HomeMy WebLinkAbout0478 PITCHER'S WAY - Health 478 PITCHERTS WAY, HYANNIS
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No. a.o [ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye .
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pphLation for Disposal 6pstrm Construction JPrmit
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon(
) ❑Complete System �ndiidual Components
Location Address or Lot No 40Z>,�17C�Gt`4Z`P 10 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel O '
Installer's Name,Address, d Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Aot Size sq.ft. Garbage Grinder( )
Other Type of Building Ot'�P No.of Persons Z Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow pr ided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Code and not to place the system in operation until a Certificate of
Compliance has been issued by this BZoflh.Signed Date
Application Approved by Date f2
Application Disapproved by Date
for the following reasons
r Permit No. Date Issued
f ,
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s
No.
a,C�(I V�� Fee -7 l
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
��
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pphration for Misposai e6pstem Construction permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components
Location Address or Lot Noy?(f e,:Z r I.&,lf Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
,i
Installer's Name,Address,a d Tel.No. Designer's Name,Address,and Tel.No.
I—
T pe of Building:
Dwelling No.of Bedrooms ' ,Lot Size /sq.ft. Garbage Grinder( )
Other Type of Building".�,.4,p No.of Persons Showers( ) Cafeteria( )..
Other Fixtures
Design Flow(min.required) gpd Design flow p ided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. -T
' I
Description of Soil
Nature of Repairs orAlterations(Answer when applicable) e -,otIV
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 Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board ofHeVth.
3
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Signed t1Z Date �/ ✓�
� 2
Application Approved by C / Date > C (7
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )
Abandoned( )by
at 7 7(:P1 ��.�'G/� Y✓' �tiAf -001,r has been constructed in accordance ++
with the provisions of Title 5 and the for Disposal System Construction Permit No. t)1 - 0',,0 dated 3 )9': -7
Installer\J> ! � �®��// Designer
� I '
#bedrooms 10' Approved design flow A gpd
The issuance of t�iispb rmit shall not be construed as a guarantee that the system will �,4i,,n ass)designed.
Date 11 / Inspector / f ✓ ��
No.Q)(D k-7 ^ 6(10 Fee -7 >-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal .6pstem Construction Vermit
Permission is hereby granted to Construct( ) Repair e—� Upgrade( ) Abandon( )
System located at �J00 1P Ile-If
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. /
Date_ �� ( Approved by 1�11 y�C �� -
AsBuilt `- Page 1 of 1
TOWN OF BARNSTABLE
LOCATION k ei kl?e/` is, SEWAGE#
VILLAGE_ .,1141 I t ASSESSOR'S MAP&LOT AAQ
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) i-i/" /70//7OR r (size)
NO.OF BEDROOMS :Z
BUILDER OR OWNS "
PERMITDATE: C011PLIANCE DATE: 9
Separation Distance Between the: .
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
is
A LA 131 ,
Ay
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=291024001&seq=1 3/9/2017
oz)7
Commonwealth of Massachusetts r
L F TitleOfficial I �� �'5 Inspection Form i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessmen �A
^M 478 Pitchers Way
Property Address
Anne Minor to
Owner Owner's Name
information is
required for every Hyannis ✓ MA 02601 March 9, 2017
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. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David B. Mason
use the return Name of Inspector
key. Company Name
Company Address
East Sandwich MA 02537
City/Town State Zip Code
508-833-2177 S 1287
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
zx�l U&Mw4/ March 9, 20178
Inspector's Signature V 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 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.
t5ins doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 C
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. Cityrrown 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:
The information contained in this report represents the condition of the system for a moment in time
on March 9, 2017 and does not represent or guarantee the condition or the operation of the system
from this point forward.
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):
t5irs.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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:
i
❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
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 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 1h day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
w Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
_
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.
❑ ® 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.
I
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.cloc-rev.6/16 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
478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is Hyannis MA 02601 March 9, 2017
required for 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
15ins.doc•.rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 478 Pitchers Way
M
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage Yes
9 ( Y 9 (gpd))�
Detail:
Per Hyannis Water Department; 2016; 39,750 gallons and 2015; 42,750 gallons.
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
I
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:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M , 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
ipage. Cityrrown 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: Barnstable Board of Health
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
i
❑ 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) 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):
t5irs.doc•rev.6/16 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
478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is Hyannis MA 02601 March 9, 2017
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Compliance issued 8/6/1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 10'+feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 12"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 Typical
Sludge depth: 211
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. Cityrrown 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 39
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 3„
Distance from bottom of scum to bottom of outlet tee or baffle
11"
How were dimensions determined? Scour Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic Tank is 12 inches below grade. PVC tees in place.
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.doc•rev.6/16 Title 5 Official Inspection Form: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
;M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
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
15ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. CityTrown 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 Effluent level with outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
DBox due to corrosion recently replaced with an H2O dbox which is 20" below grade with a riser
within 6". No evidence of solids carry over.
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name,
information is required for every Hyannis MA 02601 March 9, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5 Infiltrators
❑ 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.):
No inspection port. Probed soild and determined that soil is dry.
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
4 Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. Cityrrown 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.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 478.Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is required for every Hyannis MA 02601 March 9, 2017
page. City/Town 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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 478-Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is Hyannis MA 02601 March 9, 2017
requirey
d for every
page. Cityrrown 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: 20
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:
Groundwater Contour Map
® Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used Town of Barnstable Groundwater Contour Map
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 478 Pitchers Way
Property Address
Anne Minor
Owner Owner's Name
information is Hyannis MA 02601 March 9, 2017
required for every y
page. Cityfrown 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 1 of 2
TOWN OF BARNSTABLE r
LOCATION 97S1 eZ7Gy PZ, k d(y SEWAGE# (/ — c
VILLAGE ASSESSOR'S MAP&L04A 1—QA
INSTALLER'S NAME&PHONE NO. ^Ithciwe
SEPTIC TANK CAPACITY /0 6 0
LEACHING FACUM:(type) U (size)
NO.OF BEDROOMS
y
BUILDEROROWNER
PERMTTDATE: COh4LIANCE DATE: &I
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
i
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=291024001&seq=1 3/9/2017
rA; TOWN OF BARNSTABLE
LOCATION Ack e SEWAGE # 3
All
IhLLAGE ,Llti�s ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. / ,,h e
SEPTIC TANK CAPACITY XO G v
LEACHING FACILITY: (type) f I A(061".f(size)
NO.OF BEDROOMS Y
y
BUILDER OR OWNER Ir�
PERMTTDATE: CO V1 IANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
m
1Al
1
t TOWN OE BARNSTABLE
LOCATION. .t}7A ;t�?�Pr' irla�;_H4;a.nr�is SEWAGE # 87-47�-) =
VILLAGE Tgv;n.'rri sZRarrstnbl e ASSESSOR'S MAP & LOT�A-291-24-1
INSTALLER'S NAME & PHONE NO. CASH'S TRUCKING INC, 362-3221
000 Gallon
SEPTIC TANK CAPACITY 1,000 _
LEACHINQ FACILITY:(type) Fr e-Cast (size) 1,000 Gal
NO. OF.BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER Pu h i i c
BUILDER OR OWNER: ELIZABETH HINES
DATE-PERMIT ISSUED: 7/,2k/87
r
DATE .COMPLIANCE ISSUED: 7/28/87
` VARIANCE GRANTED: Yes ;; No
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Town of Barnstable Health Inspector
•4� °Fz►+E rw�� Regulatory Services Office Hours.8:30-9:30
°.� Thomas F. Geiler,Director 3:30—4:30
s��B> Public Health Division
t,S.
9� i639. A �Thomas McKean Director
SEC MAC
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE
Date:April 6,2010
1. General Information:/f Size of Property: 0.44 acre
Address:078 PITCHER'S WAY HI'ANNIS'At 026017 Map/Parcel 291-024-001
Name:ANNE M MINOR Phone#: 508-957-2721
2a. How many bedrooms exist at your property now?3
2b. Are you planning to add any bedrooms?NO If yes,how many? —
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? YES or NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?
5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
6. Is the dys!ling connected to an ONSITE WELL or to PUBLIC WATER?
C
7. Is a disposal works construction permit on file? YES :or NO -
tw
C)
8. If yes,how many bedrooms were approved according to this permit? ~Bedrooms.ca
9. Were any building permits obtained for construction of additional bedrooms? YES or NO .
10. Is there an engineered septic system plan on file at the Health Division? YES r NO_
11. Has the.septic system been ins]Vcted by a DEP certified inspector within the last two years? YES or NO
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed:. Date: —7 441,v.
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• ,,�.;� TOWN OF BARNSTABLE
LOCATION �/7k OeZ7Gy el` Gvi/ SEWAGE#
VILLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. b C24 c 5 ,
r
SEPTIC TANK CAPACITY /o
LEACHING FACE=: (type) lA!�/- /Tr(N 7GR 1' (size)
NO.OF BEDROOMS: /
BUILDER OR OWNS l
PERMITDATE: CO LIANCE DATE: 9
Iq
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility .
Private Water Supply Well and Leaching Facility '(If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)
Furnished by r
b
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hqp://issgl2/intranet/propdata/prebuilt.aspx?mappar=291024001&seq=1 4/7/201 D
•
Town of Barnstable Health Inspector
'THE
ro Regulatory.Services Office Hours,
8:30-9:30
Thomas F. Geiler,Director 3:30—4:30
sAaxs�rAa «
' Public Health Division
v� 1639. ��� Thomas McKean Director
cr A '
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 568-790-6304
AMNESTY PROGRAM APPLICANT— SEPTIC QUESTIONNAIRE
Date:April 6,2010
1. General Information: Size of Property:.0.44 acre
Address: 478 PITCHER'S WAY HYANNIS MA 02601 Map/Parcel 291-024-001
Name:ANNE M MINOR Phone#: 508-957-2721
2a. How many bedrooms exist at your property now?3
2b. Are you planning to addany bedrooms?NO If yes,how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d.Please.include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show.all existing rooms in the.
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? YES or NO
- O
If the dwelling is connected to public"sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? # '.
5 . Location of dwelling is INSIDE" or OUTSIDE a Zone of Contribution to public supplywells?
6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
7. Is a disposal works construction permit on file? YES or' NO
8. If yes,how many bedrooms were approved according to this permit? Bedrooms.
9. Were any building permits obtained for construction of additional bedrooms? YES ` or ' NO
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
k
4.
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
------ - ----- ------ ------- ----------------- --- - -----------------------------------
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date: /d
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LOCATION k 01?Z kk e/` ivr/y SEWAGE#
VILLAGE ,MT a��ss ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. /kl Ufa C.
SEPTIC TANK CAPACITY /o G c.
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER> >
PERMITDATE: CO LIANCE DATE: 9
Iq
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist ? t
within 300 feet of leaching facility) 4-
Furnished by f<<
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=291024001&seq=1 4/7/2010.
Town of Barnstable Health Inspector
F114E t Regulatory Services Office Hours.
Off, g 3' ery 8:30-9:30
o„ Thomas F.Geiler,Director 3:30—4:30
BAMSPABLE, % Public Health Division
MASS.
9� 039 ,0� .,erE p A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE
Date:April 6,2010
1. General Information: Size of Property: 0.44 acre
Address: 478 PITCHER'S WAY 14YANNIS MA 02601 Map/Parcel 291-024-001
Name: ANNE M MINOR Phone#: 508-957-2721
2a. How many bedrooms exist at your property now? 3
r i
2b. Are you planning to add any bedrooms?NO If yes,how many? `�
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the
home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room
clearly.
3. Is the dwelling connected to public sewer? YES or NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? y
5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? �
7. Is a disposal works construction permit on file? YES or :'•r NO co
r
8. If yes,how many bedrooms were approved according to this permit? Bedrooms. Ci)
.9. Were any building permits obtained for construction of additional bedrooms? YES or NO LV
trt rn
10. Is there an engineered septic system plan on file at the Health Division? YES or NO
11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
------------------------------------------------------------------------------------ ----------------------- --- -- ��,,.,
FOR OFFICE USE ONLY ®l)✓V
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date: elf lif"410
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TOWN OF BARNSTABLE
LOCATION c17 e SEWAGE # C
VILLAGE .�/i��1 �,v� c ASSESSOR'S MAP & LOTS
�1
INSTALLER'S NAME&PHONE NO. /Y7/b c to c i7`.c
SEPTIC TANK CAPACITY /0 6 v
LEACHING FACILITY: (type) 14171,, 17011702 (size)
NO.OF BEDROOMS Y
BUILDER OR OWNER 1
l
PERMITDATE: I I CO LIANCE DATE: �- 9 1
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
--T L1:
JFT
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LV
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. 1
l � No. Y / i� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for )Dizpaar *p5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System `W t dividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel ^�(�0 CQ cr
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
5T- � ,
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 SA.�-vp gallons per day. Calculated daily flow `A 57 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �Z1 Z S 4 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) r %tip
e� ,
Date last inspected:
Agreement: j
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-
cate of Compliance has y t is _ c
Signed Date �L G
Application Approved by Date ""I<-
Application Disapproved for the following reasons
Permit No. '� Date Issued -'
Fee '✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for Migpogal 6p5tern Congtruction Permit
Application for a Permit to Construct( '' )Repair( )Upgrade( )Abandon( ) El Complete System 'Qndividual Components
Location Address or Lot No. L —7F t-CG sl'c Owner's Name,Address and Tel.No.
fe- t`'.`
Assessor's Map/Parcel I , O �` Cu'r �e0
"M
Installer(('ss�Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
V�1 —C qX-.,e_cp
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 �A A gallons per day. Calculated daily flow SA 57 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �x 't St C�nZ>S�1 Z/ Type of S.A.S. i r�C' CO--
- Description of Soil tnn('•_.Q S K1uh J
t:.
Nature of Repairs or Alterations(Answer when plicable \ �- /�� f r CQ t 1 r
v( le `l i ls�\C i ��'S - VK v- e,,c�'�
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 Code and not to place the system in operation until a Certifi-
cate of Compliance has y is nip /gyp/
Signed' Date 1,
Application Approved by j Date
Application Disapproved for the following reasons
Permit No. ` Date Issued
'THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(✓'I
Abandoned( )by -C t-- S is l
at i C A�` has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.? dated
Installer s Designer n G
' The issuance of this permit of b co trued as a guarantee that the fe w_ill function as deZgned.
r
f
4
Date � I �� Inspector "f� �yl, / �:�r� 11 � NfL —'
——— ——— ————————————————————————————No. Fee
%' Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIQ HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Y N
x1i6poga[ *pgtem Congtruction ermit
Permission is hereby granted to Construct( )Repair( grade( )Abandon( )
System located at
1
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 must be completed within three years of tl '�of this petj%it.
Date: f �,� Approved t6
1/6/99
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 DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated �— c1 / concerning the
property located at '7 o �,-S tc..1 �,�—, meets all of the
following criteria:
( The failed system is connected to a residential dwelling only. There are no commercial or business
ruses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation +the MAX.High G.W. Adjustment./i
DIFFERENCE BETWEEN A and B
SIGNED : _ DATE: 0- �C
[Sketch proposed plan of system on back].
q:health folder:cert
f
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Q
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,{
CO-MMOINTATALT11 € F N SAC 1�SETTS
St:symC S 1 T OFFICE OF EIV VIROI EN7AL A.F`F;AIRS
DEPARTMENT OF ENVIR.ON-MENTAL PROTECTION
r
s
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name:
Owner's Address: s
~` A/
Date of Inspection:
Name of inspector: leay
print)
Company
n Name: L�kw� -
� 1
c
Mailing Address: Ajoweare&-sZap ;
SP
Telephone Number:—_.fig—�g.S=7�DF36I1
CERTIFICATION STATEMENT 1
I certify that I have personally g disposal ;
Pe y inspected the sewage dis sal system at this address and that the information,eportecl=='
below is true;accurate and complete as of the time of the inspection. The inspection was performed based on.my P
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DIP rn
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The syste
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:
- — ate. �
The system inspector shall submit a copy of this inspectio Approving Authority{Board of Health or
D£P)within 3Q days of completing n report to the A this inspection.If the system is a shared system or has a design flow of 10
PPr, g
gpd or greater,the inspector and the system owner shall submit the report to th e appropriateateional office of the
regional DEP.The original should be sent to the system ow the buyer, if.ap ,and the a
authority. ner and copies sent to
PProving
Notes and Comments
***This report only describes conditions at the time of inspection and under the conditions of use
at th time.This inspection does not address how the system will perform in the future under the saute or dif at
conditions of use.
rent
Title 5 Inspection Form. 6115<2000
page I
Page 2 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE, SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: �� � G
Ovrmer.
Date of Inspection.
Inspe,ction Summary: Check.A,B,C D or>E/ALWAYS complete all of Section iz
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 3:I0 CMR 15.304 exist.Any failure criteria not evaluated are indicated below_
Comments:
& System Conditionally Fusses:
One or more system components as described in the"Conditional Pass"section need replaced or
repaired.The system;upon completion of the replacement or repair,as approved by the and of Hea
lth,will pass_
Answer yes,no or not determined(Y,N,ND)in the for the following ments. If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the se ' tank(whether metal or not)is structurally
uasound,.exhibits.substantial infiltration or exfilttation or 'lure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as- oved by the.Board,of Health,
'!'A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance
indicating that the tank is Iess than 20 years old is le.
ND explain:
Observation of sewage backup out or high static water level in the distribution box due to brokers car
Obstructed pipe(s)or due to a brok ttled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pox(s)we rwhmd
obshparmisTwtoved
distribution box is&�aeled or replaced-
ND explain:
The required pumping more than 4 times'a year due to broken or obstructed pipe(s).The sin will
Pass inspe if(with approval ofthe Board of Health):
4
broken pipe(s)are replaced
obstruction is removed I
ND explain:
2
Page3ofii
OFFICIAL INSPE O FORML -'NOT"FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 4
u
Owner:.
Date of Inspection: p�
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in ord to determine if the system
is failing to protect public health,safety or the environment_
I. System wilU pass unless Board of Health determines in accordance ith 310 CMR 15.303(i)(b)that the
system is not functioning.in a manner which will protect public eaIth,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 veg ted wetland Ora salt marsh
2. System will fail unless the Board of Healt and Public Water Supplier,if any)determines th
system is functioning in a manner that Prot the public health,safety and environment: at the
_ The system has aseptic tank and it absorption system(SAS)and the SAS.is within.I00 feet of a
surface water supply or tributary to urface water supply.
— The system has a septic and SAS and the SAS is within a Zone I of a public water supply.
— The system has a septic and SAS and the SAS is.within 50 feet of a privatewater supply well.
_ The system has a se is tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply w **.Method used to determine distance
**This system p if the..well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and vola'e organic compounds indicates that the well is free from pollution from.that facility and
the presence of- onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria a triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DOPOSAL SYSTEM ENSPEC ION FORM
FART.A.
CERTIFICATION(continued)
Property Address: _e178
�►:�
Owner:
Date of.Inspectiou:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
�C 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
_.c Liquid depth in cesspool is Iess than 6"below invert or available volume is less than%day flow
_01�_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed
of times pumped Pipe(s).Number
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool,or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zane 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 1 OO fleet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.IThis system passes if the well water analysis,
performed at a D)EP certified laboratory;for cofiferin bacteria and volatile organic componn&
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 a'plani,provided that no other failure criteria
,� y� are triggered.A copy of the analysis must be attached to this form.]
s�" (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..
lc. Large Systems:
To be considered a large system the system must serve.a facility with a flow of 1 0,000 gpd to 15,Ui#0
SFd-
You must indicate either`yes"or"no-to each of the following:
('The following criteria apply to large systems in.addition to the 'a above)
yes no
_ — the system is.within 400 feet of a surface g water supply
— _ the system is within 200 feet of a utary to a surface drinking water supply
— — the system is located in a ogen sensitive area(Interim Wellhead Protection Area-IWPA).or.a mapped
Zone 11 of a public supply well
If you have answered"yes" o any question in Section E the system is considered a significant threat,or answered
"yes"in Section D.abo the large system has failed.The owner or operator of any large system considered a
significant threat Section E or failed.under.Section D shall upgrade-the system in accordance with 310 CMR
15304.The cyst owner should contact the appropriate regional office of the Department.
4
r
Page 5 of i 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address; s�G
Owner: df
Date of Inspection•
Check if the following have been done.You mast 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?
e 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 NIA)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
-49 _ 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
mhintenance 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,&.plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J
5
f
Page 6 of 1
OFFICIAL,INSFI C I WN FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSPACE SEWAGE DISPOSAL SYSTEM INSPEC I ON FOR-NJ
PART.0
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents I.
Does residence have a �e garba� grinder(yes or no):
Is laundry on a separate sewage system(yyes or no): D(if yes separate inspection required)
Laundry system inspected(yes or no):A-V
Seasonal use:(yes or no):e
Water meter readings,if available(last 2 years usage(apd)):
Sump pump(yes.or.no):
Last date of occupancy:_ M
COMMERCIAIANDUSTRIAL
Type of establishment:
Design flow/st
on 310 CMR 15.203): opd
Basis of des (seats/persons/sq.
Grease trap (yes-or no}:
Industrial wasteholding tans:pr nt(yes or no}:—
Non-sanitaischara to the Title 5 system(yes or no):
Water meters,if Bitable:East date of use:OTHER(d
Pumping Records GENERAL INFORMATION
Source of information:
Was system pumped as part of the inspection(yes or no): [�
If yes;volume pumped:iJgallons—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 tarok _Attach a copy of the DEP approval
Other(describe): .
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no : 1W
6
I
Pate 7 oft'
OFFICIAL NSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORIM
PART C
SYSTEM INFORMATION(continued)
Property Address 7 1� i j7A,fs
Owner•
Date of Inspection: fj
BUILDING SEWER(locate on site plan) .
Depth below grade:
Materials of construction:____cast iron 0(40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition'of joints,venting,evidence of.leakage,.etc.):
SEPTIC TANK:_(locate on site plan)
r�.
Depth below grade: fs
Material of construction: q(concrete_metal fiber;
other(expla lass polyethylene
_ in) — _
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no): (,attach.a copy of
certificate)
Dimensions: <000
Sludge depth: V
Distance from-top of slugge to bottom of outlet tee or baffle: 7
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 y
afr3e:
How were dimensions determined: u�r
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,et�c..):� �
C
GREASE'TRAP:_(locate on site.plan)
Depth below grade:
Material of construction;_eonorege_metal glass
(explain): _p _other
other
Dimensions:
Scum thickness:_
Distance from top Of scum to top o utlet tee or baffle:
Distance from bottom of scum t ottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping r ommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet inv evidence of leakage,etc.):
7
Page g of I I
OFFICE,INSPECTION FORM—NOT FOR:VOEUNTARYASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date
Date of Inspection: j>
TIGHT or HOLDING TANK: (tank must be d at time of inspection)(locate on site plan)
Depth below-grade:
Material of construction: concrete tai fiberglass----polyethylene othe a lain
K xp :)
Dimensions:
Capacity: Ions
Design Flow:. gallons/day
Alarm present(yes or no):
Alarm level: A in worldng order(yes or no):
Date of last pumping:
Comments(conditio of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be openWocate on site plan)
Depth of liquid level above outlet invert: a ye�i1
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence.of.
leakage in or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no)
Alarms in working order(yes o
Comments(note conditio pump chamber,condition of pumps and appurtenances,etc.):
8
page 9 of I I
OFFICIAL N'SPEC 17ION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SIBSIUAFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
�,,
Owner:—L/�r`ot r,
Date of Inspectio /06
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: _-01'
leaching trenches,.number,.length
Ieachin-fields,number;dimensions:
overflow cesspool;number
innovative/alternative system. Type/name.of technology:
Comments(note condition of soil,signs of hydraulic failure, level ofponding,damp soil,etc_): condition ofveoe
� _. 5 � tation,
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 laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater in (yes or no):
Comments.(note conditio 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 cond' ' n of soil,signs of hydraulic failure,level of.ponding,condition of vegetation,etc.):
I
9
Page 10 of I l
OFFICIAL INSPECTION FORM--NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: ('
Irate of Inspection:
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.1.00.feet.Locate where public water supply enters the building.
b
Rea
tea
t
Page I I of 11
OFFICE.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner or.4 d do-
Date of Inspection: Gz�
SITE EXAM
Slope NO -
Surface waterA)(9
Check cellar Y
Shallow wells N
Estimated depth to ground water�'d 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)
Q_Accessed USGS database-explain:
You must describe how you established th
e high ground w ter elevation:
i
Il
TOWN„ F BARNSTABLE BAR
Ordinance or Regulation W 36 4
WARNING NOTICE
Name of Offender/Manager Pay d Anhtll-k Cell-1,11
Address of Offender .?/ Ahr Ae4-10,1 MV/MB Reg.#
Village/State/Zip litJ /P.l4 � 6 1
�
Business Name y OD amt M on J1�! 19_J",j
Business Address '` # �� C
Signature of Enforcing Officer
Village/State/Zip
Location of Offense 412E P-A' -
r�r�
!!// Enfocing Dept/Division
Offense �/�.� �'� Yloo 60a
_ f
Facts /1 Oh A-n)(-)Ad In 4-aVV Ll A"t,*- Y74-4e---1- Psa N o&-e
�► sti ..�
This will sere only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
/ TOWNIOF BARNSTABLE gj„j 364
Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager heT Y N
Address of Offender '� Y-f)' AjY tly6 e MV/MB .Reg.#
1 Village/State/Zip / r C1
��� �f�/�,
Business Name V UUam/p on „3 ! 191S
Business Address
Signature of Enforcing Officer
Village/State/Zip J
Location of Offense V2F !""1 1"
ar Enforcing Dept/Division
Offense
Facts dit An1t.!/td 1t7 Ai2;il V / s4l"_"e-� k
This will sere only as a warning. At this time no legal action. has been taken.
It is the goal of Town agencies to achieve voluntary compliance. of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result . in
appropriate legal action by the Town.
TOWN-OF BARNSTABLE BAR:W 364
Ordinance or Regulation
WARNING NOTICE
vt
Name of Offender/Manager `- 'I k gr
Address of Offender `d j/ ''e'/e Awny'— MV/MB Reg.#
Village/State/Zipt, 'r�r`s°, ! 1 41
Business Name U-am/pm on 19
s. Business Address ( 1 4, 1h Ast`
Signature of Enforcing Officer
Village/State/Zip
j
Location of Offense 4/2F t " • %' '��
Enforcing Dept/Division
Offense
Facts /� �" ob r,ivotk In t a,,,d 4e.< 4P- e kyi,
This will sere only as a warning. At `this time no legal action has been taken.
It is the goal of- Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to .-gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
SSESSORS MAP NO:
"ARCEL NO.:
No------------------- Fmc.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
'1,0..........--OF
Appliration for Bi-spagal Works Tomitrurtion ramit
Application is hereby made for a Permit to Construct or Repair Individual Sewage Disposal
System at
. ..
.............................................................................
................................................................................
Lo�x on-Add,,ss or Lot No.
.... . . ...................................... ............................................ ...............................................
carer .................................Xw�ress...n .. ........... ..Installer Address
Type of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms........:...................................Expansion Attic Garbage Grinder (
Other—Type of Building ............................ No. of persons......_...........__.______. Showers Cafeteria (
Other fixtures ..................................................................................................................................I
......................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length...:--------*... Width................ Diameter.........._..... Depth.....__......_..
Disposal Trench—No................. --- Width.................... Total Length....__............._ Total leaching area....................sq. f t.
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. 1....------------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---__-____----..._--__--
--------------------------------------------------------------------------------••-•-----------••---........................................................
0 Description of Soil.......................................................................................................................................I.................................
---------------------------------------------------------------------------------- --
--------------------------------*.............------- -------------------------------------*---------------
.............. .............-- ------------------------------------ ....... ----------------------------------2::;*,-,
bl I
------------------------------------------------- ....... .....
&roff aRpairs or Nteptions—Answer when app
p
4 --4 ------------------------
Agreement: ---- 69109d,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T"_7 f-of the State Sanitary Code—The undersignedfurther agrees not to place the system in operation until a Certificate of Compliance has bee i sued by the bo of h Ith.
...............................
.. .... .........-....... ................................. ...... ......... .......
by the 'I e of Compliance has bee sued e bo of.. . . .... . .. ..!............ ... .......
�Asn�
Application Approved By............ ........ .......
Date
Application Disapproved for the following reasons:..............................................................................................................
.........................................................................................................................................................................................................
Date
Permit No.... .57-.-S-------- Issued.......................................................
Date
YHE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAffL�TH
...............O F.... /... ',i11 1:9 d' .--3 _.....................................
Appliration for Bispvii al Works Tonstrurtion 11amit
Application is hereby made for a Permit to Construct ( ) or Repair (,.�<an Individual Sewage Disposal
System at• / $ /
Loc ion Address -------- - ---------"----------"-----------------"or Lot No.
-----------------*----------------- --------
:7... ...... ---•-------------------------•...-•-----••--------...._..--•------••-------....
caner J p Address
.............•------------...-----..........-----------------------.........•........:.........---
Installer Address
Q Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p•l Other fixtures ---------------------------------- ------
W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons.
94 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
xDisposal 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........................................
aTest 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---___-__-_-___---___--.
a ----------------------------------••----•-------•-••----..........------............-------•-----•--.........................................................
0 Description of Soil........................................................................................................................................................................
W •---•-------- ----------------------------------------------- •••-----••----•-•-....----•----- --•• ...............................................................
0 Natu e of Repairs or Alterations—Answer hen app cable. -e� / �� ) _ l -.C �.
�'
Agreement: _
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions off_ of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beer sued by the bo of1/h lth.
.---- -------•--•--•-----------•------.. J`... -
f -� s
Application A roved B �. a
Date
Application Disapproved for the following reasons---- -----------------------------------------------•---•---•--------------------------------------...........---
------•------------•----....-•--------••-----•--------------------••------...---------•--............-•--I-•-----------------•------------------------•---------------•--•••----------------•------------
Date
PermitNo...............: -•-.. ...................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....:.......:: .........oF.... ,.. ': "� :. ....................................
j .. . ,
Tatifiratr of Tome iFanre
THIS IS T )CPRTIFY, Th�the Individual ,Sewage Disposal System constructed ( ) or Repaired }
by.......... l_.r _ ;.. ... r. a . mrs lam._ ?:L --------------•----•------------•..........----•..............----....--------
•... -- -
( /� J Installer '
at ''" €a A! . '_E a.A o Z 1�-ya_�i.!�1,13l1 ............ . ......................................................•-••-••---
has been installed in accordance with the pro lions of I �", 5 7 T State Sanitary Code,4s descjib)d in the
application for Disposal Works Construction Permit No.......................}��__...... dated------.--__-2__ZG1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE (�j' Q--�•--..... Inspector •----•-••----------------•-•-----••--
✓� �J. THE COMMONWEALTH OF MASSACHUSETTS
5�
BOARD OF HEALTH if")
........
NO.-.. z?..[.........., FEE--
., ' k� �nn�#.rairrn �erani�
Permission.is hereby granted----.0.1_4,:7._., ... ,,A i.ahzi.?.Zi. ' ...............................................
to Construct ( ) orat
?Repair ( ) an Individual Sewage Disposal System(17 'q. -I �I
as shown on the application for Disposal Works `x ted---
--•--------- -
Boar
d of Health
DATE.-.............. .. �......................... '
FORM 1255 HOBBS & WARREN, INC.. PUBLISH
YI�s�`