HomeMy WebLinkAbout0047 MIDWAY DRIVE - Health " 7 Midway Drive
yannis
252 — 078
COMMONWEALTH OF MASSACHUSETTS .. ...
` « EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OFENVIRONMENTAL PROTECTION
RECEIVE®
w :`' 19 2002
'tNCV
TOWN OF BARNSTABLE
TITLES HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 47 Midway"'Dr: SAP `ZS�
en ervi e, M 632 WORM
Owner's Name: Mark Delaney PARCEL
Owner's Address: ' ^T
Date of Inspection: 2 (j
Name of Inspector: (please print) Wi 1 1 jam F._ .Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address. P 0' Box 1,089
_Centerville, MA Telephone Number: ( 508) 775-8776
CERTIFICATION STATEMENT Y
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Y
Inspector's Signature: - Date:/�J � �—6 -
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heal&,-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.
I
% Title 5 Inspection Form 6/15/2000 page I
Page 2 of l l
OF
FICIAL INSPECTION FORM NOT FOR VOLUNTARY`ASSESSMENTS r o
SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTLON FORM
PART A
CERTIFICATION(continued):
Property Address: 47 ED idwa_y_Dr.____�
Centerville MA 02632
Owner: Delane
ly
Date of inspection:
Inspection Summary:
Check A,B,C,D or E/ALWAYS complete`all of Section
A. Sy em Passes:
t d any information which indicates that any
1 have 10 no of the failure criteria described in 310 CMR
found
15.303 or av`3no MR_15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. yytem Conditionally Passes:
,section need to be
One or more system components as described replacement or repair,as approved by the Board of Health,replaced
will pass:
repaired.The system,upon completion of the p
Answer yes,no or not determined(Y,N,ND)
inthe 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
tmsound,�cxhibits substantial infiltration or exfiltra tank
r s tank approved be is the Board of Health.will pass inspection if the
existing tank is replaced with a complying septic tank as app y
•A metallseptic 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 exp0in:
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
approv 1 of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND el plain:
tThe system required pumping more than 4 tunes a year due to men or odd pis) The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND c plain:
Pa&e 3 of l l
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:. 47 Midway Dr.
Centerville, MA 02632
Owner: Delaney
Date of Inspection:
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 fa ling 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 - u
system is not functioning,rn a manner which
y ' will protect public health,safety.and the environment: K
Cesspool or privy is within 50 feet.of a surface water
Cesspool or privy is within 50.feet of abordenng 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 fronl a
private water supply well•'.Method used to determine distance
"This system passes if the well water analysis,performed at 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 triggered.A copy of the analysis must be attached to this form.
3. (her:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
OFF s.'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION-,(continued)
Property Address: 47 Midway Dr. w
_..
,a
enterville, MA 02632
Owner: Delaney
Date of Inspection:
D. System Failure Criteria applicable to all systems.
you, ust indicate"yes"or"no"to each of the following for all inspections:
Yes or
Backup of sewage into facility or system comp of the u around overloaded or surf a water s due to anooverloaded or
Discharge or ponding of efI]uent to the.surface gr
'clogged SAS or cesspool invert due to an overloaded or clogged SAS'or'
Static liquid level in the distribution box above outlet to
cesspool
_ Liquid depth in cesspool is less than V below invert or available volume is less than'/:day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed p�pe(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.
y portion of a cesspool or privy is within a Zone 1 of a public well. PP Y
_ y:portion of a cesspool or privy is within 50 feet of,a private water su 1 well.
_ y portion of a cesspool or privy is less than 100 feet.but greater than 50 feet from a pnvate 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
i amonia
dicates that the well is free from pollution from that facility gthe pi-csee'of
oaded hat no other failure criteria
itrogen and nitrate nitrogen is equal to.or less than 5 m,p ,
re triggered.A copy of the analysis must be attached to this form:]
(Y s/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 be cLSystems:
m side
red a large system the syste must serve.a facility with a design flow of 10,000 gpd to 15,000
8P
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 o PP 1
_ the system is within 400 feet of a surface drinking water suY
_ 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 ave answered"yes"to any question in Section E he system is considered a significant threat,id answered
Y or of any large system considered a
"yes"i: Section D above the large system has fnilcd.The ovvtt�or operator
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.
4
Page 5 of]]
` OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI SYSTEM INSPECTION FORM
PART B
CHECKLIST'
Property Address: 47 Midway Dr.
Centerville, MA 02632
Owner: Delaney
Date of Inspection: i9�•-3 �--�7
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yee 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?.
✓ Nave 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?
—L/— _ Waiihe site inspected for signs of break out? ,
v _ 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:
Yes. no
_ 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(3)(b))
i
i
5
Page 6 of I I
OFFICIAL INSPECTION FORM :NOT FOR,VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.0 .
SYSTEM INFORMATION
47 Midway Dr.
Property Address: Y
CenterviIle, M 02632
Owner: Delaney
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(destgn):,�?_ Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):'?G d
Number of current residents:
Does residence have a garbage • der(yes or no):&0
Is laundry on a separate sewage system(yes or no):�A-J[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):�i O
Water meter readings,if a, ailable last 2 ears usage d 01 _ -'1 21 '5 0 0 gal g , ( Y g (gp ))''
Sump pump(yes or no):�fl 0 0- 107, 250 gal. w
Last date of occupancy: /(�'�_
COMM RCIAL/INDUSTRIAI.
Type of a tablishment:
Design fl (based on 310 CMR 15.203): gpd'
Basis of d sign flow(seats/persons/sqft,etc.):
Grease tra present(yes or no):_
Industrial aste holding tank present(yes or no):
Non-sani waste discharged to the Title 5 system(yes or no)
Water me er readings,if available:
Last date 'occupancy/use: °
OTHER describe)•
GENERAL INFORMATION
Pumping Records
Source of information: /IT 9 9 0—
��,-vie.
Was system pumped as part of the inspection(yes or no):A10
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TTSepticOF SYSTEM
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�lown)and urce of information.
Were sewage odors detected when arriving at the site(yes or no): C)
6
Page 7 of i 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
X.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `` F
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 Midway Dr.
Centervilie, 7A 02632
Owner: Delaneyozo
Date of Inspection: " 2—C�
BU DING SEWER(locate on site plan)'
Dep below grade
Mat als of constructions_� cast ifon 40 PVC .. other(explain):
Distan a from private-water supply well or suction line:
Comm nts(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_/ocate on site plan)
f
Depth below grade:
Material of construction:�oncrete_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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: _ r,
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
Ve
GREAS TRAP:_(locate on site plan)
Depth belo grade:_
Material of onstruction:_concrete_metal_fiberglass Aolyethylene_other j
(explain):
Dimensions:
Scum thickn s:
Distance fro top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last ping:
Comments( n pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of l 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL`SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION'(continued)
47 Midwav Dr_
Property Address: Centerville MA 02632
Owner: Delane
Date of Inspection:
or HOL G TANK: _( must be pumped at time of inspection)(locate.on site plan)
TIGHT
Depth below grad — concrete metal fiberglassPolyethylene other(explatn):
Material of cons ction:
Dimensions: allons _. _.: .._.. ... . _ _.... .
Capacity: allons/day
Design Flow: .
Alarm present(y s or no): _
Alarm level: Alarm in working order(yes or no):
Date of last pu ping:_
Comments(co dition of alarm and float switches,etc.):
DISTRIBUTION BOX: f/(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
evidence of solids carryover,any evidence of
Comments(note if box is level and distribution to outlets equal,any
leakage into or out of box,.etc.):
PUMP CRAM ER: (locate on site plan)
Pumps in work g order(yes or no):
Alarms in wor ing order(yes or no): pumps and a urtenances,.etc.):
Comments(n a condition of pump chamber,condition of ump PP
8
Page 9 of I 1
OFFICIAL INSPECTION FORM NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a
PART
SYSTEM INFORMATION(continued)
Property Address: 47 Midway Dr.
Centerville, M 02632
Owner: Delaney
Date of Inspection: /0—X2--02 w .-
SOIL ABSORPTION SYSTEM(SAS): t/(locate on site plan,excavation-not required)
If SAS not located explain why
TYPe/
1/leaching pits,number:
leaching chambers,number:
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.):
e.
CE POOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Numb and configuration:
Depth top of liquid to inlet invert:
Depth f solids layer:
Depth or scum layer:
Dimcns ons of cesspool:
Materia s of construction:
Indicati n of groundwater inflow(yes or no):
Comme its(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRI (locate on site plan)
Materi Is of construction:
Dime sions:
Dept of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of l I
OFFICIAL INSPECTION FORM NOT FOR VOtUNTARY ASSESSMENTS
SUBSURFACEk�`SEWAGE DISPOSAL SYSTEM INSPECTION`FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 Midway Dr.
Centerville, MA 02632
Owner: Delaney
Date of Inspection: /:b—02,7-0 2.' r
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.
21,
L-
f'
w
10
f
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 47 Midway Dr.
Centerville, MA 02632
Owner: Delaney
Date of Inspection: to�a22—a 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
�G
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you establl''she the high ground water elevation:
1'x_ G G--o D
Y
11
TOWN OF BARNSTABLE
LOCATION y'? c�p-,vf_ SEWAGE # `1 - r7q
VILLAGE W-t,-v ),+j IS ASSESSOR'S MAP & LOTAS.2-01)2
INSTALLER'S NAME & PHONE NO. H i t-y-=i e-",s T 41 z 91
SEPTIC TANK CAPACITY X, Oo 0
LEACHING FACILITY:(type) (size) f uve)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR, QWN_R
DATE PERMIT ISSUED: 36 9;
DATE COMPLIANCE ISSUED: A 1 1 Q
VARIANCE GRANTED: Yes No I�
�� �_ o�
..-
�.a;-
���
G '�
W
cs � _
_.—
~' �,
��
�� c�
.K
No.?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Di!ipwml Works Towitrurtion ratnit
Application is hereby made for a Permit to Construct ( ) or Repair ('Loy an Individual Sewage Disposal
System at:
Location-At dress •------••-- or-Lot No.
own r Address
Installer Address
UType of Building Size Lot............................Sq. feet
�., Dwelling- No. of Bedrooms______AY___________________________________..Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building --_________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' 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:
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit.-.__-_---___-----_. Depth to ground water........................
fr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ •---•-----•-----------------•-------------------------------------...._.--------------------•---.............................................................
ODescription of Soil........................................................................................................................................................................
x
W ........................................................................................................................................ ................................................:..............
U Nature of Repairs or Alterations—Answer n a _plicable. '..` _��N�__..__1.°1?.......
..t.,k !V� � S i°-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
e -............................................ ..!/-3 .....
Application Approved BY .................... .. ............ .. ..:..��—�
.. .
Da[e
Application Disapproved for the following reasons: .......... .... . ............................................................._..............---..................
........................ ........... ............................. . ............................................................................... . .. ..... ................. . .................................
' Date
Permit No. ... :..-t=✓...`.?:..77........................... Issued ....... ... .... ..., .
Date
'.,,�.__ ____. �_. �,._ �jf„jl�hr'v�.. _...� _ u .__ r � .• ..._ � v �_ _. _. w _.�—y __—___— --_ey _ =r_` —__
I / —
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH J
TOWN OF BARNSTABLE
Appliratiuit for Uhi—puml Wnrks' Ta tuitrurtinn lirrniit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at:
' t
_y'7.......!'.:�.`.?Rw'.�:�............��gl ......................H 4 n�vv�S
........... J ... ...........
Location• \ dress or Lot No.
...................... D ---------------- ................................................
Own r Address
tL
goInstaller Address
VType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.____ ________________________-._-_.Expansion Attic ( ) Garbage Grinder ( )
pi Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a'I, Other fixtures -----------------------------------
.....----•-•••................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter-_- ............ Depth...............
x �Dis Disposal Trench—No. .................... Width.................... Total Length.........__......... Total leachingarea....................s . ft.
II P ----- q I
Seepage Pit No......... ...... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution.box ( ) Dosing tank ( )
a Percolation Test Results'-..,Performed by P......... ............................. ..........
-•-... Date........................................
I' 04 Test Pit No. I----------------minutesp er inch Depth of Test Pit.................... Depth
to ground water........................
fZ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 .......-•-•---•--•-••-•..................••---......---•-
0 Description of Soil..........................................-------------------------------------------------------------------•-----------------------------------------...........-•---
x
Uw ................••--
Nature of Repairs or Alterations—Answer V.�en�a�_plicable_A0v't le . . "?... `��� ✓.�`...
`� - /.uFtl-nc S ?r......5
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ........ -- `. ............ . ........................... ..�'�.3 ` . - :......
Dare
Application Approved BY .....- .�i e ...... .. - �/."...r l `- —
... ...--------....-.-..-'----'------ Dare
Application Disapproved for the following reasons: ................................................................-----..-...-..-.-...-..--.-.-....-......----------------------------.
................... .. ...................................... . ... . . . . ............................... -- .-- -- .-...:
jPermit No. ... ... ...'.. {-------------------------- Issued ------- '" � ... ........�---. e.....-
Dace
i
— - -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
VTT Ertifirtite of Olum linure
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by .... etc-" c.........�AXN7.--.... _........... ........... .............._............ ..--.............. ._.. ............ . ................. ...........................--..--....
Instiller
at .A7.........._...-1 `.. h `......` ` 1 .tom---------.----.---.--- 'FL! -N\:—_-------------- ---------- .. ........................ ............... .. ...
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _.... �- .�.e ..._. dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
SATISFACTORY.
DATE.-.......m/rr... `...` ....,./..... ._..........._........................... lnspectorq...-'._... ................... /
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(� ... � TOWN OF BARNSTABLE
NO......... ..........� FEE'.'....• ll.n
Biopo.oal Worb Tunotri dion Wrniit
Permission is hereby granted..
to Construct ( ) or Repair K an Individual Sewage Disposal System
at No. ` �`'!.Pk!�f-4 ' !ems. .......�-- "�'� a
......
Street
as shown on the application for Disposal Works Construction Permit
Board of Health
DATE------•/ .. -....--�.... � 5'..: .............•---.....
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS