The URL can be used to link to this page

Home My WebLink About0191 BAY STREET - Health 191 BAY STRel�TT ISTERVILLE A= « - i3 / t l I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: rim PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes �iplication for Disposal 6pstetu Construction 3pPrmit 0�� —. Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon)k4 ❑Complete System ❑Individual Components Location Address or Lot No. 9t R p7 4'� / er's Name,Address,and Tel.No. A 2L�aLy�o w 4'�' Assessor's Map/Parcel t t 77D M "v C,nl C3o1^o C� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: �Oter o.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd � Design flow provided 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 Bo d f Health. �el-1 5 0 3(,q-CO U—, Signed 1Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No.�/ s[ ' / 3 q Date Issued y` No. �4 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: POBLIC HEALTH DIVISION :-TOWN OF BARNSTABLE, MASSACHUSETTS Ys 2pplication for -Misposal 6pstrm Construction Permit Nj Application for a Permit to Construct Repair Upgrade Abandon [I Complete System ❑Ej Individual Components Location Address or Lot No.0)/ k6wner's Name,Address,and Tel.No. Assessor's Map/Parcel r-1 c--ri, Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling c.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( Cafeteria( Other Fixtures Design Flow(min.required) gpd Design flow provided 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 B�ooaZrof Health. 0 R,(0 4-(_C7, U_) Sign, Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No., / 31�;10 1 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 (!Ab5anddo7e1( )by at as'been constructed in accordance with the provisions of Title 5 and the�b)Disposal System Construction Permit NOG I L- /3 L1 dated bl�� hig, Installer Designer bedrooms Approved design flow ✓ _gpd d. I ,The issuance ofth' pe as it not be construed a guarantee that the system cti n as Li e Date I- Inspector \Ij --------------------------------------------------------------------------------------------------------------------------------------- No. �)n Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Disposal 6pstem (Construction Permit Permission is hereby granted to Construct Repair grade Abandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with ii Title 5 and the following local provisions or special conditions. Provided:Construction ust be c7 p pleted within three years of the date of this e it, Date Approved by 1 p� 2 TOWN OF BARNSTABLE LOCATION' 1011 t 1 1► 4,`j 6 'S SEWAGE # VILLAGE a O's-ri" � 1� ASSESSOR'S MAP & LOT V 7 /53 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY CZ Is ot LEACHING FACILITY: (type) as S Q60 (size) NO. OF BEDROOMS 3 BUILDER OR OWNER G�1 1 SIB I 1 PERMITDATE: COMPLIANCE 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 leachi g facility) Feet Furnished by �nS(�GGI on �Or � � � � . � � � i � O � W �� 1vo� n � _ Y'-' � � Commonwealth of Massachusetts f�� 4 Title 5 Official Inspection orm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M •'•y 191 Bay Street ; Property Address 191 Bay Street Realty Trust ' Owner Owners Name information is / required for every Osterville V MA 02655 7/31/il 5 page. City/Town State Zip Code Date of Inspection ' Inspection results must be submitted on this form. Inspection forms may n t be altered in an r•.� way. Please see completeness checklist at the end of the form. 1 y Important:When filling out forms A. General Information t on the computer, s'# 11191 use only the tab 1. Inspector. key to move your , cursor-do not James Ford use the return key. Name of Inspector Company Name - P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 Telephone Number License Number B. Certification t 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 niaintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant t6 Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fa'ils k ❑ Needs Further Eva ation by the Local Approving Authority 8/17/15 Inspecto s Signature Date The s st m inspector shall submit a copy of this inspection report to the Appr ving Authority(Board of Hea or DEP)within 30 days of completing this inspection. If the system 1 a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system ownr 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. i ""This report onlydescribes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. i r > tSlns•3n3 Title 5 Official Inspection Form:Subsurface Sdwage Disposal yS s of 17 t g Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Dis posal sposal System Form Not for Voluntary Assessments 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name £ information is r required for every Osterville MA 02655 7/31/15 page. CitylTown State Zip Code Date'of Inspection B. Certification (cont.) 3 Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: i ( I i B) System Conditionally Passes: r ❑ 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 orfrepair, 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 app loved by the Board of Health. t *A metal septic tank will pass inspection if it is structurally sound, not leaking land if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I i I i 7 t5ins•3113 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 2 of 17 a s I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4 •''� 191 Bay Street Property Address i 191 Bay Street Realty Trust Owner Owners Name R information is required for every Osterville MA 02655 7/31/I 5 page. Citylrown 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 ❑ ton 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 dist ibution 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 II Explain below): El distribution box is leveled or replaced ❑ Y ❑ N ❑ ND Explain below): s ( ❑ 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): ❑ brokenpipe(s) are re laced p ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): I ' C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health i i 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 wil 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•3/13 Title 5 Official Inspection Form:Subsurface Seage Disposal System•Page 3 of 17 t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 191 Bay Street Property Address i 191 Bay Street Realty Trust Owner Owners Name ' information is required for every Osterville MA 02655 7/31/ 5 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) i 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 Zone1 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 feel but 50 feet or more from a private water supply well"*. Method used to determine distance: 3 **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 ana nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A c'py of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: I You must indicate "Yes" or"No"to each of the following for all inspectins: Yes No ❑ ® Backup of sewage into facility or system component du to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the gr and 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 6vailable volume is less than 1/z day flow l5ins•3/13 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 4 of 17 i f pp 4 f Commonwealth of Massachusetts Title 5 Official Inspection Form nSubsurface Sewage Disposal System Form - Not for Voluntary Assessments o 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name ` information is I required for every Osterville MA 02655 7/31/h 5 page. City/Town State Zip Code Date cif Inspection B. Certification (Cont.) t Yes No f ❑ ® Required pumping more than 4 times in the last year NjOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below highground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a Jurface water supply or tributary to a surface water supply. ; I ❑ ® Any portion of a cesspool or privy is within a Zone 1 of b public well. I ❑ ® 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.I_ copy of the analysis and chain of custody must be attached to this form] ® The system is a cesspool serving a facility with a desig j flow of 2000gpd- 10,000gpd. I ❑ ® The system fails. I have determined that one or more�f the above failure criteria exist as described in 310 CMR 15.303, therefor z the system fails. The system owner should contact the Board of Health to deermine what will be necessary to correct the failure. I 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. I For large systems, you must indicate either"yes" or"no"to each of the follow ng, in addition to the questions in Section D. 4 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 (Intern Wellhead Protection Area.— IWPA)or a mapped Zone II of a f?P Y public water su I well P � 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 f system considered a significant threat under.Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I t5ins•3H3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 s Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/#15 page. City/Town State Zip Code Date df Inspection C. Checklist Check if the followinghave been done. You must indicate"yes"or"no"as to each of the following: Yes No ® Pumping information was provided by the owner, occup nt, or Board of Health ❑ ® Were any of the system components p um ped out in the Previous two weeks? ❑ ® Has the system received normal flows in the previous tw10 week period? ❑ ® Have large volumes of water been introduced to the sys lem recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examine?(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 o�scum? ❑ ® Was the facility owner(and occupants if different from o ner) provided with information on the proper maintenance of subsurface se age 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)] r D. System Information Residential Flow Conditions: ! w 3 Number of bedrooms(design): n/a Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedro ms): 330 I c, t5ins•3/13 Title 5 Official Inspection Form:SUDsunace Sewage Disposal System•Page 6 of 17 f 4 Commonwealth of Ma ssachusetts D. = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bay Street Property Address t t 191 Bay Street Realty Trust Owner Owner s Name information is required for every Osterville MA 02655 7/31 15 page. City/Town State Zip Code Date oaf Inspection D. System Information Description: t t t ( Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No t Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.). t Laundry system inspected? El Yes ® No ) Seasonal use? I ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): unavailable Detail: Sump pump? I ❑ Yes ® No ( Last date of occupancy: g unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gp�) Basis of design flow(seats/persons/sq.ft., etc.): I i s Grease trap present? ❑ Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No N I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No I Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Swage Disposal System•Page 7 of 17 I i • � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/1 5 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Last da te of occupancy/use: Date } Other(describe below): t f t General Information Pumping Records: Source of information: pumped yearly per owner I Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons C How was quantity pumped determined? Reason for pumping: t Type of System: • i I ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ® Overflow cesspool ❑ Privy i ❑ Shared system (Yes or no) (if yes, attach previous ins ectionfrecords, if any) 1. ❑ Innovative/Alternative technology. Attach a copy of the curre9t 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 f t ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): r t t5ins•3/13 Title 5 Official Inspection Form:Subsurface S ge Disposal System•Page 8 of 17 f r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 191 Bay Street Property Address o 191 Bay Street Realty Trust Owner information is Owner s Name required for every Osterville MA 02655 7/31/15 page. Cltyfrown State Zip Code Date otf Inspection D. System Information (cont.) Approximate age of all components, date installed(if known) and source of i formation: system installed - unknown # Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): 1 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): I z I Septic Tank(locate on site plan): Depth below grade: even feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylenel ®other(explain) cesspool acting as a septic tank. Made of cesspool block i ) 1 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ElNo Dimensions: i Sludge depth: Eit t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 6 t Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ••'� 191 Bay Street Property Address i 191 Bay Street Realty Trust Owner Owners Name information is Osterville required for every MA 02655 7/31/ 5 page. Citylrown State ZipCode Date o�Inspection D. System Information (cont.) Septic Tank(cont.) 1 s Distance from top of sludge to bottom of outlet tee or baffle � Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle t .How were dimensions determined? I 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 cesspool had 6"of water on the bottom. A steel cover was to grade. r t t I f I Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: f Scum thickness t Distance from top of scum to top of outlet tee or baffle t ' Distance from bottom of scum to bottom of outlet tee or baffle F { Date of last pumping: Date I x t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Seyrage Disposal System-Page 10 of 17 l+E i I t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/�5 page. Cityrrown State Zip Code Date o!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.): t Tight or Holding Tank(tank must be pumped at time of inspection) (locate c in site plan): Depth below grade: X Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): N/a i r Dimensions: Capacity: gallons � Design Flow: gallons per day !t' 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.): I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 1 I Commonwealth of Massachusetts Title 5 Official Inspection Forme. I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bay Street Property Address 191 Bay Street Realty Trust Owner information is Owners Name required for every Osterville MA 02655 7/31/ 5 page. Cityl1 own State Zip Code Date o Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): I . Depth of liquid level above outlet invert n/a t 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.): t i Pump Chamber(locate on site plan): Pumps in working order: ❑ Ys ❑ No" • Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump.chamber, condition of spumps and appurteelances, etc.): r * 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: . II Y t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sew$ga Disposal System•Page 12 of 17 i s Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bay Street Property Address 4 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/ 5 page. Ci crown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ innovative/alternative system Type/name of technology: 1 Comments (note condition of soil, signs of hydraulic failure, level of ponding, tamp soil, condition of vegetation, etc.): The overflow was 6'wx7'tx10' btg it was dry. There was no sign of failure fromcesspool. A steel cover was to grade. i I I 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 I t s Depth of scum layer Dimensions of cesspool I t i l Materials of construction , 1 Indication of groundwater inflow ❑ Y�s ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface SevIage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bay Street Property Address s 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/ 5 page. City/Town State Zip Code Date cf Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t I Privy(locate on site plan): Materials of construction: Dimensions Y Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): N/a i I ) l Y I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sage Disposal System•Page 14 of V e I i A_ _S\', Commonwealth of Massachusetts Tit le 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 191 Bay Street ; Property Address ' 191 Bay Street Realty Trust Owner Owners Name information is required for every Osterville MA 02655 7/31/15 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 1 o I I i At- -A Q I t i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Saw age Disposal System•Page 15 of 17 1 y Commonwealth of Massachusetts t t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/ 5 page. City/Town State Zip Code Date of Inspection D. Sy stem Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet { Please indicate all methods used to determine the high ground water elevatio : ❑ 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: Topo and water contours map ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed•USGS database-explain: 4 You must describe how you established the high ground water elevation: Before ;filing this Inspection i g p ton Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface See age Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yt 191 Bay Street Property Address 191 Bay Street Realty Trust Owner Owner's Name information is required for every Osterville MA 02655 7/31/15 page. Cityrrown State Zip Code Date oaf Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All System)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t _ 1 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE . OS'ITiWV }6 ASSESSOR'S MAP & LOT117 ° /53 INSTALLER'S NAME &PHONE NO. SEPTIC TANK CAPACITY _ CeISpyv i LEACHING FACILITY: (type)• CL-SS 60 1 (size) NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE! Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom ofLeaching 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 leachi g facility) Feet Furnished by L;eA e,G on -- Fpr „ i o _ ' 03 yo c�- COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF;,ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A r ..CERTIFICATION Property Address: 19) Bay Street Osterville, MA 02655 , Owner's Name: Gail Nightingale, Executor Owner's Address: Date of Inspection: November 9, 2001 Name of Inspector:(Please Print) James M. Ford Company Name: James M. Ford ` Mailing Address: P.O. Box 49 RE��V� � Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 NOV 2 .0`20�i CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this a dr&�ltbtjjiformaton reported below is true,accurate and complete as of the time of the inspection. The insptriiediaseii on my training and experience in the proper function and maintenance of on site sewage disposal systems. a DEP approved system inspector pursuant to Section'15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs; er Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: November 12, 2001 The system inspector shall su t a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 4 Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 191 Bay Street Osterville, AM Owner: Gail Nit htinizale. Executor Date of Inspection: November 9. 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 IL { Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: '791 Bay Street Osterville,MA s Owner: Gail Nikhtingale, Executor ` Date of Inspection: November 9, 2001 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 z system is not functioning in a manner which will protect public health,safety and the environment: -Cesspool or privy is within 50 feet of a surface water ` Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines,_that the system is functioning in i 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` ais within Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, .for coliform bacteria and volatile organic compounds indicates that the wellis free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,-provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form. 3. Other: - 3 r%- 4 i o- • { Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale, Executor Date of Inspection: November 9, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"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 'h day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. _ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale. Executor Date of Inspection- November 9. 2001 ` Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No s ✓ _ 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? n/a 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? F ✓ 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)].' 5 r Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale, Executor Date of Inspection: November 9, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 1999- 13,000.gals.; 2000-12,000 gals. Sump Pump(yes or no): No Last date of occupancy: Unknown CONMIERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on file-per treatment plant Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system Single cesspool ✓ Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: _Approximately 1950s-per owner Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE_ SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 191 Bay Street <s Osterville. MA Owner: Gail Nightingale, Executor Date of Inspection: November 9.-2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction'line: A Comments(on condition of joints,venting,evidence of leakage,etc.): - SEPTIC TANK: ✓ (locate on site plan) Cesspool acting as a septic tank Depth below grade: To grade Material of construction: _concrete metal- fiberglass _polyethylene Y ✓ other(explain) cesspool block If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 6'W x 7'T x 10'bottom to grade Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: " Scum thickness: 0" Distance from top of scum to top of outlet tee or baffle:, -- Distance from bottom of scum to bottom of outlet tee or baffle. -- How were dimensions determined: Measuring 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.): The cesspool was dry No outlet tee was present The cover was to grade. GREASE TRAP: None (locate on site plan) Depth below grade: T 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): a 7 Page 8 of 11 a OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale, Executor Date of Inspection: November 9. 2001 TIGHT or HOLDING TANK: None (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) Depth of liquid level above 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.): PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale, Executor Date of Inspection: November 9, 2001 E 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: leaching trenches,number,length: leaching fields,number,dimensions: ✓ overflow cesspool,number: 1 , - Innovativelalternative system Type/name'oftechnology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): G The overflow cesspool was dry The scum line was 2'up from the bottom. There were no signs of failure, The bottom to grade was 10' The cover was to grade CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan), Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: - Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of poriding,condition of vegetation,etc.): PRIVY: None (locate on site plan) -- Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale, Executor Date of Inspection: November 9. 2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 0 �I 5� C�- B A ' ` A;L- yo 10 i Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM:INFORMATION(continued) Property Address: 191 Bay Street Osterville, MA Owner: Gail Nightingale; Executor _. Date of Inspection: November 9, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 14'+/ 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: x Checked with local excavators,installers (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: The bottom of the overflow cesspool to grade was approximately 10'. Hand augered down 4'on the bottom of the cesspool to Around water, which was 14'below grade. There is no high mround water adiustment for this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a . warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 . 1� O O � � o 1 c � 3 2 r, 09-07-2001 11:33AII CENT 05T F, KEPT 5087902:38.5 P.02" �� )5 Make application to focal Fire Department. �� r? Fire Department retain(original application and issues duplicate as Per , S I KV APPLICATION and PERMIT for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMA 9.00, application is hereby made by. Tank Owner Name(please print) Mr & Mrs Nightingale X Address 32 _Sset Lane nstpvi t tQ MA 02655 5111" cxr sue. "Zb Company Name Enviro-Safe Co.of Individual Emriro-Safe AW PM1 Address P•0:BOX 810, E.Sandwich, Address P_ 0. Bn �x 810 ;�-Sanaiaich,,11A-1112W Signature i ying forperm�) �natu , h�i g or rrn4) i j _ 0 iFCI Certified Qther O IFCI Certified 0 LSP# Other Tank Locatien 191 Ba7 Street _ Ostervi.11e _ &oWAdCw9s CRY — Tank Capacity(gallons) 500 _ Substance Last Stored heating o i 1 Tank Dimensions(diameter x length) Remarks! AA ZIL R Z Ian ;_�-b - l Firm transporting waste - Bnviro=safe �StateUc.#,- 329 MA Hazardous waste manifest# MAK 772515 EP,A.# MAD985269323 Approved tank disposal yard Turner Salvage Tank yard# 002 Type*finert gas Tankyardaddress 235 Commercial Street Lynn, MA PCity or Town Osterville F0100 01920 _Permit# T Dale of issue July 9 2001 Date of expiration July 15, 2001 aver 3 o 1/13 - Dig safe approval number.' Dig Safe Toil Free Tel.Number-800-322-48" Signature 17,118 of Officer granting permit T - After removal(s).send Form Ft'-290R'slgned by Local Fire Dept.to UST Regulatory Compliance unit.One Ashburton Place, Room 1310.Boston,MA 02108-1618._ TOTAL P.02