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Home My WebLink About0639 PITCHER'S WAY - Health 639'PITCHEItS WAY,HYANNIS A= o i q 0 1 Commonwealth of Massachusetts f Title 5 Official Inspection Form 0?-3-I --I ao Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name/ , page. Hyannis M MA 02601 June 25,2020 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. A. Inspector Information 1. Inspector: Nicholas Geneseo Name of Inspector Wind River Environmental Company Name 46 Lizotte Drive Suite 1000 Company Address Marlborough MA 01752 City/Town State Zip Code (973)830-6126 SI 13988 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true,accurate and complete as of the time of my inspection;and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: Q Passes ❑ Conditionally Passes ❑ Needs Further Evaluation by the Local Approving Authority ❑ Fails June 25,2020 Inspector's Signature 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. Please note: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. .r 1 1, 4 t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection C. Inspection summary Inspection Summary: Complete 1,2,3,or 5 and all of 4 and 6. 1)System Passes: Q 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 system is working properly at this time.There are no signs of hydraulic failure at this time. 2)System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below) t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 2 of 19 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c, 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) 2)System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3)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. a. 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: t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 3 of 19 I . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) ❑ 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 b. 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. c. Other: 4)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ z Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ z Discharge or ponding of effluent to the surface of the ground or surface waters,due to an overloaded or clogged SAS or cesspool t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 4 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c, s 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Q Liquid depth in cesspool is less than 6"below invert or available volume is less than''Y2 day flow ❑ Q Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:_ ❑ Q Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ Q Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Q 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.] ❑ Q The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd. ❑ Q 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. 5)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 CA. 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 t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 5 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection C. Inspection summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or answered"yes"in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No Q ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ Q Were any of the system components pumped out in the previous two weeks? Q ❑ Has the system received normal flows in the previous two week period? ❑ Q Have large volumes of water been introduced to the system recently or as part of this inspection? Q ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ Q Was the facility or dwelling inspected for signs of sewage back up? Q ❑ Was the site inspected for signs of break out? Q ❑ Were all system components,excluding the SAS,located on site? Q ❑ 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? r Q ❑ 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: Q ❑ Existing information. For example,a plan at the Board of Health. ❑ Q 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)] t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 6 of 19 I • Commonwealth of Massachusetts W Title 5 Official Inspection Form ao Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information 1. 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 GPD Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes 0 No If yes,discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Unavailable Detail: Unavailable Sump pump? ❑ Yes 0 No Last date of occupancy: Current Date t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 7 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is Owner's Name required for every page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): General Information 3• Pumping Records: Source bf information: Wind River Environmental last pumped on 10/30/19,see attached. Was system pumped as part of the inspection? ❑ Yes 2 No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5ins.doc 0 rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal system a Page 8 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form ao Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 CityfTown State Zip Code Date of Inspection D. System Information (cont.) 4. 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/Altemative 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): Approximate age of all components,date installed(if known)and source of information: 1997 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5• Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron - Q 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints,venting,evidence of leakage, etc.): Unable to go inside due to COVID-19.The main line is clear with no obstructions or leaks. t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 19 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: r Q 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: 8' X 5' X 4' Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle = 30" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The liquid level is normal and both baffles are intact.The tank appears to be in good condition with no leaks or cracks. Recommend pumping annually. t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 19 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 8. 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 t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 11 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The distribution box is 4'below grade with two outlets taking equal flow.The box is watertight and level with minimal corrosion present. Recommend installing a riser to 6"below grade for future access. t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption S stem SAS locate on site Ian,excavation not required): Y (SAS) P 4 ) If SAS not located, explain why: Type: [J( leaching pits number: 1 0 leaching chambers number: q ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 19 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS)(Cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): There is one leach pit and there are four leaching chambers.The leach pit is empty and the chambers are showing no signs of hydraulic failure.The soil is dry sand and the vegetation is normal.There are no signs of hydraulic failure or aroundwater infiltration at this time. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 14 of 19 i Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 19 Y 9 ICommonwealthof Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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: Q hand-sketch in the area below ❑ drawing attached separately �a 1 t5ins.doc rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal system 9 Page 16 of 19 ICommonwealthof Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code I Date of Inspection D. System Information (cont.) 15. Site Exam: Q Check Slope Q Surface water ❑ Check cellar Q Shallow wells Estimated depth to high ground water: 10'+ 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 Q Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: . ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: The leach pit is dry and there are no signs of groundwater infiltration. Before Fling this Inspection Report,please see Report Completeness Checklist on next page. t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 17 of 19 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page: Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: Q A. Inspection information:Complete all fields in this section. Q B. Certification:Signed&Dated and 1,2,3, or4 checked Q C. Inspection Summary: 1,2,3,or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed Q D.System Information: For 8:Tight/Holding Tank-Pumping contract attached For 15:Sketch of Sewage Disposal System drawn on pg. 16 or attached For 16: Explanation of estimated depth to high groundwater included t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 19 Ir Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 639 Pitchers Way Property Address Owner Stacey Kurtz information is required for every Owner's Name page. Hyannis MA 02601 June 25,2020 City/Town State Zip Code Date of Inspection Pumping Record Work Orderlf0217075149 Cast#1503997 CutomerSinw.2012 Twc6.2500 % .hob Comments Tech Comments 10/30/20.19 CQUP0W CODE', R0050, Service 1500gals little 10/26/2012 sezvieed lsea gallon sy,tm; no visible issues; digging back yard an the tack porch looking out into the light solid,; light sludge; continue regular servicing; yard its on the right toad side. Wes, CC in office - RE rammLend use of cow and installation of filter. OW) jap System System L.ocatbon Stacey[sins Rental rase: 639 Ditchers Stay 6.39 citaherm gray Hymn" Wa.02601 8yannia.., ma 02601. (61s) 966-6740 Rurtz Stacey: 4615) 9s6-B7a4 ServweDate: mw 10/30/2019 11.40 at Frequency: Call tAcaftm: Servfr:e Type: atww rd PrevibusServir- 0/26/2012 Approx. Gals: 0 CCLS: 10/30/2019 Dzpdt Below Grade: Custom Clew: Location D Is: Cust : go Fihe: Tawnsshi¢t: Irspecbcnn 5: CMElty_ .oiagnng 3401, a50o - ,{ 0 44 9 324 76'36 $ 0.0� �'�Jr Digging per 6 innc�s,�BLrat fi Ineha¢FiCei'' 0 40 Aso 0000 $ I4.ti0 Coupon-aoosc - 1 4o B o ooAo sa.as ffivizoimmtal Cbmpliayse Rodideat L,l ' 7✓04 $ 3 00�f0 $ 3.C74 Fuel /Energy$tcovezy 1 p4 ,Q 6924 40" $z SAsrp1oa _ $.,957 94 ffit of a000 sal copb0 $ .197 63ao::,$ 197:.64 toupon oz isimccavnt .4 ,1 04.u,$ 20 0000-$ 20 Oar 4 i $ 612.81 Vft siff"#we 3 11"SSWP to k"W%Yom ha kty:: Taff ;$ 12.35 'It poar"Mtslg s S '(Ise 0%bacteria40d"+t rows2s.16 •U*aNeer 011soze stet Yazaouth M vattime. PaymentOotaA. Waste Code<Ruo!PSmPtic 1000.0000 ' visa�tl[E020 09/2.033 Rep: . C.St: Raquel Normandin Due oa Receipt Tnick Te<hotdmt S Tomhma Sell Ch Site.09 s ac as P To:h HOW Syst—Operating Fine:.. .Wurzel.water 1eve1.. moderate tap.solids.. Nodcrate bottom ... sludge., inlet.baffles ere intact. main Hine clear. no filter is present on the tank; current task can.be cut Eitted with a filter., coaer(s) secured. Reoeancnd.d Boost additive,CTW additive,instal ling a filter. Cusiwner S*Qture y •vim x Sri#� �g �7��r � ' VIR t5ins.doc 0 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 19 of 19 i f � 4a TOWN OF BARNSTABLE BOARD OF HEALTH r ARTICLE IL MINIMUM STANDARDS FOR HUMAN HABITATION Date P ( � Time: In ut Owner Tenant n ( Address �`-gU Add A wff� ress Complia a Remarks or Regulation# Yes XNO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use - 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents "3 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) 5 Number of Persons Allowed (max) Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here �I 1�1 I � . I � I ji Y I �� I � �� f, { • ' r rl . � �i { . � � r � i � _ �, � I t � I , � • I f ++� I I I �. 1 yl 1 l f i t 'r r � 1 I it f - „_x �- w �, r.:. �. �C �. is '� I � � � � � � �._ �� .�. �� .. . � � , �, �� .-� -� = �i � � a �- � � �, --�. �: �� . . ..: g r� �:. ��..z;� �• ti I Q,� V � J f 1� y Y� �n 3 6� v E - NAME OFOfFENDER � iqndi ,e BAR41-1 TOWN OAF ADDRESS OF OFFENDER BARNSTABLE CITY,STATE,ZIP CODE iNE tpw ` MV/MB REGISTRATION NUMBER � OFFENSE (� y� /�/j ) /f ItANMASSBLE. • .� ' .i Q Ii 7,w+C` _,�•idr !D ! t� •' LJ • Y O FD �, LJ NOTICE OF, TIME AND DATE VIOLATIONA.M. P. ON .+.- 19 LOCATION OF VIOLATION Z W Q SIGN' E OF ENFORCING PERSO ENF RCING DEPT. BADGE NO. rw VIOLATION OF TOWN . ' o I HEREBY ACKNOWLEDGE RECEIPT OF ITATION X LL' a a +Unable to obtain si nature of offender. ~ ORDINANCE Y'� 9 THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ 3 j � W Date mailed -� LU OR YOU HAVE THE FOL OWING ALTERNATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPITON(1)OR OPTION(2)WILL OPERATE AS A FINAL a DISPOSITION WITH NO RESULTING CRIMINAL RECORD. W N REGULATION (1(You may elect to pay the above fine,either by appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, w before: The Barnstable Town Clerk,367 Main Street,Hyannis,MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk, a P.O.Box 2430,Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. (2)If you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT, FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA 02630,Att:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. (3)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature NAME OF OFFENDER BAR 40250 TOWN OF ADDRESS OF OFFENDER ICI BARNSTABLE CITY,STATE,ZIP CODE r �1HE►D� MVIMB REGISTRATION NUMBER- OFFENSE LLi MASS. tee$ A A � � .f ^� /f !!°�.n`A /). O QED IA►r► .,.. J W 7 TIME AND DATE OF VIOLATION _ LOCATION OF VIOLATION1 p UJI Z NOTICE OF vJ (A.M.1 rW)ON 19 SIGNATUR OF ENFORCING PERSON ENFOR INl,DEPT. - BADGE NO. N VIOLATION G{. �r` r r, e a.l-4-6 CD OF TOWN II HEREBY ACKNOWLEDGE RECEIPT OF CITATION XLU ORDINANCE Jam+ Unable to obtain signature of offender. <F l� THE NONCRIMINAL FINE FOR THIS OFFENSE IS $ .5: 0 W Date mailed +' w OR YOU HAVE THE FOLLOWI ALTE NATIVES WITH REGARD TO DISPOSITION OF THIS MATTER.EITHER OPITON(1)OR OPTION(2)WILL OPERATE AS A FINAL d DISPOSITION WITH NO RESULTING CRIMINAL RECORD. LL,I REGULATION 11I You may elect to a the above fine,either b appearing in person between 8:30 A.M.and 4:00 P.M.,Monday through Friday,legal holidays excepted, Q Y pay Y PP 9 P Y 9 Y 9 Y IL) before: The Barnstable Town Clerk,367 Main Street,Hyannis, MA 02601,or by mailing a check,money order or postal note to Barnstable Clerk, a P.O.Box 2430,Hyannis,MA 02601,WITHIN TWENTY-ONE(21)DAYS OF THE DATE OF THIS NOTICE. 121 It you desire to contest this matter in a noncriminal proceeding,you may do so by making written request to DISTRICT COURT DEPARTMENT, FIRST BARNSTABLE DIVISION,COURT COMPOUND,MAIN STREET,BARNSTABLE,MA02630,Att:21 D Noncriminal Hearings and enclose a copy of this citation for a hearing. 13)If you fail to pay the above offense or to request a hearing within 21 days,or if you fail to appear for the hearing or to pay any fine determined at the hearing to be due,criminal complaint may be issued against you. ❑ 1 HEREBY ELECT the first option above,confess to the offense charged,and enclose payment in the amount of$ Signature e TOWNOF 'BARNSTABLE ..BAR-W 366 Ordinance or Regulation 4 WARNING NOTICE t.K Name of Offender/Manager 1►'E'-t.�x.� Address of Offender 635 MV/MB Reg.# ' Village/State/Zip��N IT_{� 6 (0� ,3 , j00 Business Name amOm on 19 Business Address / � �i.�► / � , �` �' ignature of Enforcing Officer Village/State/Zip 3 Location of Offense Enforcing Dept/Division Offense 1VU1JC'A'hCt' eomuT ol Facts %/-asi j�o(ij , lum a^h, jyXec-, Y-e4_we jin ze �I This will serve only as a warning. At this time[ no *l g 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. TOiWOF BARNSTABLE BAR-W368 Ordinance or Regulation ' WARNING NOTICE Name of Offender/Manager F'C i .�-F")�h i'�- Address of Offender 635 P4 rt MV/MB Reg.# Village/State/Zip /fir n�.o�r _c� of ig -47 Business Name V am pm on `3- 19 Business Address \ ' Signature of Enforcing Officer Village/State/Zip Location of Offense / Enforcing Dept/Division Offense IV Ui.S64-Ace 60M / 9 Facts / h:W 4y4J� ,A-wMt- e 1�u Y`e r jt, ZQe* `..N_"l=t,S h , ./--u'�U�'�• d.° (y NY+�E:v �Y°�'i,t�•� � � .,f t COY � �,� ��H't� l 1/ This will serve 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 Ordinance or Regulation 368 WARNING NOTICE Name of Offender/Manager . P�" E a. Address of Offender 6 3cj 00/-W .1 k" MV/MB Reg.# Village/State/Zip r., Y�l Business Name r j r �Q am/''m i on 19 Business Address ` Signature of Enforcing Officer Village/State/Zip / f Location of Offense _. Enforcing Dept/Division Offense /yUt 5�+ y� 0-&21 X�Il llkllykl )/) .� Facts " kr � k ir..3 AzroJot, ato') f k-p4uL r^ Jt, 12 t Ai This will serve 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. ,�,... �.. � , .: ,:x,.. .� T..-, ...-�..,.. ...:.. ,f,.. ., .. r:.,t...., ,_ ,-i7--••,� .-.,.-. ,-:'v'w3r!F"w.kT"�.,,,"'v� .-an. o. r. TOWN- OF BARNSTABLE ; BAR-W 360 Ordinance or Regulation - WARNING NOTICE p Name of Offender/Manager -A4L'1 n 4 a i yqk,. Address of Offender / bu nr4-r,. P414-A MV/MB Reg.# Village/State/Zip V a4eh,4L,4- ► Business Name 7 am pm; on 3 do 19f Business Address J� L Signature of Enforcing Officer Village/State/Zip Location of Offense 63 t P 4c nU;/, f 4A."j A"fi/ Ak44A I r ' Enforcing Dept/Division. Offense OUISC6l Facts U M, WC�� des � vr� / 1�4'il This will serve 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-jQF't BARNSTABLE BAR-W 360 ` Ordinance or Regulation WARNING NOTICE 0wr.3 ( . Name of Offender/Manager A4 I'fn FlIz -A kiac *A9 -- Address of Offender-1 V I?.t - f.- PlL` A MV/MB Reg.# Village/State/Zipi1 �44' ; ! `�Y,l'' tit . Business Name am/pm; on 3 " P 19 1S Business Address' Signature of Enforcing Officer Village/State/Zip Location of Offense 6.39 Phk-tea V" Aa'01sIs � � Enforcing Dept/Division Offense UI ,� ft2l Facts 7L� S aka) fa."9J -7q-ec /�'7 (.l Jr A This will serve 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 360 Ordinance or Regulation WARNING NOTICE tic z'7- Name of Offender/Manager ft-01tn 4 F /I ?'Mi / =C "" Address of Offender SV"4 4-rr f MV/MB Reg.# Village/State/Zip + r v 6 � t'o- o.3 Business Name t amta on 3 , 19 is Business Address Signature of Enforcing Officer Village/State/Zip j Location of Offense 6-3 14 �wnn 1( � " A }� Enforcing Dept/Division 9 ' l "- Offense Ort,S�" Facts 1 dS4 Y?V ► 1 VU�`C-� y i 4 l t dam.,y S This will serve 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. THE COMMONWEALTH• OF MASSACHUSETTS OFFICE OF THE DISTRICT ATTORNEY CAPE&ISLANDS DISTRICT PHILIP A. ROLLINS 3231 MAIN STREET DISTRICT ATTORNEY P.O. BOX 455 BARNSTABLE,MA 02630 (508)362-8113 August 29, 1996 Department Of Health, Safety & Environmental Services Mr. Thomas Geiler P.O. Box 2430 Hyannis, Ma 02601 COMMONWEALTH VS. MARCIA ANDREWS 95-75 2 Dear Mr. Geiler, Please be advised that the above-referenced matter is scheduled for status on November 13, 1996 at 9:00 a.m. Your appearance is not necessary at this time. However, we need a written narrative, advising us of the facts, before the scheduled court date, in order to prosecute this case. Include any witnesses you may have with their names, addresses, and telephone numbers, before the above court date. Thank you for your prompt attention to this matter. If you have any questions or concerns, please feel free to contact this office. Very truly yours, Sharon J. Thibeault Assistant District Attorney SJT/njb Town of Barnstable Department of Health, Safety, and Environmental Services � E Consumer Affairs Division 230 South Street, P.O. Box 2430 's BARNSfABM Hyannis, MA 02601 Tel: 508-790-6250 MASS. 0,19. .0 Fax: 508-778-2412 Jack Gillis ' Supervisor TO: Christina Kuchinski FROM: Jack Gillis SUBJECT: Marcia Andrews - Ordinances#40249 and#40250 DATE: September 9, 1996 Attached is a copy of a letter from the DA's Office regarding the above ordinance citations. Please send is a written narrative of the facts and we will forward them to the Assistant District Attorney. Any questions,please call. I TOWN OF BARNSTABLE Ltd+ iOtd .� �f/C A e R.S WA;/ SEWAGE # ! 7 I VILLAGE 11V AAlAl%S ASSESSOR'S MAP&LOT a71 - 190 INSTALLER'S NAME&PHONE NO—Te M A C O A4 I6eX 4 S60- 77J-- 3338` i SEPTIC TANK CAPAC= A 0 LEACHING FACU rrY: (type).(type) .# ec h A K G eif S(size) 310 NO.OF BEDROOMS BUILDER OR OWNER 1 PERMTTDATE: -�i—cOMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility r eet 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 Q60, � � o "INSPtCTION DATE/TIME: M/P # 1 .. No..�✓ 5 Fss.......5 0..0 0._ THE COMMONWEALTH OF MASSACHusETTS BOARD OF HEALTH •••---...TOWN ' B.. n s't:atb'1 e-----------•.............••...•••••- Appliration for Disposal Works Tonstrurtion Vrruti# Application is hereby made for a Permit to Construct ( ) or Upgrade (ggg ) an Individual Sewage Disposal S stem at: Pitc hers Way Hyannis ,Mass . ....... ..___...._.........................•........--•---------•••••......-•-•--.•-_... .........-•••••-•.....--•-••-•-...•••-•--•••-••-••••••---.......•-•---.....................•-•-... Location-Address or Lot No. � t y MacArtur Owner Address. ................................ Installer Address Type of Building Size Lot............................Sq. feet V Dwellings*No. of Bedrooms.........4.............. .....Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of persons............................ Showers — Cafeteria Q, Other fixtures .................................. W Design Flow.....44q..............................gallons per person per day. Total daily flow..4Xi.1Q............................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................. Diameter.----........... Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below,inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ........... ------------•--------•----------------------------------•-----•--•--------•---....-----......--------------•-•-............•........... 0 Descri tion Qf'Soil................................ . . .. vMem...iu sand to fine sand ............................................................... W N ,. = .•°... ---•---------------------•--•------•-----••••----------•-----•--•••-••-----•----••---•--••---------•••-----••----••-••--------------•---•----....-•---..................._......... U re of.Alterations ———— Answer when applicable-•4--3.3-0---z ult-e.c....racha.r-g-ex-a..-----•---•--••--••••-•--. = '----•-•--•-•--••--•----•---•-•------•---------•-•----••--------•..............•-----•-••-•---------•-------•--------- .....---•j 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 Complia ce has be i eddbb the bo d of h Ith. " .. .- G- C .Signe �" .. 5/14/9 7 Date PP PP Y ....... ......... .... ................. j Li'----�C- 7 A lication A roved B Date Application Disapproved for the following reasons- ------ -- ------------------------------------------------------------------- ---------- -------------------- --------------- .......................................................................................... ....................................... .......... ............................... .................... ...................................... �7 Date PermitNo- ------ ----- —.. .....�-2---�--------.... Issued ....---------------------------...------....------.-------------- Date IN5F'�CTION DATE/TIME: '�, _ M/P # No...l..l.'..t 5 Fim..$ 0.........5... THE COMMONWEALTH OF MASSACHUSETTS BOARD Or H EA H TOWN ........................-------*.-----....OF.........'s �. . ..:, .. '.. .... ............_._..._.........__...._..-- Appliratiun fnr Disposal Works Tonstrurttun Frrutit Application is hereby made for a Permit to Construct ( ) or Upgrade (XXX ) an Individual Sewage Disposal System at: 69 Pitchers Way Hyannis,Mass . .._...__...------- - .............. ................•-•-----------•---......-•_. ..........-----....-----......____....... 'MAy MacArtmrcation-Address or rot No.D - ..»................... ............................................ ......_.._....._.........»..... Owner S ' s Address --••..............•--_....:----..........---•---......................._•-•--•- Installer Address Type of Building Size Lot.............................Sq. feet Dwellinj� No. of Bedrooms____.__.4.................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) C4 Other fixtures ...................................................... W Design Flow.....AAO..............................gallons per person per day. Total daily flow_.420.1.�. ...........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. 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........................ fz, Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water..................r_... x ODescri tiorl�of Soil.................................................................................................................................................................1-••-•- W MedpiAm ;sand to fine sand ` • - •---------------•-----------------------------------•------- -------------------------------------------------------•---------------- ---------------- W ................. U Nature of Alterations ———— Answer when applicable--4 33.0--_Galt_er__-rah+har•crareq_•_______________•••••••. .. 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. / igned -.... r,� ......�' t ..... .......� .......... ....5/ 4/97 - -------------------------- Dare Application Approved By -------------�_ _ � c - - ------...---------...--------------------...----.........-------- 5 .-.. ..... Date Application Disapproved for the following reasons: ........................................... ------------------------------ . GJ �-7 —, Date Permit No. / 7.........�.:�...,�.................. ` Issued r Date THE COMMONWEALTH OF MASSACHUSET`rS BOARD OF HEALTH a� TOWN OF l' �_ l� J� ............................................... ......--...--.5.? y �.. -. .-.. ;:4..............-..........-........--.. �el`#i�i�tt#E o��(�ulctt�Cittxcce . THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or upgraded ( ) by ..J.P.l�ia c.o.m e r---&---.S.o.n.--.Inc---- .........................................-----.............------------------------------------.. .............................................----- O Pitchers Way Hyannis l. at .- - - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- has(fee installed in accordance witWthe provisions of TITLE 5 of�The State Environmental Code as described in the application for Disposal Works-Construction Permit No. ......77...... :.7 dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................... .... ..... ...L4......... .....t�... Inspector ----._�:..:.....,....... ---�.................................................. - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF..........Z a q / 7 �. .......................................... .......................................... 50-00 No.;...,...:........ .:. 1 FEE....................... Disposal Worho Tunsirurtion Vprrutit Permission is hereby granted..J.•P.M e o mb�r---R._•• ox�---Inc•4-----•---•..........................................................__. to Con st�r ) or Upgrad<, XX.f) an Individual Sewage Disposal System � uu, Pitchers ..play N� annis --•-•------- at No.. Jv. ............:_.-•-•••- -- ............................ P i Street as shown on the application for Disposal Works Construction Permit No---- 3 S___ Dated.......................................... gr........................ , .. Board of Health DATE.-•---•--•-- ) -.__._.J......-••-••••----•-••---------------- Revised 7.20.94 TOWN OF BARNSTABLE __ LOCATION; /rG A e RS U/A v SEWAGE # VILLAGE_' V.QNi1/%S T r� ASSESSOR'S MAP& LOT a�71 - 18D INSTALLERS.NAME&PHONE NO. •ry .�vl A r p,t t .R 4 SQ,y 7�� 33 38' SEPTIC TANK.CAPACITY A O a D L EACHWG FACII.TTY: (type) size 3 SQ NO,OF BEDROOMS BUILDER OR OWNER PERMTTDAT'E COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water-Supply Well and Leaching Facility (If any wells exist on site or witliin 200 feet of leaching facility) Feet Edge of Wedind.and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet - Furnished by 0 \ � 14 Xj Qj .14 CERTIFICATION Or S`KETCII AND APPLICA'1'10N FOR A DISK, . WORKS CONSTRUCTION PLR-MIT MI` HOU'I' DESIGNED PLANS) 1, Joseph P. Macomber_ Jr.. 111;1t tltc application for disposal works construction permit signed by my d:::ted _�1�1/�� , concerning the Pro ert located at�39 Pitchers Way Hyannis meets all of the P Y following criteria: • There are no wetlands Within 3GU fc..t of the proposed septic system • Thcre are no private %yells within 13U feet of[lic proposed septic system • The observed groundwater table 4 ftct Or greater below thu bottom of the leaching facility There is no increase in llow and/or ch;nigc in use proposed • There are no variances requested or uccdcd. SIGNED : 1 r DATE: 5/14/97 LICE D SEPTIC SYSTEPA INSTALLER IN'IT LE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed s)s;cm. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. a Tfi +t J �� t � ,4 l r T�wK 6� '`aaPV�sT�D�`Q u � COMMONWEALTH OF MA,�SACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTKP,NT OF ENvmoNMENTAL PROTECTION ONE WINTER STREET,BOSTON MA 02108 (617)"2-5500 TRUD'i WXE 8ietstary ARCrZ0 PAUL CELLUCCI DAVID B.V..MUHS Go.arno, ComsD:issiotru fi:uewRFACE SIEWAGE DISPOM S1/sTESiI INSPECTWN fnnM PART A GM7i1G1T101it J, �j PteDarbAdAaaa: �•3'qt wP.��`.c�! Wa�c Nan+.crow+~. �� Q.L1n �c�•c,a{�'�.vr b\kCx NV!--5 0%fQ S Add mes of 0 -no:_ .1m �1.k9s l Dift art fatapee'-A N 6 l301 l�f`l choral wC��tEE �t�ay.w�S M"s emiop l none sc hopeeissr:fPMsaaa Prkse) I sea s D!epprstred sYaMrrr irsipactor p rousba as U pd, r 15.340 of'tide 5(310 CMR 15.000) MGM"Addiftew. am on Tate WW 1111hrA or: sm WF' ors.M041 I eoMy that I have,personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and eawnpiets as of the time of inspection. The Inspection was performed based on my training and experience In the proper function and maintenance of on•stte sewage dispoul aysams. The system: Passel Conditionally Pubes Nosds Furthar Ev slustion By the Local Approving Authority Falls IsnpscRor's ll�navra: Alt Dsr1e: The$,totem Inspector shut submit a cope of this inspection report to the Approving Authority Idoard of health or DEPYwitlrin.thirty(301 days of eonosting this inspection. if the system Is s shared system at has a design flow of 10,000 gpd or Waster,the Inspector and the systern owner chap submit the report to tin approprNM re 10"off c*of the Department of Eriviron mental Protection. The original should be sent to the system owner and copies sent to the buyer,if 000C81bfe.end the approving&M-10rity. NOTES AND COMMENTS 3 g ti ti 2d301i1Tt13i1 is 31AylM:10001 ( 666t 6 n C �' . �3�M revised 9/2/98 Pop t of it P%ntW on RwycW P@W r . t SUBSURFACE SEWAGE plipOAAL SYSTEM MPECT10M FORM PART A Ci1111EICATIOM(oarrlbu" o �terr Dow 4 BIISPE Pro SINEWY- Greet A, it A. lIYSTi1111111 PABM: I have not found any informatha indicates fly of the failure conditions described in 310 CMR 16.303 exist. Any faikue crlteria flat ovskoted an claw. COBH�fTs: -- —Z __� L VYSTW C0II10fT1pMAiL4Y PAB'M: One or more system components as described in the"Conditional Paso"section need to be replaced or repaired. The system, uo.on completion of the roplacemem sir repair,as approved by the Board of Health, will pass. indceto yes,no, or not determined(Y.Al..or MO). Describe bash of dotemminsoon in all instances. if"FS t dstwmined",explain why not. The septic tank Is nwntal,uNess fits owner or cporstor has provided the system in whh a copy of a CertMcate+sf Compganeo Isttschedl Indicating that the tank was installed within twenty(20) prior to tits dato of the inspoodon;or the septic tank,whoilser or not metal,is crooked.structurally unsound,shows storrdol infiltration or oxflkradon, or tank faikue Is imminent. ''he system wig pass inspoetion If the existing septic is replaced with a complyWo septic tonic as approved by the Basalt of Moolth. Sewage backup or brieskout or high"We water ry Ia seed in the distribution box is due to broken or obstructed pipets) or due to a broken,added or uneven distr)butl x. The oystom will pass Inspection if(with approval of the Board srf Health). br.*on pipelal ere od alistruetion a ran dliatribudan bo Isvamed or replaoed The system rerauind more than four limos s year d+hs to broken or obstructed pleats). f10 system will peas inapecom if(with sp wo of the Board of Health): br sn pi WSJ an repNrced etruetion Is removed revised 9/2/98 Pegesori� SUBSURFACE SEWAGE OIS►OSAL SYSTEM POKCTWN FORM PART A CM I WVLA I MM(aeMm uad) Oanse~ Aar C. FUJRTH61 E1IALtDAT10N•11010110 BY THE BOARD OF HEALTH: Condlyons exist wMch require further evaluation by this$amd of Health In order rm na kf�1i system Is f@Mng to protect the publk hedth,ssfh"and the�rrkanment. 11 SYSTM WILL PASS UNLESS IOARO OF HEALTH A4=OIIOANCE WITH 310 CUR 16.303(1Xb)THAT THE 8116TEM IS NOT FU NCTUONiNO N A Wilmot WIMCH WS.L PRO THE PUSLiC HEALTH AND SAFETY AND THE MANS T: Coespeet or privy Is erf""60 feet of a water Cesspool or privy is witMn 60 a bordering vegetated wetland or a salt marsh. I 211 SYSTEM WELL FAIL UNLESS THE BOARD OF HEALTH 1AND PUBLIC YUATEA SUP►LIMM.IF ANY NS THAT THE SYSTEM 16 FURrCT1DNNNA IN A MAWM'IHAT PNDTECTB THE PUBLIC HEALTH AND SAFETY A MOIINI®MT; The system has a septic tank and soli absorption system(SAIS)an SAS is wiftn 100 fast of a surface wafer supl;dy or tributary to a surface crater supply. The system has a ee;tic tank and soli absorption system the SAS is wittiin a Zone I of a public water supply wall. The system has a soptle tank end soli absorption s and the SAS Is wttNn 60 feet of a private water supply well. The system has a*slide tank and coil sbsorptie tam Ion th end the SAS Is Ioen 100 feet but 50 feat or more from s private water supply wall,unless a well w slyds for ccd)orm becterls and voieft organic compounds indicates teat the well is lrso from pope lion from 4Mt faoi and ft presence of ammonia nitrogen and nitrate nitrogen is equal to or kas than 6 ppm. Method used to dater distance (spproairnodon not va6d1. 3) OTHER revised 9/2/98 ftr3at11 a WWSUMACE WWA"CWPOSAL SYSTW VWKCTM POW PART A C1111TVICAT110N iaorMtsnradl 11►AMA ra DI 10100108610" 6 a� o. J;TSTSM witu: t You imaret indieats either"Yes"or"Aio" in aach of the following: _ i have detarmir"that one or -Pre*of the following failure conditions exist as described in 310 CMA 16.303. The basis for thin determination is identiflod belovr. The loud of Health should be contacted to determine what will be necessary to correct the tynlure, Yas No Backup of sewago Inds facility or system component due to an dad or clogged SAS or cesspool. _.. Discharge or pondint of effluent to the surface of nd or surface waters due to an overloaded or clogged SAS or d eeaspool Static squid level in the distribution box audat invert-due to an overloaded or clogged SAS or cesspool. e, Liquid depth in uteaprtol is lass than " below invert or aveilabla volume is{ass than 1t2 day flow. _ Required pumping rm)rs than A "*a in the last year IM due to clogged or obstructed pipeisl. Number of!Mies puniped .... _ Any portion of the Errs on Systam,cesspool or privy is below the high groundwater elevation. Any portion of a ee ar p vy is within 100 fleet of a sui�i*cs water supply or tributary to s surface water supply- Any portion of a ovi,pool or privy Is within a Zone{of a puk4le was. Any portion a cesspool or privy is within$O fast cf a private water supply wall. Any of a cesspool or privy Is less-dian 100 feet but !,treater than S0 feet from a private water supply well with no we a water quaiky orWyels. if the wall has been analyted to be occeptabie. attach copy of well water analysis lot calf bacteria,volulle orgenic compounds.anrmonle nitragen and nitrate nitrogen. E. IAJI E SYSISM PALS: You must indicata either"Yee" or'NO" to each of the following: The following erkerla apply to large systems in adati the crkoria*bow: The system serval a facility with a design flo 10.000 gpd or greeter(large System)and the system Is a signifieent threat to pubic hoakh and so"and the environment bee is one or more of the following conditions exist: Yes he the system is within, test of a surfeeo drinking wow supply M the system is wi :100 feet of a tributary to a surface drinking water supply the syagm Is W in a nitrogen saneNve was(Interim Walhaod Protection Ame=fWPA)or a mopped Zone of of a public wow wall The leveller or operator y such•ystr n1 shad upgrade die system in soeerdariea with 310 CMR 1 b.30lt21. Pleas eorwult the local re1iorud offias of tin fuNiar Wnftla'"atIon• reprised 9/2/98 fraertl A OI POM SYSTBA 11113PECT10N FOAM f�liBSlJ11FACE SEWAGE PART 0 CHBCKLMY o nw G V) V dMAMP VJ O.Ia of tnapacfiae. b (;Lot tM 1 Check.it the following haw been done.You must Indicate either "Yes" or "No" tee to each of the following: Y No 1 pumping Information was provided by the owner,occupant.or Board of Health. Nano of the system components hew been pumped for at least two weeks and the system has been rocaMne namat''ioa rates du►Mrg that perkd. Large volumes of water have not boon Introduced into the system recently ter as part of this Impectlon. r As built plans have boon obtek►ed and saamined. "a if they we not available with NIA. The fscgky or dwellimli was inspected for signs of sewage bask-up. _ The system does not fecaiw non•senkary or industrial waste flow. The eke was Inspected for signs of breakout. AN systanm COMM neMe,excluding the Soil Absorption Systern, have been located on the tile. The septic tank menholes ware uncovered,opened,and the interior of the septic tank was inspected for condition of biMlas or test, material of oe!tstructloa,dimensions,depth of liquid.depth of sludge, depth of scum. The site and location-nf the Boll Absorption System on the site,has been determined based on: Exi idng kNormation. f or example, Plan at B.C.H. _ Detwmined in the flokl Of any of the failure criteria related to Part C is at issue,epproxlmatlon of distance is unacceptalAe) 116.3024011 The facility owner Iwrf occupants.11 diffwent from owner)were provided with information on tM proper maintenance of "Surface Disposal ty terns. revised 9/2/98 Post lof11 :i,,N URFACE SEWAGE DapOSAL SYSTM INSPECTION FORM 'ART C . stsTN�NN INPORNNATtoN Pyepwtr 4tt ow�ar : r Nlwt of 11-1 i+1•� aow cow o�u Ilow: g.p•d.lbadroom. NumbrM of dssIP):—Y— Nambor of bedroams(ec"):7 TOW DESKMI Sear Nurnbor of currant residarKa: OEM gib(Yoe or no): Laundry(sepsnabs syatam) (ram at no):J& tf yes,sspersto inaptaflon�7�d Loun*,y try*Inspected or not Y' aeesansl use Iyes or no):_ _ g , Water metar readWV.S pest t%Vo year's us"*(opol: 6�unp Purrs(Vas or no): Lest deb of oaoupnaner ' Type 44 sotsmishment: Design gow: and (eased c 031 gaols of dedgn flow --._--- - arm,)trap present:lyes or rte) Industrial WMta Hahne Ter* sent:1paa at nol_ Non.au wy waste dlecher to the TRIP 6 system:(rss or no)— Water meter rsed)ngs.H ------ Lost date of eeauperie OTHNR:(Dese `.est data of Y: 09121At E040IIMAT10N1 PUNAFUA R®OOW"end System pumgd e. ast a bap on:( a<na1_,, 1 M yes,volume pumped: Selbnt i Roston for pumping: TYIPMOVS1 Sapda uMddlatrl3 den boated absorpdon syetem SMplo oesepod O"tow oetspool _ pAvy _ Shared system(res ar not (if Its,susch previous lnspsedon records.N my) _ IIA Toohna off ate.Attach copy of up to date operaftri and mdntsnence contract Tight Tank Copy of Dili►Approval Other ApppOX"ATE AOE of ag components, :kits in"ed(if known)end souroo of InfactnethM t �rsAa edam detested when srNeAng st tla alto:het or not revised 9/2/98 PaN.boftl JAWWRfACE UWA"DMPOSAI SYSTEM NSPECTIM FORM PART C SYSTM geFORMATm las nrimsedl Ortnar« OTC.. J f Dnl.e(I bwroef� b leg[�tq lLocots on also pion) Depth balow psde:,E Mot rkil of construction:—Cart Ira►'NO PVC r oiler loxpleini Distance"rive"water supply won im,suction Ina DWMW at Cormnomte:lcondtlon of Joints•veMktg, evidence of look"*,ate.) arm TA1U• . docete on dta pion) Depth blow ro".A Motarktl of constructlon:Aconcroto—riotsl—Fiberolass _Polysthylons_othoriexpfoln) Of tank Is metal,Eat age_ Is age confrmod by Cortifreate of Compliance (YsslNol Oinreratlens: „ Studo depth: A Distance from top of Id"to bottom of outlet tas or baMe: Scum thickness:_ Dkrtarete from top of scum to to of outlet tee or boffle: / DknaMIS from bottom of sown to bo1wof WAN t tow dimensions were dole nlnediCS Comments: (recornmondatlon for pumping, on a at toes or baffles.d 1 of(iqui av In rol 'on to outlet' ,Mail into 'ty, evidence of looks", .) Ar i e4s L— Aid tie GFAA E TRAP: (looeta an dh phn) Depth below rode:l Material of aonatruetlon:__eo ncrow lnnetai_11borgloss _POIYethylerw_othor(e n) okmenelorno: -- Sw on ddaknea: Dkntaaoo from top of oaum to top of w&t me or baffle: Distance from bottom of sewn to bottom of outlet tee o►bafflo: Date rnf lest pun"*: Comments: (reeesnrrarndetlen fta pumping. Condition of met and at teas or baffles,deptlh of liquid level in reletlon to outlet ktvet,struCtwd Int101014, evidence of leakage,on.) rev-_sed 9/2/98 hp7ofIt $tJSSLMACE UWA®E DISPOSAL SYSTDA WSPECTM FORM PART C SYSIM MPOWSATION foo manse Dao.of 61ag TltMfil OR HOISIMO TAUK: (Tar4c must be pumped Prim to, or at time of., InePOCOM) floss"on a"pia) *so below pods:..° Mstsrid of construction!., comrsto,_!nstd ,Flimeplass_pal one,othw(exptain) , Capacity: S Dedpa flow: Sallonslday Awn present Atom,Mvd: Ahrm In workiftl :Yea_ No_ Dots of preNome Pumpirq: Corrrmanta: (amw9kion of host tea.eondlthm nr and float switches,etc.) OMTI�tf'f>>mM 11100t� "come on sits plan) Depth of pqui0 tors)show eudst inwR: Cww ff Com1w : (ews� d distribution is equal, ev donee of solids ar ver,a�denes of id Into or out o4 X.sta.9 sv +�I Iw• '��X lV ��l C M� tom,l O PUr►ClMfwfBls Ooosma an oft plan) PW%*in workkq order Idea at Nol,__ Alarms in workWq order(Yes Of NO)___ (rwta condi4la►of purnp chamber,eon*-Ion of pumps a murtsnances,ate.) revised 9/2/98 �of1� I f,U'KURFACE SEWAGE 01SPOSAI SYSTEM NSPECTION FORM PART C SYSTE111111 NPOMAATM loanlirwdl Owner: 1r +�-1� td r Does of' b��O�� )locate on aita plan,if posslbls;excavation not squired, location may be approximawd by non-)ntnulve methodal R not located,explNn: Type: IaaeNn0 Gig.nurt*er:_ load**cowl on,rurmbar: , tescli tg 1 o"O. a,m+iMer'— lose**vatolrs,number.l.ngtt,: hioOft 11",number.dkn wwicos:_•,-, overflow oesapool,rombw:—. Almonedve system: Nome of Teohrwh Y: , Comments: (note conAWon of*W sl f level of ryo damp soft, condition of vegetation, ste.) Cam' jOn \ �_ IMSS, UMS: pooste at site plan) Number and eenflgurOtlon:.,�,_._. ,apth•top of Equid to ktla invent:,,_.,,. ape of sOMds,layar• -- - Oeptlh of statrtt lays: Olmatalons of cesspool; Materials of oonstruetlon, Indioallon of grourufwratp: Inflow loaaapoel nwst p�!ij as pert of inepection) - Co nrnunts, inote c:ondMon Of sell,signs of hydraulk 1;snurs,level Of portding, condition of vegetation. Orel PIMVY:. iloOate on ske plan) Matainls of won pin w"dons: Depth of a kb' Carwnartts: (mote c orA*m of @a, of hydraulic Impure,I"of pondlrtl0,condition of wjetation,ete.l revised 9/2/99 r - :NMUriFACE•&WAGE OMPOSAI SYSTEM WOIPECTHM FORM PART C SYSTEM RM4)RMATM �-:: Irta.�. �I►�r SWCH OF$WAGE OsroaAL SYS I fil. k eWde tlos to at least two pormsnent reference landmarks or bonohmarks kioats an woK within 100' iloente whore pubk wow supply comes into house? II r � r� revised 9/2/98 Par 1oof 11 SUSSURPACE SEWAGE DISPO"L STSUFA NSrECTlt31o!FOM PORT C SYSTM"Wom"TgM loond nr.df Omm D.s et lleame ftr►: MRCS Report TTPIsd depth to USGS Dees webafte visited Observallon Wells checked Groundwater depth: Shallow_,.._ Moderate _._Deep___ SITE EXAM $Iolw Surface water Check Cellar Shallow walls I Eetimsted Depth to Groundwater 1a Feat Please indleato all the methods used to dutormins High Groundwater Elevation: Vlrtdnod from Design Plans on record Observed Site(Abutting property,observation halt, basement sump etc.) Detseminod from Food conditions Checked with local Soa►d of health Cracked FEMA Maps CMeked pumping records Checked local excavators,instdiers Used USGS Date Describe how you estoWishad tho Nigh Gniundwater Elevation.(Ma be competed) 0.v�a,r pep11of11 revised 9/2/98 LOtCATION SEWAGE PERMIT NO. -VILLAGE INS LLER'S NAME & ADDRESS re B UiI*L D E. R OR �OWNER DATE PERMIT ISSUED 3 15' - 77 DA E COMPLIANCE ED T NCE ISSU = 7`7 k G�l - 0 O THE COMMONWEALTH OF MASSACHUSETTS BOARD )DF HEZAT .....7Z, .....OF... ..... ..................... T1//0 -------------- Applicatio, is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal Syst �_�St X7`1 Location�-�jd" s or Lq� No. ow Addres Type of Building Size Lot_.Za. feet Z Other Distribution box 0 -------yo. ----------------------------------- The undersigned agrees to install the aforcdescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Co.mpliance has bep issued by,the board of eaI Date --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date _ Permit Issued........................................................ � Date ` � No.--- -7 ...... .............................. f THE COMMONWEALTH OF MASSACHUSETTS 77 BOARD,h O F HEAP H Appliration -fur Di-quaiia1 Works C-owitrurtion Van it Application is hereby'made for a Permit to Construct :(. or Repair ( ) an Individual Sewage Disposal System at: _ ,y - . / � -»�.,�;� - fir` --�� r��-�-rr��-r.•,��t✓.,�._. Location.Add / or Lot No r /r sss �r Jr / i � _•,� --------- ----- -- Owner'' t �✓ /r Address�� W t . _A / yam.+( /f..... _ ----------- Installer � Address _ d Type of Building Size Lot-./'da_�.____ - feet U Dwelling—No. of Bedrooms__________________________________________Expansion Attic ( ) Garb_age Grinder ( ) Other—Type T e of Building ----------------- G, YP g ----------- No. of persons.------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures --•--•'" ':''`-----`--•------•--------- --..-"-•-•---•---------------------------•--•-• ---- ---- ----•-------------••-• ---- Desi n Flow............ :� P P P Y• Y - --------------gallons. WSeptic Tcuik—Liquid capacit if. Length---------------- Width................ Diameter__.--....__-_._ Depth.-..-__-._----- x Disposal Trench—No.�.�..._..��..., W y---.-- _ Tota-L°Lennth-.--___---.-_-_--. dal leaching area-.----.- _sq. ft. Seepage Pit No._��- ---- Diameters__.: i1.elrr area. ._ sc it / y g< 1. z Other Distribution box ( ) Dosing tank ( ) a_ ,i 2. - 77. aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---•----------------------------------- ,� Test Pit No. I----------------minutes per inch Depth of 'Pest Pit.................... Depth to ground water..___-__.-_-..--.--_- Grq Test Pit No. 2................minutes per inch Depth of Test Pit.--_----______------ Depth to ground water--.--.--------.____-... t� _ -----------. D Description of Soil �� `' �� ' �` x �-� � - cry 'i-- �4 ?. .. -- --------------------- ----------�------------------------ w UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ----------------------------------------------------•-----•---------•------------....----------------------------------------........................ -----------------------------•--•---•---------------------•-•------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by-the/,board/of healtl�Y. �, Sign �.------ I. G.' /1- '� � -- _ Date Application Approved BY r-�' (",./ L�1�1 -------------•-- . ---�...�...�.5...^_�. ._... �1�� 7' Date Application Disapproved for the following reasons--------------------------------------------------------------------------------------------.................... ..........................--------------------------------------- -------------------------•--------------------------------'----------------------------------------------------- -----------......... Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS �^ BOARD OF HEALTH a- .......... i�/�r..� ^. O F...... ............. .......... Uprrtifiratr of T"Tainjilitturr ---� THISLS-TO CERTIFY, That the Individual Sewage Disposal System constructed ( ' or Repaired ( ) by............ ►- � c-=-= � 't' 'f In tau r -- . . •---- ------•-•-••. ---- . •• ---- - �.r'..... has been installed in accordance with the provisions of Arti ehI of The State anitary Code as described in the application for Disposal Works Construction Permit ______________ dated....3-- .15-�_...................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE dONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----------.A./.g7............J_-.. ........... Inspector...... - ---------------------•---•-- THE COMMONWEALTH OF MASSACHUSETTS - -: BOARD OF, HEALTHY•- -71 N .._._._..7 ....----- FEE---...-...-----------•- in > ttl1 -0 rk ii. ( 0wrurttoitrr�tit Permission is hereby"granted........ ��. � - ------t 1•��--4c��._.`f`-�`*� __ y --- - = --------- ---------------------------- -- , to Construct(', or Repair ( )-an Individual Sewage Dis oral System- at No.......= ` ...._.� ^' .'c.-� , �,e t-- -- .r -.G9 f -. -Y• j r: ----•---• •---------• ............... /' _ as shown' on the application for Disposal Works Construction Permit- o_______ ____________ Dated.--3'�S-__ 7 7 G % L/s� 4i d�aleli ------- Board of Healt DATE................................................................................ r. .x FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1, Y e; ri m �` w 0D-rl x o AA t) 4p. rig (t 10 (- 1 ' to w.- V D 1 i .. .1� f r r+ L ; L � - 0il z a WIT .n o PI Z I �► • o � ram! TC" W19 z w IT, d V �' rig y