HomeMy WebLinkAbout0014 THANKFUL LANE - Health 14 THANKFULS LANE, COTUIT
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s. �y 14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
important:When filling out A. General Information
forms on the
computer,use 1. Inspector: �1
only the tab key v
to move your P.Scott Campbell
cursor-do not Name of Inspector
use the return
key. Cardinal Construction
Company Name
32 Ridgetop Rd.
Company Address
Cotuit Ma 02635
CitylTown State Zip Code
508-420-1295 S1388
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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails .
❑ Needs urther Evaluation by the Local Approving Authority
-v
4/6/2012
Inspe or's Sig'natgV 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..
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Lt5ins1/10 Title 5 OfficiLIVce Sewage Disposal System-Page 1 of 17
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Citylrown 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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner owners Name
information is required for Cotuit Ma 02635 4/6/2012
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
El Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 177
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Cityrrown State Zip Code. Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or Iless 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 Y2 day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® 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 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 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary"to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , ' 14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Cityrrown 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.
® El approximation
in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , y 14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is
reqquireduired for Cotuit Ma 02635 4/6/2012
o
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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 readin s, if available last 2 ears usage d see detail
9 ( Y 9 (9P ))
Detail:
2010= 31,000 gallons. 2011 =28,000 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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
a
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is Cotuit Ma 02635 4/6/2012
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 2009
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)
El Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by.system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
<a 14 Thankful Lane
M
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1981
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
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):
Depth below grade: 1 .5'
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:
Sludge depth:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t 14 Thankful Lane
Property Address
Gloria Lariviere
Owner owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3.5
T
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6'
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? sludge stick, 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.):
system should be pumped. Scheduled pumping for 4/17/2012
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Thankful Lane
.Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11110 Title.5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
t
every page. City/Town State .Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
T / f technology:Type/name name o tech o ogy.
Comments(note condition of soil, signs of hydraulic'failure, level of ponding, damp soil, condition of
vegetation, etc.):
dry soil, no signs of hydraulic failure, no ponding or damp soil, normal vegetation:
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5ins•11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Plot for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. Citylrown State .Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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13
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AA last
A B
Ac =3Ok r
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t5ins•11110 Title 5 Otfiaal Inspecfion Forth.Subsurtace Sewage Disposal System•Page 15 or 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
14 Thankful Lane
Property Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® -Check cellar
® Shallow wells
Estimated depth to high ground water: 12+
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:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
14 Thankful Lane
Property.Address
Gloria Lariviere
Owner Owner's Name
information is required for Cotuit Ma 02635 4/6/2012
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure.Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Govemor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
6
Property Address: 14 THANKFULL LANE COTUIT LOT 32 '� A
Name of Owner JORDAN MALIK r .
Address of Owner: BOX 2105 COTUIT MA.02635
% 0
NDate of Inspection: 2117/99 ti
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) "7T
Company Name: John Graci Title V Septic Inspection
Mailing Address: P.O.Box 2119 TeaTicket,Ma.02636 $ t
Telephone Number: (608)564-6813
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 inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X Passes The inpection Is based on criteria defined in Title V
_ Conditionally Passes code 310 CMR 15.303.My findings are of how the system Is
_ Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My inspection does
Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: .1 Date:314/99
The System Inspector sha submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title W inspection
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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
NO The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exriltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
IQ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_ broken pipe(s)are replaced
_ obstruction is removed
distribution box is levelled or replaced
NO The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_ broken pipe(s)are replaced
_ obstruction is removed
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17199
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety
and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nta_(approximation not valid).
3) OTHER
nLa '
revised 9098 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303 The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool Is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped n(a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and
safety and the environment because one or more of the following conditions exist:
Yes No "
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page e4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates
during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption
System on the site has been determined based on:
X Existing Information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
FLOW CONDITIONS
RESIDENTIAL
Design flow:-=g.p.d.lbedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):.3
Total DESIGN flow: =
Number of current residents:11
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no): YES
Water meter readings,if available(Iasi two year's usage(gpd): n/a
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COM M ERCIAL/INDUSTRIAL
Type of establishment: n/A
Design flow: n&gpd(Based on 15.203)
Basis of design flow: n&
Grease trap present:(yes or no):JM
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available:n/a
Last date of occupancy: n&
OTHER: (Describe)
WA
Last date of occupancy: n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
NONE
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped n(a_ gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n&
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1991 PERMIT#81-934
Sewage odors detected when arriving at the site:(yes or no): NQ
revised 912/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2�
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: Wa
Diameter: Wa
Comments: (condition of joints,venting,evidence of leakage,etc.)
n[a
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 2
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
Wa
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
n/a
Dimensions: L 8'B"H 5'7"W 4'10"
Sludge depth: r
Distance from top of sludge to bottom of outlet tee or baffle: L"
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: Q
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE TRU TURA Y SOUND RECOMMEND PUMPING SYSTEM FVFRY TWO YEARS
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nla
Dimensions: n[a
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:x&
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n(a
revised 9/2198 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: WA
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene other(explain)
n/A
Dimensions: nLa
Capacity: n& gallons
Design flow: n& gallons/day
Alarm present: NQ
Alarm level:. /a_ Alarm in working order:Yes_No_ i�lQ
Date of previous pumping: n&
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:nla
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
n/a
PUMP CHAMBER: MQ
(locate on site plan)
Pumps in working order:(Yes or No): �LQ
Alarms in working order(Yes or No): MQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nla
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17199
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: jm!a
leaching galleries,number: ji&
leaching trenches,number,length: n/a
leaching fields,number,dimensions: n&
overflow cesspool,number: nLa
Alternative system: nta ,
Name of Technology: -n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: Wa
Depth of solids layer: n& -
Depth of scum layer. Wa
Dimensions of cesspool: n&
Materials of construction: Wa
Indication of groundwater: nfa inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
PRIVY: _
(locate on site plan)
Materials of construction:nfa Dimensions:Wa
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
oec�
4
dC AA a�
A8 11
� �3a
q?6
revised 9/2198 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 14 THANKFULL LANE COTUIT LOT 32
Owner: JORDAN MALIK
Date of Inspection:2/17/99
NRCSReportname: n&
Soil Type: Wa
Typical depth to groundwater: n&
USGS Date website visited: nla
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
_ Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,Installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 912/98 Page 11 of 11
OF
,; y
LOCATION ' SEWAGE PERMIT R0.
VILLAGE CZ3 ^ v5K,
INSTALLER'S NAME ADDRESS
J HN A. AALTO ;BACKHOE SERVICE
Ise lwainut et
West Barnstable, Mass. 02668
BUILDER OR OWNER
DATE PERMIT IV—SUED 2)`��
DATE COINPLIANCE ISSUED
a
a
s
G ,
No. 1.. ... c FHs.3.6_!, ....
! THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
......................... ---.............OF........................................
Ole
Appliraation for Uispva al lForkii Tonstratriion Vantit
ya 1 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
1 System at� --�� .!/ ...--•--- -----••---•-•--------------•---•- ---•---•-- - •--m qa,;onAddrAs
or L
;tAd
s r�Vi ------- ...... �
/. .............................
-
Address
Type of Building Size Lot............................Sq. feet
.-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ') Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers —
a YP g ---------------•---•-----•-- P (---->.......Cafeteria ( )
Other fixtures ------------------------
-•---------
W Design Flow............................................gallons per person per. day. Total daily flow----........................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter...-..------_- Depth................
x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. l................minutes per inch Depth of Test Pit.------............. Depth to ground water......------............
fY4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...`'.--............--...
W ..----•------•--•---••-•----••-••---••-•-------------------------•-•---------•......-------•••-••-•...-•--•-•---•------•--•--•---------..........•--••.------
0 Description of Soil........................................................................................................................................................................
V ..............•-•---•-------------•--•-..------••----•--•••-••------•---------••-•••-------••-•-----•--...--------•••--------•----....----------••-------•-•--------------............-•••-----•--------.
W
x ------------------------------•-•--•---•-----•--•--••--•-•---------•-------•••-------------•.....•-------•-•----_•-•--•-•----------•---...•-•--•-•-------•---------------•--••-•-------•-....--•---•----
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
------------------------------------------------••-•--•----•-------------------•-------.....-----------•---•-------------------------------------------•------------....----------------•••••--.......--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iIT,LZ' 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee i ued by the board iealth.
Signed
�D to
-------
Application Approved By............ ,x1 .----�� ...................................... ----•-- - -?Av -.................
Date
Application Disapproved for the following reasons--.................=.............................................................................................
..---•---------------•------------••-----......---------••-------------•...-•----...•---------------......-•••----•-------------•------------------•--------------•---•-----.........------•-------...._.
Date
PermitNo.......................................................- Issued.......................................................
Date
No.-( 4J�_
...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ ................OF..............
...............................................................
Appliration for Ohipoiial Workri Tonstrurtion frrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System P I _-)
(—.0 /" ,U 41,11 oil............F.r.. ....... ....................................
o Eo Add;(FIS 'or Et ---------
. .............
.......... 4 .......... .......................
Ada
V .. ........ ..........
' o r Add
........................
A-11MVh-1. - 11 .?�M., I...... ...............................
nstaller Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
Otherfixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter-_._..._._...... Depth................
Disposal Trench—No..................... Width.._................. Total Length.._....._...__._.... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet..................... Total leaching area..................sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by---------------- .......................................................... Date........................................
Test Pit No. I.................minutes per inch Depth of Test Pit___.._....._......._ Depth to ground water.___.._.................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground, water.._..-..._...........__.
P4 .........................................................................................................................7"-------
0 Description of Soil........................................................................................................................................................................
U ................................................................................................................................. I ............................ ...............................
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 TITU, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee il . ued by the bo��Jgqpf*ealt
Ifs
.... ...... ...... ... ............ ........
Signed......y
Application Approved By................. ...................................... ......MIA ..............
Date
Application Disapproved for the following reasons:...............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................
1,K.......i.................................I.........................................
if iratr of Toutpliattre
THIS tS TO CERTIFY_, That the Individual Sewage Disposal System constructed or Repaired
6
by................�P. 2- ____
-----------*.............*................"--------------------------------------------------------------------------------------------------*------------
1nstallcr,
,4t - —
at............................................... ......................
........................................................................
has been installed in accordance with the provisions of I I The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.6�
-----------................... dated_...._......._......____.._..._..__.._._.______.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................ -------- Inspector...----... ...........................................................
-----------"---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................................... ...OF............. .................... ..................................................
NO --- ....... FEE........................
—usrurton mit
Dispos I Vorks TWIt i prr
Permission is hereby granted
I---�ivi-----*.......*-------- ------------------------------------------------------------------------.............. .........
to Construct oi��epair a Individual Sewage Disposal System
atNo............ ................................................................................................................................................................................
Street
as shown on.the application for Disposal Works Construction Permit No................0---- Dated...._...__._.__........_..._........._....
d'.7_. iri� ✓
.............................................
and of
DATE.. 1'2 -- ------------ Health
---------------/ ,/I
FORM 1255 HOBBS.& WARREN, INC.. PUBLISHERS
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