-[k.K PERMIT DATE: ATE`4,� P I is I to Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY {y�l r f F t t \l\ \ t \ \ \ \ t \ \ \ \ \ \ \ 4 t \ \ t \ \ t t t \ t \ \ \ \ t 4 \ \ \ t \ t \ \ \ \ t t t \ \ \ \ \ k t h \ \ h h t \ \ f f f ! /. f / J t \ t \ \ \ \\\�p(�1t/Q�\.�y\/Q�ht{/(��\./�♦�\ \ \ t t \ \ \ \ t t t h \ t t \ \ 1 \ t \ t \ 1 \ t \ / \J\J\ \-SJ\ \M lf1Jt�\rtJ tftf\FtftJ\Jtrtr\/\J4•f\f\/\ft/tftftJtftrtf\f\J \ \ \ \ \ tht \ ht \ \ 27 17 / 45: 40 24 .z I Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 382 Santuit'Road — Property Address _ Richard Seeley — Owner Owner's Name• information is Cotuit f MA 02635 February 16, 2010 • - — required for State .Zip Code Date of Inspection every page. City/Town s. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the u `- computer,use 1 Inspector: only the tab key p to move your Patrick M. O'Connell — cursor-'do not, Name of Inspector- use the return key. Septic Inspection Services Co.. - — Company Name rBe 189 Cammett Road — Company Address Marstons Mills MA 02648 — renen Cityrrown State Zip Code 508-428-1779 SI 12855 — Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails f ❑ Needs Further Evaluation by the Local Approving Authority February 16, 2010 Ins ctor's Sig atur Date 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. F 10.24 Seeley doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 382 Santuit Road — Property Address Richard Seeley Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes; ® 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: Tank is not in need of pumping at this time, leaching system shows no signs of surcharge or saturation. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent: System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box duty to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 10.24 Seeley.doc•08106 i I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 382 Santuit Road — Property Address Richard Seeley — Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 — required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑, distribution box.is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health):. ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: 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 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. 10-24 Seeley.doc•08106 Title.5 Official Inspection Form Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 382 Santuit Road — Property Address Richard Seeley Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) - C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 coliforrn 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 "ivo" to each'of the following f6r all inspections: Yes No El ® 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 El 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 El ® Liquid depth in cesspool is less than 6" below in or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 10-24 Seeley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 382 Santuit Road — Property Address Richard Seeley — Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 — required for State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence) of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ® 10,000gpd. El ® y The system fails. I have dete rmined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. They 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 ❑ El 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. 10-24 Seeley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 i r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 382 Santuit Road Property Address Richard Seeley Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for State Zip Code Date of Inspection every page. City/Town C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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 tans; inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information 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)] Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 10-24 Seeley.doc•08106 I L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 382 Santuit Road — Property Address Richard Seeley — Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 — required for State Zip Code Date of Inspection every page. City(Town D. System Information Residential Flow Conditions: 4 Number of bedrooms (actual): 2 Number of bedrooms (design): ) DESIGN flow based on 316 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 1 Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No N/A irrigation Water meter readings, if available(last 2 years usage (gpd)): system. Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 10-24 Seeley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page'+of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form U19"E Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Santuit Road — Property Address Richard Seeley — Owner Owner's Name information is Cotuit MA 02635 February 16 2010 — required for State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) General Information Pumping Records: Tank pumped summer 2009 - 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 System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 12/27/93 Were sewage odors detected when arriving at the site? ❑ Yes ® No f 10-24 Seeley.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Santuit Road — Property Address Richard Seeley — Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 — required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Building Sewer(locate on site plan): 2' _ Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 16 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------------------------------- ------------------------------------ 10.5' long x 5.8'wide- 1500 gal. Dimensions: 2" Sludge depth: 31" Distance from top of sludge to bottom of outlet tee or baffle Trace Scum thickness 6 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet-tee or baffle 14". Measured How were dimensions determined? 10-24 Seeley.doc•08106 Title 5 Official Inspection Form,Subsurface Sewage Disposal System•Page 9 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Santuit Road — Property Address Richard Seeley Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for State Zip Code Date of Inspection every page. City/Town 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.): Liquid level was found at bottom of outlet invert, tees were intact and clear. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): - Depth below grade: feet Material of construction: ❑ ccncrete ❑ 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 cif last pumping: Date 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): 10-24 Seeley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1(1 of 15 <, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 382 Santuit Road — Property Address Richard Seeley — Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons r 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 Distribution Box (if present must be opened) (locate on site plan): 0° 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.): No solids or high stains present liquid level at bottom of outlet pipes. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 10-24 Seeley.doc•08/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Santuit Road Property Address r Richard Seeley Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: 7 Flowdifussors. ❑ 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.): Area of SAS was probed with no evidence of saturation. 10-24 Seeley.doc•06106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 382 Santuit Road Property Address Richard Seeley Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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.)-. 10-24 Seeley.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form ,I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 382 Santuit Road `'tic-_5k= -----. _.._....----------------- -- -- Property Address Richard Seeley_.__._._-__.-----.--------------------.- Owner Owner's Name information is Cotuit MA 02635 February 16, 2010 required for ---- — -- — -- ---- — ---- -- every page City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. a!a/ r r f ! J f a f ? /a J / ! / ? ! ♦ i / a l a/ l ? f / •a/a'I a/ 'a'/ •a'/af a/ + f far ♦ /af ♦ / J + l a/ / / / / a/ai ! J f ! f + +a fa r + f ? 1 f f / ? ♦ / f J / f + / / ! ! / f�a'�OYJ GJ f / f • l • / f / i / r r / / 27 17 40. 24 Santuit Road A; f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 382 Santuit Road Property Address Richard Seeley - Owner Owner's Name information is required for Cotuit MA 02635 February 16, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 10 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ 'Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database-explain: USGS topo map dnd town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el. 5 and topo map shows property at el. 20. 10-24 Seeley.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 -\ COMMONWEALTH OF NLASSACHUSETTS l Fr. EXECUTIVE OFFICE OF ENVIRONMENTALAYFAIRS.- DERARTIYiVNT:OF.ENVIR:ONMtNTAL PR'QTECTIONT TITLE 5 OFFICIAL-INSPECTION FORM—NOT FOR ti.OLUNTARY ASSESSMENTS.., , SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION p Property-Address Owner's Name: .. . Owner's Address. -Date of Inspection: l 41S. Name-of Inspecto : (please print]. Company Name - - - - , Mailing Address:. T"x zll� ,4 00 Number: Telephone cryZp- ' CERTIFICATION STATEMENT, I certify that I have personally inspected the sewage disposal system at this address and that the inibrmation reported below is true, accurate and.complete as of the time of the inspection.The inspection was performedi based one my CD traming and experience.in the proper function and maintenance of on:site sewage disposal systems.I am a DEP rn -approved system inspector pursuant t.o ection 15.340 of Title' (3.10 CMR 15:000) The syste Passes Conditionally Passes Needs Further Evaluation by the.Local Appro�ing'Authority I I)LO all Inspector's S3gIlature:. Date:.— �a " 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 Beater,the inspector and the system owner shall submit the report to the appropriate regional oftice`ofthe DEP.The original should'be sent to the system owner and-copies sent to the buyer, if applicable, and the approving authority. Notes and Comments **** - This report only describes.conditions•at the time of inspection.and under-the copditions:of use at that time..This'inspection does not address'how the system will perform in the future under the same or different conditions of use, Title,5 Inspection Form 6%15/22000 page 1 Page 2 of 11 . i • 'if OFFICIAL:, INS.PECTIO.IY:FORK-NOT FOR YOI.UNIARY ASSESSINSEi`[.TS a SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART A p CERTIFICATION (continued) , Property Address: o Owner•. Date of I pection: Inspection�Summary Check A,B',C,D orE./ALWAYS complete:allof Section.D A. ystem Passes: 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 crite.ria.nbt 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;Vill pass. Answer yes,no or not determined(Y,N;ND)in the for the following statements. If"not determined"please explain. The septic.tank is metal arid'over 2.0 years:oW or the septic tank (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltratioh or.iank 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 tham20 years old is available. . ND explain. Observation of sewage.backup or break out or hi,-h static water level in the distribution box due,to broken or obstrucied'pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board.of Health): broken pipe(s)are replaced obstruction is removed distribution,box is leveled or replaced ND explain: The system required pumping more than.'4 times a year due to broken or obstructed pipe(s).The-system will pass inspection if(with.approval.of the.Board of.Health): broken pipe(s),are replaced obstruction is removed . ND explain: Paee 3 of 11 FFICI AL INSPECTION Ft3RlYi -.N OT FOR V OL UNTA' �' RYASSESSMEI�TS SUB SUk ACE SEWWAGE.DISPOSAI� SYSTEl11INSPECTI ON FORM PART.A CERTIF-ICATI(?N(continued)s . Property.Address: O e t wn r•-- Date afIPection° " � 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 heahffi.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 noffunctioning in a manner wfiich will protect:public.health,safety and:fhe environment: E , Cesspool or privy is within 50 feet of a surface water Cesspool or p'rrvy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health Viand Public.,Water ,supplier,if any).determines that the system is functioning in z manner that:protects the public health,safety.and environment: _ The system has a septic tank and soil absorption system (SAS)and the e SASis.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 withm a Zone 1 of a:public water supply. The system has a septic tank and SAS and the SAS is.within 50 fe'et of a private wvater supply well. The system.has a septic tank and SAS and the SAS is less than 100 feet but.60 feet or more from a private water supply.well**: Method `used to determine.distance **This system passes if the well water analysis;performed at aDEP certified laboratory;for co liform bacteria and volatile organic compounds indicates that the well is.free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen-is equal to or less:than 5 ppm;provided that no other failure criteria are trig"ered. A•copy of the analysis:must be attached to this.form. 3. Other: ,k i Page 4 of. 11 i OFFICIAL INSPECTI.0N:FOR�;1 NOT F.OR VO]LUNTARY.A.SSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM Ii SPECTION.FORM PART A CERTIFICATION(continued) Property.Address:3scQ OwnerjL Date opection: C D._ System Failure.Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the-following for all inspections: Yes No/ _ i/ Backup of sewage into,facility or system component due to overloaded or clogged SAS or..cesspool 2 Discharse or pondimg of effluent to the-surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool Static liquid-leveLin the distribution box above..outlet,invert due to an overloaded or.clogged SAS or l cesspool. 1/ Liquid depth in cesspool is•less.than 6"below invert or available volume is less than %day flow _ Required pumpine more.'thail 4-times in.the last year NOT.due to clogged or obstructed pipe(s).Number of times pumped f Any portion of the..SAS,cesspool or privy is..below high ground water elevation. Any:portion,of cesspool or privy is within 100-feet of a surface.water supply or tributary,to.a.surface water.supply. Any portion of a cesspool.or,privy is within a Zone 1 of a.public well. Any portion of cesspool.,or privy is within.50 feet of'Lprivate water supply well.: Any portion of a cesspool or-privy is.,less than 1.00 feet but.grpater.ihan.50 feet.from a private water supply well with no acceptable.water quality analysis...[This system passes-if.the.well water analysis, performed at..a DEP certified laboratory,for coliform.bacteria arid:volatile organic.compounds indicates that the.well is free from pollution from that.facility and the..presencd of ammonia nitrogen and;nitra.te nitrogen is equal:to or less.than 5 ppm,.provided•that no other failure.criteria are triggered.,A..copy-of the analysi".must,be attached to this form.] (YesfNo)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,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 1.5,000 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 _ - the system is within 4.00 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 15304.The system owner:should contact the appropriate regional office of the Department. 'Paae S of 1.1 OFFICIAL INSPECTIO, FORM 'NOT FOR'v6LUNTARYASSESSIvIEiVTS SUBSURFACE'SEW-AGE DISP.OSAL,SYYSTEM IlVSPECTTON FORKS PART B CHECKLIST `1 Property Address: 9 Owner: Date of I spection: ro Check if the following have.been done.You must-indicate"yes"or"no"as to each'of the followins: i . o V -. . . . . . Pumpin-.information was.provided by the.owner,•occupant, or Board.of Health, Were 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) c/ Was the facility or dwelling inspected for signs.of sewage back up ? ' Was the site inspected for signs of break our? 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.sludgeland 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: Yes no Existing information.For example,wa plan'at the Board of Health. Detemnined in the field.(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3110 CMR 15.302(3)(b)] Page 6 of l 1. OFFICIAL:ZNSPECTIOIV.FO.R1V'i O FOR VOLUNTARY.ASSESSMENTS SUBSURFACE-SEWAG'E:`DISP.O SAL SYSTEIMA INSPECTION FORM PART.C SYSTEM::INF.ORtMATI OIN Property Address: O cJCPJ Owner: Date,of I•spection:_ 4 Aln 7 / FLOW CONDITIONS RESIDENTIAL V Number of bedrooms(design): Number of bedrooms(actual).: DESIGN flow based on'310 CMR 15.203 (for example: 11:0 gpd x#of bedrooms): Number'of current residents:. c� Does residence have a garbage grinder(yes or no). Is laundry on.a:separate sewage system(yes or n �.[if yes separate inspection required] Laundry system inspected(ye .or no): 0 j Seasonal use:(yes or'na): � // 00 Water meter readings, if available (last 2 years usage:(gpd)): ®V Cl l eda © '�D �l �7 Sump.pump (yes.or no):Last date of occupancv:: C O M MER CIAL/IND USTRIAL/�o Type of.establishment:. Design flow(based on 10 CMR 15.203): Qpd Basis of-design flow(seats/persons/sgft,etc.): Grease trap present(yes or-no):_ Industrial waste holding;tank present(yes or no): Non-sanitary waste discharged to the.Title 5:system (yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source-of information: Was system pumped'as part of the. nspection`(y. or no): If yes,volume pumped: ;allons--How was quantity pumped determined? Reason.for pumping: TYP F SYSTEM —Azseptic tank, distribution box,soil absorption•system Single cesspool _Overflow cesspool Privy _Shared system (yes;or no)(if yes, attach previous inspection records,.if any) _ va Inno tive/Alternative technoloY Attach a copy of the.current o eraCion and maintenance co ntract to be�obtained from 's stemowner Y ) Tight tank _A.ttach a copyof the DEP approval _.Other.(describe): proximate age of all components, date installed(if own)and source of information: Were sewage odors.-detected when.arriVing at the site(yes or 6 Page 7 of l l" OFFICIAL INSPECTION FORM—NOT FOR•VOLUNTAR ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL•SYSTEIVS I3VSPECTTON FORM PART:.0 SYSTEM.I�1FORlVfATIOl�(continued) Property Address: r✓ ' Owner- Date bf I pection: BUILDING SEVER(locate on site plan) f. Depth below glade: Materials of construction:_cast iron _40 PVC other(explain): Distance-from private water supply well or suction line: Comments (on condition'ofjoints,venting, evidence of leakage, etc.): SEPTIC TANK:Zlocate on site plan) Depth below grade:' Material of construction:. oncrete=metal_fiberglass':. Polyethylene,` —other(explain) If tank is metal list age:_ "Is aae:confu-med by a Certificate of Compliance(yes"or no)`.`._(attach..a copy of certificate) Dimensions: /t(.� .� • X�o ' k Sludge depth: !� l/ 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"pr baffle: /r3 How were dimensions.determire.d: Comments(on pumping reconnmen ateT ions, Net and outlet tee or baffle condition, structural integrity, liquid levels s related to outlet invert evidence Ieakage, etc.): • •�la ��� �� lJl•V , R GREASE TRAP: (locate on site plan) Depth below grade:_ 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 bottcm of scum to bottom'of outlet tee or baffle: Date oflast,pumping: Comments(on pumping recommendations, inlet and outlet tee,or baffle condition,structural integrity; liquid levels as related to outlet invert,"evidence of leakage, etc.): Page 8 of 1.1 i j OFFICIAI:.INSPECT�O i FORM—NOT F0R:.0.LU-NTARY:ASSESSMENTS ; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C.- S.YSTEM•'INFORMATION(continued) Property Address: C Owner:- o Date of I pection:j it r c)�� i TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on.site plan) j Depth,below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain);. y Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no):. Alarm level: Alarm in working order(yes'or no): Date of last pumping: Commentsi(condition of alarm and float switches, etc): DISTRIBUTION t BOX: Zif present must be opened)(locate on site.plan) Depth of liquid Ievel above outlet invert: Comments (note if box is.level and distribution to outlets4,-qual;.any evidence of solids carryover, any evidence of age into or out of box, e PUMP CHAMBER:.26 .(locate on site plan): Pumps in working.order(yes or no): Alarms in working order(yes or no): Comments (note condition of.pump chamber, condition of pumps and appurtenances, etc.): Pate 9 of 11 OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEAE':DISPOS: L SYSTEM INSPECTION FORIYI PART C SYSTEM INFORMATION(continued) Property Address: l K Owner: Date of spection: —7 SOIL ABSORPTION SYSTEM (SAS):�}ocate on site plan, excavation not.required) If SAS not located explain why: Type F leaching.pits,number: _. eaching chambers,number: ' eaching.galleries, number: - leaching trenches,number, len_ath: leaching fields,:nunber, 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): 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: Y . Depth of scum layer: Dimensions of cesspool: Materials of construction'. Indication of groundwater inflow(yes or.no): Comments (note c-ondition-of soil;signs of hydraulic failure,.level of ponding, condition of vegetation, etc'): PRIVY: (locate on site plan) r Materials of constriction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,). Page 10 of 1.1 ' OFFTCIAL IN`SPECTiQi FORM=.�10I` FAR�TOLU3�tTAR3t ASSESSMENTS . SUBSURFACE SEW-AGE DISPOSAL SYSTEM INSPECTION FORM. j PAIgT-C. SYSTEiI'I:Z1Y:FORMAT"ION(continued).. Property Address: CC�-�%� Owner: .• n Date of s pection.:. wG 7 I SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the;sewase disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all:wells within 1 OQ feet:Locate.where public water supply enters the building. i . I • i U 0 t3 i i U J:S { Paoe 11 of I 1 OFFICIAL INSPECTION FORM -NOT FOR'VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM-INFORMATION(continued) Property Address: ga � Q Owner: . Date of spection: 00-7 ro SITE EXAM Slope Surface water Check cellar - Shallow wells Estimated.depth to"ground water f feet ';Please indicate (check):all methods used to determine the high ground water elevation: Obtained from-system design plans on record If checked, date of design plan reviewed: Observed site (abutting'property/observation hole within 150 feet of SAS) = Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) 7Accessed USGS database-explain: You must describe how you established the high ground water elevation: ` AI s.z 11` Permit Number: Date: Completed.by: HIGH GROUND-WATER LEVEL COMPl1TATI0N Site Location: aw !J/ tLot No. Owner:. G l 1 Address: Contractor: G.. Address: >q $_ Notes:. 0 STEP. 1 Measure depth to water table to nearest 11110 ft. . .:....:.. " ....... ..............:.....:........... .Date I �d month/day/year STEP '2 Using Water-Level Range Zone and`Index Well Map locate' site and determine: r 0 Appropriate index well............................... � �..� ...... OB Water-level range zone ....... ........ ....... ...... ...... STEP 3 Using monthly report"Current Water Resources Coriditions" determine current depth to + j water level for index well ......... O.F Z month/year 'STEP 4 Using'Table of Water-level Adjustments for indexwell .(STEP 2A), current depth to water level-for index well (STEP 3), and water-level zone (STEP 213) j determine water-level adjustment ........ ......... ......................................... .................:............. `` 7 STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) - _from measured depth to water level at site (STEP 1) .. Figure 11--Reproducible'computation form. 15 00 • ;y _ F k. fic a � Town of Barnstable F 1HE TaY Regulatory Services s�xxsTns Thomas F. Geiler,Director MASS. A Public Health Division rFD MA'S Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. No..-7--. ...Ll. FEs.........�L'1..4........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � �`� ...............0'._D , pphration for DiiiVatial Workii Tnntxnrtion Vamit Application is hereby made for a Permit to Construct (K or Repair ( ) an Individual Sewage Disposal System at: ........�-h.......... VT--_.?e-).. .:... :` ... --' .. . .............. Lo at'on-Address or Lot NO. w '„ �iceF'7 �,v nip Qn� - ..................... Owy - .................� �• -• ......•. ------•- -•---•---...Ad' •i .............. Installer Address Type of Building Size Lot.___.1.'___4�____.�-#eet a Dwelling Type Building iooms-------- -__..__:•-No. of persons Attic ��Showers Garbage Grinder Cafeteria P�p, Otheryp g P ( ) ( ) Q' Other fixtures w Design Flow_________________________ ____'S __.gallons per person pqr day. Total dai,, flow-------------- "_ ..........gallons. WSeptic Tank—Liquid capac ity j.�7 gallons Length.IQ.__._____ Width__.__._.__. Diameter..-- .__:•._-__ Depth_ x Disposal Trench—No_......__............ Width---0.......... Totat Length.......`O___?Q.... Total leaching area__.__(_�..sq. ft. Seepage Pit No--_---------------- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( yIj' Dosin tank '-' Percolation Test Results Performed by.._ 'X _.�d _-_�: .��'u __ Date' fZ _- � -. aTest Pit No. 1....--2..mmutes per inch Depth of Test Pit----1v?........ Depth to ground water__�7^_C.f_______. Test Pit No. 2........_.......minutes per inch Depth of Test Pit____________________ Depth to ground water........................ x -r_ ________am _O Description of Soil....... � ---- •-=-•--------•-•----- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant as been i ue y the board of health. Signed _-_... ApplicationApproved BY ------------------------------------------------------------------------ ...- Da[e Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- ------------------------------..................................---------------------------------------------- - Da Permit No. ..... a---.-,,---```�................................. Issued ........................D--- .--...-.-._....._..----.. -1- te ... �arre+� i Fiml,. .._.............. THE COMMONWEALTH OF MASSACHUSETTS z� BOARD OF HEALTH ��-- T1.�, l� Appliration for Dispniia1 Works Cfnnstrnrtiun ramit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ff ......... . -.--......... .L ... �`...C,,� C�(> �v i Lo ti n-Address or Lot o. Ow�i'er_ f 'r L Address W ; , . Installer Address --7 QType of Building Size Lot_____{ ......Fn' t Dwelling!No. of Bedrooms______________ ___________________________Expansion Attic (3r_) Garbage Grinder P d P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ............................ . d -----•------------------------- W Design Flow..............................5 ;7...____gallons per person pgr day. Total daily flow............... .�:.Q:..__._. lons. WSeptic Tank—Liquid capacityj'Zz4__Wgallons Length_1 9..._.._.. Width.._$-_-_-____ Diameter______________ Depth.-_!..5...!_. .. Width...... .......... Total Length .._ Total leaching area.... ? ...s ft. x Disposal Trench—No...____'_....._:_ g g q. Seepage Pit No------------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( Yr Dosin tank ( - 5 IUMJ - " Percolation Test Results Performed by . ( __-_ _.M� _. _________________________ Date Test Pit No. 1___ -____minutes per inch Depth of Test Pit----/ ........ Depth to ground water.. ___- -. (Tq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water____-_--------------_--. W ------------------- ----------------------........................a........•••------•-•-•------------ O Description of Soil------. d ------. . # v!`Sv l ='1�........ ..../CJI'Vl--� N............................ x V ...... ......•--------------------•-•--•-••-•---........-•••----------•-------- 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ............. ..................:..........<............ ............................... ........................................ Application Approved By ......... `�'� - .................(*'."- ...... .•,t,C -.K....... _ '4v'v':cs c,.-e::,. -_...................................................................... Date Application Disapproved for the following reasons: --...................................................................................................................................................................................... ........................................ ------.... --'-'- Dare PermitNo. .. _....! ( '-- Issued .................................................... ---------- Date THE COMMONWEALTH OF MASSACHUSETTS BOAR.P OF HEALTH `lJ C .... ..... OF ..._.../'AWI 7�:/'1..�-------------------------------------------------- C�P>r#ifi atr d C1umylianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( L-1 or Repaired ( ) /r./ - r r)___ --------�.----- Inu er at ........ .f:....�.......----.�� -...�-/-T------. �. - I ---ram== �.I...��...---' " ........................................." ' has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....'..-.J!..`.1................ dated -----------------.-............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. . .:'.........�..................................... ........................... Inspector ----..-.--. .... ------------------------------------------------------------------ t_! -` L) Jay THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH oF..... �3 !�-��,' . ::�.......----------..........................7.......................... , No...I.. ...11% FEE........................ Disposal nrkii T.1n#r ion antic Permissionis hereby granted.............................................................................................................................................. to Construct ('K) or Rep it ( ) an Individual Sewage isposal Syst at No......... .............................../.........-� Street �%f as shown on the application for Disposal Works Construction Permit No 2nL/.c....... Dated.......................................... ...........................•------•--•------.•----------------------------••-•--------•........-•----••-- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - y , OWN OF BARNSTABLE LOCATION �17-19 . SEWAGE # �LLAGE ASSESSOR'S MAP & LOT Ddb INSTALLER'S NAME & PHONE NO. V4YLI�Cbw-7 y SEPTIC TANK CAPACITY LEACHING FACILITY:(type) O � (size) NO. OF BEDROOMS PRIVATE WELL O BL1C WATER UILDE R OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: �J VARIANCE GRANTED: Yes CNo R - t. 1/ � ����� 1 '1 .` Z� � � �� N mac i I Ii i 6 i � _ 1 / /�- ��4 p t��� �•z _y,_ ! �G- ld-- �,,� .4 � ._r����' I�. ,� � -- E-z_._ : 17 Q fs! y 4.a L 07- 1Z. ►d t-1eDUc-_ dfU r `------c �Z1Z►d 2�d �Z I� I2. '��ilk_.. 13,U ?� . rA•N�'G' 1 � 5 Co "` t � - / � N J 1� -7�t r�� 1STl►�} t- 4� Wf C 1a 1-Z .. 1�� 4t-P, -4 "emsIfE.Lvc.E A / I"V — z_.,�> M, -�—r�—'T►�►l, I I l u q '3�''( 7 14,U 1 i ! i i vie-,t V_1� > w AIJ, . 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