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HomeMy WebLinkAbout1202 SANTUIT-NEWTOWN ROAD - Health (2) 1202 SANTUIT-NEWTOWN; RPAV-, COTUIT A=026-0.20 a { I COMMONWEALTH OF MASSACHUSETTS s EXECUTIVE OFFICE OFENVIRONMENTAL AFFAIRS W DEPARTMENT OF ENVIRONMENTAL .PROTECTION F TITLE 5, RECEIVE® OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM MAY 2 3 2002 PART A CERTIFICATION TOWN OF BARNSTABLE HEALTH DEPT. Property Address: 1202 NEWTOWN RD. COTUIT t Owner's Name: TIERNAN MAPO;Z D . Owner's Address: SAME PARCH ' n� Date of Inspection: APRIL 2 2002 LOT - _ - _ V Name of Inspector: (please print) PETER COLLINS Company Name: SOUTH SHORE SERVICES Mailing Address: 475 FURNACE ST MARSHFIELD Telephone Number: 1781 834 0161 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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: XX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: The system inspector shall submit a opy 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. Notes and Comments ****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. Page Title 5 Inspection Form 6/15/200 1 r Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ; B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined" please explain. T 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 *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 due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced 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: Page Title 5 Inspection Form 6/15/2000 2 Page 3 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to deternne 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. 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 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,provided that no other failure criteria are triaaered. A conv of the analysis must be attached to this form. 3. Other: Page Title 5 Inspection Form 6/15/2000 3 f Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 D. System Failure Criteria applicable to all systems: , You must indicate'`yes" or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an X overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS X or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). X Number of times pumped X 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 X surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well X Any portion of a cesspool or privy is within 50 feet of a private water supply well. 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 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,provided that no other X failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine . what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. - 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 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E'or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 Check if the following have been done. You must indicate"ves" or"no" as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of X the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper X maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Yes No X Existing information. For example;a plan at the Board of Health. Determined in the field(if any.of the failure criteria related to Part C is at issue approximation of distance is X unacceptable) [310 CMR 15.302(3)(b)] i Page Title 5 Inspection Form 6/15/2000 5 Page6of11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT , Owner: TIERNAN Date of Inspection: APRIL 2 2002 FLOW CONDITIONS RESIDENTIA Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no): NO Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): NO Last date of occupancy: CURRENT .OMMERCIAL/INDUSTRIA] Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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): Pumping Records Source of information: DUNE 2001 PER OWNER Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: 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) 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: LEACHING INSTALLED NOVEMBER 98 Were sewage odors detected when arriving at the site(yes or no): NO Page Title 5 Inspection Form 6/15/2000 6 Page 7 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 BUILDING SEWER(locate on site plan) Depth below grade: 24" Materials of construction: cast iron XX 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting, evidence of leakage, etc.): ALL PIPING IN GOOD CONDITION WITH NO EVIDENCE OF LEAKAGE. VENTING APPEARS NORMAL SEPTIC TANK (locate on site plan) Depth below grade: 16" Material of construction: XX concrete metal fiberglass- polyethylene other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 8X4X5 Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 15" How were dimensions determined: DIPPERSTICK AND TAPE MEASURE Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): TANK IN APPARENT GOOD CONDITION,TEES IN PLACE,LIQUID LEVELS PROPER. NO SIGNS OF LEAKAGE IN OR OUT OF TANK. SYSTEM SHOULD BE PUMPED YEARLY. 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 bottom of scum to bottom of outlet tee or baffle: Date of last pumping: - F 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 Title 5 Inspection Fonn 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 TIGHT or HOLDING TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): 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: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.): D BOX IS LEVEL WITH NO SIGNS OF SOLIDS CARRYOVER. THERE WAS NO SIGN OF LEAKAGE IN OR OUT.BOX IN GOOD CONDITION FOR AGE VIDEO CAMERA USED FOR INSPECTION PUMP CHAMBER: (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.): t Page Title 5 Inspection Form 6/15/2000 8 f - Page 9 or rt OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type , leaching pits, number: leaching chambers, number: leaching galleries,number: 4 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.): THERE WAS NO HEAVY VEGEATION OR MOIST SOILS NO SURFACE PONDING OR VISABLE SIGNS OF HYDRALIC FAILURE. INFILTRATORS INSTALLED 1198 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 or 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.): Page Title 5 Inspection Form 6/15/2000 9 i P% io oc n OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Prope ty Address: 1202 NEWTOWN RD._COTUIT Owne TIERNAN Date t,'Inspection: APRIL 2 2002 SKEZ CH OF SEWAGE DISPOSAL SYSTEM Provid::a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benclu miss.Locate all wells within 100 feet.Locate where public water supply enters the building. jo B1t . c� ' Page Td! 5 Faction Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 1202 NEWTOWN RD. COTUIT Owner: TIERNAN Date of Inspection: APRIL 2 2002 SITE EXAM Slope SLIGHT IN AREA OF SAS x Surface water NO Check cellar DRY Shallow wells NO Estimated depth to ground water 10' 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) XX Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: DATA ON RECORD AT BOH INDICATES GROUNDWATER AT ELEVATION 40 ON HEALTH DIVISION WELL MAP . GROUND ELEVATION IS 50 . BOTTOM OF SAS IS 50"OR 5'ABOVE GROUNDWATER I Page Title 5 Inspection Form 6/15/2000 Commonwealth of{Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name Information is Cotuit MA 02635 08/22/08 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Important: A. General Information When filling out I / forms on the computer,use 1. Inspector: only the tab key to move your Michael Kellett cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspection Company Name P.O. Box 896 Company Address East Dennis MA 02641 1, r�rn City/Town State Zip Code 508-385-7608 S13742 Telephone Number license Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the t 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 s Title 5(310 CMR 15.000).The system: _ r 1 ® Passes ❑ Conditionally Passes ❑ tails Needs Further Evaluation b the Local Approving Authorit ❑ Y P 9 Authco oco rity 08/24/08 Inspector's Signature Date ---i , The system inspector shall submit a copy of this inspection report to the Ap moving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the syste 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. Commonwealth of Massachusetts MWOR Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is Cotuit MA 02635 08/22/08 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally i i nall Passes: C n+d t o❑ 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 due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): 5 ❑ broken pipe(s) are replaced ❑ obstruction is removed i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 every page. Citylrown State Zip Code Date of Inspection 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 16.303(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 El 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,N 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. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address. James Shaw Owner Owner's Name information is requiredCotuit MA 02635 08/22/08 _ every pager Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is,less than '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.. 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is Cotuit MA 02635 08/22/08 required for — every page. Cityffown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..J' 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 every page. City/Town State Zip Code Date of Inspection 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 tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is Cotuit MA 02635 08/22/08 required for — every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 — Number of bedrooms(actual): 3 — DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 2 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 Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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): Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal system Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owners Name information is Cotuit MA 02635 08/22/08 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of 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): fi Approximate age of all components, date installed (if known)and source of information: 11/12/98 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 1202 Santuit-Newtown Road Property Address James Shaw _ Owner owner's Name information is Cotuit MA 02635 08/22/08 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Building Sewer(locate on site plan): Depth below grade: 2.1 g 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): Depth below grade: 1.3 p g 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 -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: 3" Distance from top of sludge to bottom of outlet tee or baffle 29" . 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 every page. CitylTown State Zip Code Date of Inspection D. System Information (coot.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 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: 0 concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 - every page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Sox(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ® No Alarms in working order: ❑ Yes ® No Commonwealth of Massachusetts R. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 • 08/22/08 every page. City/Town State Zip Code pate 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: 4 ❑ 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.): The system has four infiltrators surrounded by three feet of stone. There was no sign of`ponding or failure. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rt 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 _ every page. City/Town 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 a 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.): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 every page. Cityfrown 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 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1202 Santuit-Newtown Road Property Address James Shaw Owner Owner's Name information is required for Cotuit MA 02635 08/22/08 every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar, ❑ Shallow wells Estimated depth to high ground water: 20feet Please indicate all methods used to determine the high groundwater 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: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20 feet. ' C G. a TOWN;OF BARNSTABLE LOCATION v A,t SEWAGE # 23<i VII.LAGE_ j;414-* L& ASSESSOR'S MAP & LOTS INSTALLER'S NAME&PHONE NO. Ali SEPTIC TANK CAPACITY l -- LEACH NG FACILITY: (type) (size) NO.OF BEDROOMS . BUILDER OR OWNER PERMITDATE:_ /Z - $ COMPLIANCE DATE:_- J 12-- FEE Separation Distance Between the: Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on,.9ite 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'`` - i Z 2.03 499 C52 US Postal Service .I Receipt for Certified Mail No Insurance Coverage Provided. Do no use for International Mail See reverse Sent St Nu ber P ice, tat Code Postage $ Certified Fee Spada]Delivery Fee Restricted Delivery Fee Ln rn Return Receipt Showing to Whom&Date Delivered Q Return Receipt Showing to Whom, Q Date,&Addressee's Address QTOTAL Postage&Fees is th Postmark or Date LL W a j Stick postage stamps to article to cover First-Class postage,certified mail fee,and f charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service y window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the QQi return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits:Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. W Cl) 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. o` LL 6. Save this receipt and present it if you make an inquiry. 102595-97-6-0145 d '4vOFTHE r�Y,� Town of Barnstable Department of Health, Safety, and Environmental Services t BARNSfABLE, MASS g 1639. Public Health Division p10 A'ED11°� P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 "I'homas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health r November 24, 1998 David Condron 1202 Santuit-Newtown Road Cotuit, MA 02635 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 1202 Santuit-Newtown Road, Cotuit, was inspected on October 16, 1998 by Peter McErlain, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1.995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS.. You are ordered to bring the septic system into compliance within two (2) years of the date of discovery. Therefore, the construction of replacement septic system component(s) must be completed on or before October 16,2000. First you must hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5. In the meantime, you shall ensure that no raw sewage backs-up into the dwelling onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic,system whenever it it necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. ER,OF THE BOARD OF HEALTH in ER, Agent of the Board of Health q\health\dbfi les\titl e5 i.doe condronhvp/q/ls I .� � Town of Barnstable Department of Health, Safety, and Environmental Services 1'639.. � Public Health Division E°N10�� 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health TO: Qn1k C-(h ZU 2 N —A� +,C a,. � DATE: Nov �� )°(�� ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at Z V�' -�� �� was inspected on llorl�` ;by c, f lay a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: n'y mr You are ordered to bring the septic system into compliance within two (2) years of the date of discovery. Therefore, the construction of replacement septic system component(s) must be completed on or before Ck4Vo-� Rp,2n 4-6 First, you must hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of proposed replacement septic system component(s) to the Town of Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, Th ate Environmental Code, Title 5. r 2 In the meantime, you shall ensure that no raw sewag s onto the surface of the ground or into any surface waters. You must maintain the system by hiring a licensed septage hauler to pump the septic system whenever it is necessary. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health q%Wth\cbfi1a\itle3i.du COMMONWEALTH OF MASSACHUSETTS T4 - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 . WILLIAM F.WELD TRUDY CORE Govemor Secretary ARGEO PAUL CELLUCCI n DAVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION d' S a+(4-P I /l/&A)40 a lv Rd C©f Gc r Property Address: Address of Owner: Date of Inspection: &'3f� 1" ��� �9q (If different)• - r n Name of Inspector: 4-ie r J.- I1gc E r (a,t yWf �r +U am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310.CMR 15.00 ) T 3 Company Name: � la Ig� Mailing Address: r. Gs a N M 4o/d a17 Telephone Number: _ oZ aO r CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reporte is t?ue ccurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper unction and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails (^� Inspector's Signature: .Date: C��►, �? ! d 5, fo5'p The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and.the system,owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Oro A] SYSTEM PASSES: c I have not foun information which indicates that the system violates any of the failure criteria as defined.in 310 CMR 15.303. Any failure criteria not a ted are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES:, , One o ore system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion o eplacement or repair, as approved by the Board of Health; will pass. Indicate yes, no, or not determined (Y, ND). Describe basis of determination in all instances: If"not determined", explain why not. The septic tank is metal, un e e owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating t a e tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cr d, structurally unsound,.shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspe if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/hvww.magnet.state.ma.us/dep e'J.Printed on Recycled Paper ,y sti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A F.. / CERTIFICATION (continued). Property Address:� �� O �- . SQ 14 T Gt f �'— Ne,)-IO O(. AI Owner: ✓4 V t J CO A)C1V D N Date of Inspection: /Q _ Its r.� BJ SYSTEM CONDITIONALLY PASSES (continued) Se a backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) ue to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of He ). Describe observations: roken pipe(s) are replaced o ruction is removed distrib 'on box is levelled or replaced Sk_ The system required pumping mo than four times a year due,to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Bo of Health): l broken pipe(s) are rep d obstruction is removed C) .FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Co 'tions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public h th, safety and the environment. 1) SYSTEM WILL PA UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTE THE PUBLIC HEALTH,AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is w in 50 feet of a surface water Cesspool or privy is within 0 feet of a bordering vegetated wetland or a salt marsh. ' 2) SYSTEM WILL FAIL UNLESS THE BOARD HEALTH (AND PUBLIC,WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER AT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption syst (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ The system has a septic tank and soil absorption system and t SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the $AS i ess than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacten and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammoni itrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximat not valid). 3) OTHER (revised 04/25/97) Page.2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,d PART A CERTIFICATION (continued) Property Address: �vc o ol• ` I. —/veGt�77�1�/I { � I.Ura 1 . Owner. ''j v 1 D. CVA)(j KOAV t - Date of Inspection: _ �/ _ '• ; ` D] SYSTEM FAILS: ? ' You must indicate either "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. 'The Board of.Health should be contacted to determine what will be necessary to correct the failure. Yes No _ Backup of sewage into faciliry:or system component due to an verloadecl or clo ed SA -Eesspsel. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level-"in the distribution box above outlet invert due to an'overloaded 'or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. I Required ?pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply.or tributary to a surface water supply. Any portion of.a cesspool or privy is within a Zone,I of a public well: Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. a = E] LARGE SYSTEM FAILS: You must indicate ei "Yes" or"No" as to each of the-following: The following crite ply to large systems in addition to the criteria above: " The system.serves a facility with esign flow of 10,000 gpd or greater (Large System) and the system is a.significant threat to public health and safety acid the enviro ent because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking w supply the system is within 200 feet of a tributary to a surface drinking ter supply the system is.located in a nitrogen sensitive area (Interim Wellhead Protecti Area- IWPA) or a.mapped Zone II of a public water,supply well) The owner or operator of any such system shall bring the system and•faciliry into full compliance.with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult.the local regional office of the Department for further information.- (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B G. CHECKLIST i ao � Saw�U1t Property Address: C'ONa rQ� Owner: _Df}�1 Date of Inspection: /0— 16 Check if the following have been done: You must indicate either"Yes" or"No" as to each of the following: ' Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection: As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. . _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: ' ✓ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] (revised.04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C C SYSTEM INFORMATION Property Addr ss: ��0' S&*t fu�1 -'/1 IX) �0,k)N I�••` 'G'v+ i�%• °� Owner: ,41)1 () co/VJ I-0/✓ 3 Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: 41Q g.p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no): 5 Laundry connected to system yes or no): S Seasonal use (yes or no):-//1J � ) Water meter readings, if available (last two (2) year.usage (gpd): :'lOW W/V kr. ' Sump Pump (yes or no):�[Q w r. Last date of occupancy: Ca" Y'etA COMMERCIALIINDUSTRIAL: Type of.esta hment: Design flow: gallons/day Grease trap present: or no)_ . Industrial Waste Holding k present: (yes or no)— Non-sanitary waste discharge the Title 5-system: (yes or no)_ Water meter readings, if available: Last date.of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information-31 ' ` �. . f System pumped as part of inspection: (yes or..no)+Q s _ If yes, volume pumped: /SDO .gall ns Reason for pumping: 6- 0 TYPE OF SYSTEM Septic tank/distribution box/soil absorption system ; Single cesspool u Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) ° I/A Technology, etc. Cop of up to date contract_? r 1 Other _SQ +-l C i�N APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected°when arriving at the site: (yes or no)`7&O (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continue ) Property Address: a ©a. Sae K-f-u - —Nert�-k�u'V Owner: Date of Inspection: BUILDING SEWER: d� (Locate on site plan) Depth below grade: Material of construction: ✓cast iron _40 PVC_other (explain) Distance from private water supply well or suction line 'O (� Diameter Comments: (condition.of joints, venti evidence of leakage, etc.) f eAl O c e- SEPTIC TANK: ✓� (locate on site.plan) Depth below grader " . Material of construction: concrete _metal _Fiberglass Polyethylene —other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: /®..X Sludge depth; Distance from top of sludge to bottom of outlet tee or baffle: /0— 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: How dimensions were determined, Comments: (recommendation for pumping, cordon of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, struct ral integrity evidence of leakage, etc. c 1 �e, 'f� Lt Lt, u e GREASE TRAP: 'A//� (locate on site plan) Depth below grade: Material of construction: _c crete _metal _Fiberglass _Polyethylene other(explain) Dimensions: Scum thickness: [distance from top of scum to top of outlet�tpr ffle: Distance from bottom of scum to bottom oe or baffle: Date of last pumping: Comments: (recommendation for pumping, condition:of inlet and outlet t s or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION,FORM 'v PART C SYSTEM INFORMATION (continued) Property Address: L9, Sa.K+tA I-{ )&4)— 0W/V R4 Owner: CotvJ rOA1 i Date of Inspection: p / E . TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade; Material of construction: ncrete _metal _Fiberglass _Polyethylene—other(explain) Dimensions: Capacity: gallons , Design flow: gallons/day \float Alarm level: Alarm in worki _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarhes, etc:) DISTRIBUTION BOX: locate on site plan) Depth of liquid level above outlet i rt: Comments: (note if level and distribution is equal, evidence solids carryover, evidence of leakage into or out of box, etc.). - PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) w Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pum nd appurtenances, etc.)' (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM //INFORMATION / (continued)/� j Property Address: of .S G1�1�1G[I "/v�li/TV `v �d .I�OT u Owner: b oy u I D c oev d roA) Date of Inspection: _y'd.(�/ f SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: ONE leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. Alternative system: Name of Technology: Comments: (no a condition of soil, signs of hydraulic failure�vel of pond g, condition of yegetation, etc l t -W ' b.Wt 40 U 1 d 8 42 e CESSPOOLS: (locate on site. Ian) r Number and configura n: Depth-top of liquid to inle vert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) 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 ure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 1 PART C SYSTEM INFORMATION (continued) t Property Address: Owner: T I Date of Inspection: t SKETCH OF SEWAGE DISPOSAL SYSTEM: ` include ties to at least two, permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3 �edr �well�HS ysa� p Se P4�-' I iv K .(revised 04/25/97) Page 9 of 10 I� P SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) I a o 5 a-+'t Property Address: �- -� `. Owner: Dor v I Cc(v d tro rJ Date of Inspection: Ib Depth to Groundwater Feet Please indicate all the methods Used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) 1,50411 So J / �" / a r l.L `( CLC� Le K T �-C 0 1^1 Alta YES i' IJGt-�-er UOa - �rd Vl be a fSS -Frowt 5 5 3 C,4� ,oN re'Ve a le,.J /t/o S��N s o 5� . v1o� !� 'r r5 /v 0a+cev base Wte, - ova su�,c�I P � (revised 04/25/97) Page 10 of 10 low First Class Mail UNITED STATES POSTAL SERVICE -Us. PS e$eFeF es Paid- ' � F i . . • Print your na dd44s d ZIP Code i tk1is ox•,a,.��--_ A=� ` Public Health ®ivislcn town of Barnstable P.O.Box 534 Hyannis,Massachusetts 02601 III$11111►1 fill fill IIIIIIIII,IIIfII„11,1��II,�1{;h�1�11 SENDER: v_ ■Complete Items 1 and/or 2 for additional services. I also wish to receive the w ■Complete items 3,4a,and 4b. following services(for an of ■Print your name and address on the reverse of this form so that we can return this extra fee): L* card to you. ■Attach this form to the front of the mailpiece,or on the back if space does not • ❑ Addressee's Address to � permit. � ■Write' 'Retum Receipt Requested on the mallpiece below the article number. 2. ❑ Restricted Delivery in ■The Return Receipt will show to whom the article was delivered and the data c delivered. Consult postmaster for fee. a' v 3.ArAple Addressed to: 4a.Article umber « II d 4b.Service Type «' [I Registered 10 Certified of W ❑ Express Mail ❑ Insured H ¢ ❑ Return Receipt for Merchandise ❑ COD e 7.Date of Delive z 2 $ i T Received By:(Print e) 8.Addressee's Address(Only if requested and fee is paid) g 6.Sigl' 2 PS Fol iceipt �- v ✓✓Z. to Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zfppltratton for Mt_qpogar *p!tem Construction Vertu Application for a Permit to Construct( )Repair( )UpgradeY,-,y Abandon( ) ❑Complete System Individual Components Location Address or Lot No. (/�j� �`�w� �/� Owner's Name,Address and Tel.No. Assessor's Map/Parcel '`1 ��'/ CO p°)V0vq\ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms F— Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 4� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank C5UQ O-J Type of S.A.S. Description of Soil ` c�21 20SILD Nature of Repairs or Alterations(Answer when pplicable) SF!�sYAV�- C-DG t Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod nd not to place the system in operation until a Certifi- cate of Compliance has been issue s qj Sign Date Application Approved by D Date Application Disapproved for the following reason Permit No. Date Issued �. _•a. .t �. .. f. - ,f �. -� w «nv-,;�r'.,�. ly.ti .. ya7 Yfiw.r.._ ��'.� s^ V s ., a+ tn.rwt.r.-.i✓�'.r..._ ° ., -Vn -,-1:;, Ito/ No. ,i / Fee =_ THE COMMONWEALTH OF MASSACHUSETTS ` Entered in computer: a Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(p plication for Mt_qpogar *p!5tem Couttructton. Permit Application for a Permit to Construct( )Repair( )Upgrade(,/—)•Abandon( ) O Complete System Individual Components Location Address or Lot No. :t -- �`4:__ j s�1 L�� may, Owner's Name,Address and Tel.No. Assessor's Map/Parcel � ° 0— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y� d Type of Building: Dwelling No.of Bedrooms ? Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 7� gallons per day. Calculated daily flow s gallons. Plan Date Number of sheets Revision Date Title �. Size of Septic Tank 4,_-. \ r {'�� ,. Type of S.A.S. ` Description of Soil 1�-�L..:.- c a C,P,IC <Q_ '5�7"EL:O Nature of Repairs or Alterations(Answer when applicable) "C` T ( \� ~' '.:� C �� ! ' Date last inspected: Agreement: F'j'!;`4w.t x� <1 `Si The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code.and not to place the system in operation until a Certifi rate of Compliance has been issue_d_by-th's-Board- f Health.- Si ne k 4` s g Date Application Approved by D Date - Application Disapproved for the following reason t Permit No. Date Issued , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT FY,that the On-site Sewage-Disposal System Constructed( )Repaired( )Upgraded Abandoned( )by. t j C_Y) e'1w S 'N7 ' at �.C�c�-• �j.v�,.1-l�'�-��.1 ��Cf��'� �i���Y`'`t{'t+�`'° � `� � hTNeonstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ed Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date I ! _ 1 - C/ Inspector 1 '" R177No. THE COMMONWEALTH OF MASSACHUSETTS Fee PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS I=t!5poga[ *p.5tem Conttruction Permit Permission is hereby granted to Construct( )Repair•( )-Upgrade( Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction st be cold ted-within three years of the date of this pe ft. Date: l ! 1 Approved by - - - i r ! - 10N197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works 1, construction permit signed by me,dated 4 , concerning the I property located at �-0� �J► vV l l eK J+& meets all of the f lowing criteria: i_ - - -- s ® /I. There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system f� I (� There is no increase in flow and/or change in use proposed There are no variances requested or needed. ' chin facility will be located within 250 feet of any wetlands, the bottom of the ._._...�.�,__ �/ /If the proposed leaching ty v proposed leaching facility will p9t be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. _. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) rA B)Observed Groundwater Table Elevation(according to Health Division well map) SI E DATE: LICENSED SEPTIC STEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted). q:ham Ibtder.eat � r V • � I /�A �s d I ........ ••---.....--•---• ; Fug. ..................... THE COMMONWEALTH OF MASSACHUSETTS o� BOARD OF HEALTH TowN. BARNSTABEE Appliratinu -fur Uhip ial Worko TonMrurtimu Veruiit Application is hereby made for a Permit to Construct ( X ) or Repair ( } an Individual Sewage Disposal System at: Lot �2 9San.. .c e......n Road.a d ..a n t uit_ .-- --• .- --•---.. .-- .... ........•------•----------•-------•---......-•-----••-----••-•---•---•-•....................... Location-Address or of No. , ... ---...----Cobb.---•--•--------•-------•--•--•----------------------- -----Depot.............................Street -- ..e n n i s p o r t William Owner Address aRobert B. Our ......Great. Ulestern Rd. ,....N-------Harus ch.......... Installer Address f'000 Q Type of Building Size Lot.... r`.'�Sq. feet U Dwelling—No. of Bedrooms--------------------------------------------.._-._._.---.Expansion Attic (X ) Garbage Grinder ( ) per, Other—Type of BuildingDu►8111n-9 No. of persons.........6----------------- Showers ( ) Cafeteria ( ) a Other fixtures .------'-•-------------------------------- -- - W Design Flow........... ............................gallons per person per day. Total daily flow..........au--------------------------gallons. WSeptic Tank—Liquid capacity".=- allons Length---------------- Width................ Diameter------ -------. Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------.------------ Total leaching area....-.-._.--._.--..-sq. ft. Seepage Pit No------ _____________ Diameter------- 8 Depth below inle _-_-_ --------- ... Total leaching area........----------sq. ft. p Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by. ... . . ............... Date_-a.-./- ----� ,a Test Pit No. 1................minutes per inch Depth of Test Pit...--_-..--_---_--- Depth to ground water-----------.-----...___- rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-._-.-.._-.---..-....__ --------------------- ---- -------- ...............----••--------------------- Description of Soil-------- Z�_— ? � � x Sandy.----...•••••.. = ' x ------------------- -•-------.... 3 ...... d �? ----------------------------------- -- --------------- U Nature of Repairs or Alterations-}Answer when app tcable............................................_.........._....._......_......_.-..._.---..---.._-. ------------------------------------------------------------------------------------------------•----•---------•--------- --------------------------------------------------------------------....---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further not to place the system in operation until a Certificate of Compliance has been issu he board hea Sign d;.. .. �t� Date Application Approved By.... . ...�.-- � � !� --I /� - Date Application Disapproved for the following reasons: ------------------------------------------------------------------- •------------------- f Date PermitNo......................................................... Issued......`.. ....................... Date 3✓t- �..' Fps..... .�..�.... ---'• f G THE COMMONWEALTH OF MASSACHUSETTS ,.,,/..._BOARD OF HEALTH ✓. .a4J F. ..OF.......... ................... Appliration -fur 4iipuial Workii Tnnitrurtinn Vrrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syf--------�.......................................................... //''l� Locati➢ef�ld�ess or Lot No. a � � . OW 0- 01,1�I Co dress -•---•'-•----------'••- Installer Address Type of Building Size Lot;�_.1 lkd!0(+�_J_ Sq. feet U Dwelling—No. of Bedrooms-. -__--_ --__--__--Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Build /.__ _ !40!eIrs os of persons fot-yp g I�j p ------------ Showers ( ) — Cafeteria ( ) 04 Other fixtures .....--------------•-•--•----- W Design Flow..........Ta_______________________gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacitylOorre-gallons Length________________ Width--.............. Diameter__._.-..-..-____ Depth---..----_------ x Disposal Trench—No_ __ ________________ Width. __-__..___-_.____ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------- Diameter__..,�� _._ Depth below inlet____________________ Total leaching area--.-_..----_-___-sq. ft. Z Other Distribution box ( ) Dosing tank ( � /- ���_ _ /� _ aPercolation Test Results Performed b p l�ydf"� ��� p d— Test Pit No. I................minutes per inch Dept est rt._ ________.______ De th to round water...-------_ .._-.--.-. �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--._-._---_.---.-------- 04 __.__._.... ••. ----•--------------•--•-•----------------•--- y---- - 0 Description of Soil---------_--- ----(} �9__ r} ���a �� y, . ..�_ -------------------------------••......--•-•--•- •--- • --• '• - -W Grp '� F ski ---------------------------------- ----------------------- - - -- ----- - -------------------- VNature of Repairs or Alterations—Answer when e� .........................................--•---------------------------------------------------------------------------------------------------------------------------------- ----------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu e board o eal Si- a 4��r ._.. ---- ............... -------------------------------- Date Application Approved B 1_ Application Disapproved foe following reason-------------------- ---••------•---------••'-•--•-----'----•-•'--•--...__.....__...._......D--e•-----••------ ................................................. ................•.................................................................................... - --------- ------ ----- Date PermitNo......................................................... Issued........................................................ Date .-- THE COMMONWEALTH OF MASSACHUSETTS it BOARD O EALTH ............OF.. . ...... .................. ........................... �rrttfir�tr of f�rrut�li�tnrr �/' T ��� FY,C%_�7 Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.......... x y .... ----- �!��/ ,G,j sta r /�� _r _ !� j at has been-installed in accordance with the provisions of gt�1..€3YI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----___•-3_____\_________________________ dated...�D--_---k--,----21 THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------- Inspector.................................................................................... t 7 THE COMMONWEALTH OF MASSACHUSETTS ✓�� BOAR 'O HEALTH ..........................................OF.- .. ......'y .......................................------.... !J`� 'No........... ............. FE •�•--'---.....-- Dinli P®rWTT�,tr �nn rrntit Per issikn is he�yw_� gran d ------ OW,to C s t (p1 orG� , ew j�poSal ystemat No............=--••--••---•---•--'- -•'--••-•----•-•-•-•---•J•-•r Gf Street as shown on the application for Disposal Works Construct�io�- e it N . .__.1.�: .............. --=--------------------- y. '�' \"` Board of Health DATE ( (--•-•-•--..5... ........✓._... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS G_o lr�n j V 5 �rj4' j1 Z9 Oky. 1 CJ 1 ] , $: Z 1 Q r p SILL PLOT' PLA /V If Z L O CA T10AI: DAT& 2O _ f"I.AN 2EF4-,eENCE: BE�Nra LoT 29-A 5 S.yv*vl\1 a/t/ PG,M/Ooo.FC -_2531 PA GE 3 1 i AE6R6$y CeVrl"' -7-AIAT 7Av�6 EX/ST- y! /N6 FOUn/DA7'7'ON 4OC.4T/OAl /,5;COZZ4 } bviL :ie:{� ;; AS 6WOWA1.4A10_Z?P,�,,6_.CONFOk'•y W17N F �' THE c�}C//LD/•WG SEJ'6AG'�-, 'EQU� M �c/7 Tayt_;;i; uM f OF THE TOWN OF Gt//GGOGt/37' -Y.42MfpU7�/�jQT MA.