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0118 BRIDGE STREET - Health
118 Bridge Street Osterville A= 093-032 5 M E A 6 No.2-153LON UPC 12134 ,OqmQL M �O �I�Mt�I�IRTiM IR � 3/air // � ,, cv AFFIDAVIT 1. I, Anne T. Moran, am the present owner of 118 Bridge Street, Osterville,MA. 2. 1 purchased the premises on or about June'30, 2005. Pursuant to the purchase of the premises, I was given a.copy of a so-called Title 5 Subsurface Sewage Disposal System Form, a copy of which is annexed hereto marked "A° and incorporated herein by reference. 3. You will note that the system was passed by the inspector, Robert J. Bortolotti of Bortolotti Construction, Inc. on May 2, 2005. 4. 1 relied on this inspection when I purchased the property as the number of allowable bedrooms (4).. Signed under the pains and penalties of perjury this day of,2019: Anne T. Moran COMMO EALTH OF MASSAC ETTS On.this day of , 2019, before me; the undersigned notary public, Anne T. Moran, personally appeared, proved to me through satisfactory evidence of identification, which was a Driver's License, to be the person whose name is signed on the - preceding or attached document, and acknowledged to me that she signed it voluntarily for its stated purpose. Notary Public: My Commission State of Fl Ida Expires: N;LOO-) County o The foregoingiastraMUt was akao iedged More sae _ _day ofy1 — -�-- ;:iai au JACK RANCE n� wito Notary Public-State of Florida Commission#GG 304470 is�rsonaii� known to me oT who Iles produced - , o���' My Comm.Expires Mar 3,2023 { Bonded through National Notary Assn, bCYP dentif°9cation 4 Wianno Avenue Osterville, MA 02655 508.420-1130 Donald Desmaris Town of Barnstable Health Department Hyannis, MA April 10.2019 Dear Don, I'm just following up on our conversation of March 29, 2019 concerning the property at 118 Bridge Street,Osterville.You stated and it is my understanding that the Health Dept. has now made an exception and has cited this property as compliant as a 4 bedroom home. I am attaching an affidavit signed by the current owner that when she purchased the home in 2005 she had depended on the Passing Title V report that stated it as a 4 bedroom home. We appreciate your attention in this matter. Sincerely, Maureen Carven, KilningGroverSalesagent Commonwealth of Massachusetts �s Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street , Property Address Anne T. Morgan Owner Owner's Name *? information is Osterville Ma 02655 3-25-19 required for every -• page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return key. Company Name 374 Route 130 ca Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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: 1. ❑■ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey ON: -W, ��...�.IUS�.o7«,..aa�����12 3-25-19 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 form 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. l5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v t 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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: > a.4 , , .._ d ❑■ 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 was in working order at the time of inspection. No system design plans were available at the local Board of Health. The dwelling has a garbage disposal and it is recommended the grinder be removed to prolong the life of the SAS. 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): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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: t5insp.doc•rev.7/26/2019 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r ' I c Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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 ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street u Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ O 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 '/2 day flow ❑ 0 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. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ a Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El 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.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ El 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 t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form I°1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every gage. 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"to any question 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 ❑ 0 Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? ❑ El 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? ❑ ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ E] Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? n ❑ Were all system components, excluding the SAS, located on site? E _ ❑ 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? ❑ 0 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: ❑ El Existing information. For example, a plan at the Board of Health. 0 ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: No design plans 4 Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA Description: 0 Number of current residents: Does residence have a garbage grinder? Yes ❑ 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 No information in this report.) Laundry system inspected? ❑ Yes No Seasonaluse? ❑ Yes Q No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2018- 166,000gallons 2017- 199,000gallons Sump Pum ? ❑ Yes No P ❑ Last date of occupancy: Sept 2018 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) s 2. Commercial/Industrial Flow Conditions: NA 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): 3. Pumping Records: Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 f Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: 0 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)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: 6-11-93 Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 11411 Depth below grade: feet Material of construction: ❑ cast iron N 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): l5insp.doc•rev.7/26/20,8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Al 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 411 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank i metal, i s eta, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 000gallons 411 Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 0" Scum thickness NS Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle NS measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA 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): NA Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 i c� Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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): 0'r 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �e Title 5 Official Inspection Form �?l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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.): NA i " If pumps or alarms are not in working order, system is a conditional pass. 11. 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: (1 ) 2'x25' leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street u/ Property Address P Y Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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, : 9 etc.): Leaching was in passing condition. No sign of past hydraulic failure was observed. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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.): t5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 y , Commonwealth of Massachusetts Title 5 Official Inspection Form °I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T.Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma 02655 3-25-19 required for every page. 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: ❑■ hand-sketch in the area below ❑ drawing attached separately :Ag�easYr+g 1k'i-tu+k Cams "�rre. r�"v ,inn�esras ,r •cjci".,_�.,� _ ti0, S�i aasr: NEY' AEPASL .EttACE-,PBFM3Z. ., RATS DATE"X#SAL1CgOyi iN9TALLEf28 t7Al48 .. - . n�uwigc. afis�Atwrr "w+ +ceva sx6x5: ----== ,� " - tY it t1r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T.Morgan Owner Owners Name information is Osterville Ma 02655 3-25-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑� Check Slope ❑■ Surface water ■❑ Check cellar W Shallow wells No GW 4' below SAS Estimated depth to high ground water: 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 El 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: A transit was used to find depth of bottom of SAS depth and to shoot the high tide marker.A separation of greater than 4'was found. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 118 Bridge Street Property Address Anne T. Morgan Owner Owner's Name information is Osterville Ma required for every 02655 3-25-19 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: �■ A. Inspector Information: Complete all fields in this section. �■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Offldal Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 , P+,;t C� C�v 0 " Cl T r 7 _. ..--...._... CD� � � � 1c= „,. 8 BORTOLOTTI CONSTRUCTION, INC. ` `"jo,�9 45 INDUSTRY ROAD,MARSTONS MILLS,MA 02648 �q-c; ?O 568-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date Of Inspection Inspector's Na e: wner's Name and Address: Q T CERTIFICATION STATEMENT• I Certify that I have personally Inspected the Sewage Disposal System at this address and that the informa- tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform- ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis- posal Systems.The system: Passes Conditionally Passes Needs Furthe v ua the Local A proving Authority Failure Inspector's Signature l'' Date: The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with Thirty (30)Days of completing this Inspection. If the System is a Shared System or has a Design Flow of 10,000 gpd or greater,the Inspector and the System Owner shall submit the Report to the appropriate Regional Office of the Department of Environmental Protection. The Original should be sent to the System Owner and copies sent to the Buyer,if applicable and the Approving Authority. INSPECTION SUMMARY: A) SYST�*PASSES: I have not found any Information which indicates-that the System violates.any of the fail- ure criteria as defined in 310 CMR 15.303. Any Failure Criteria not evaluated are indi- cated below. B) SYSTEM CONDITIONALLY PASSES: One or more System Components need to be Replaced or Repaired. The System, upon completion of the Replacement or Repair,Passes Inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. If"not determined”,explain why not. The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil- tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank is Replaced with a conforming Septic Tank as Approved by the Board Of Health. Sewage Backup or Breakout or High Static Water Level observed in the Distribution Box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven Distribution Box. The System will pass Inspection if(With Approval of the Board Of Health): _1 _ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is leveled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The System will pass inspection if(with approval of The Board Of Health): Broken pipe(s)are replaced Obstruction is removed. C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board Of Health in order to determine if the System is failing to protect the Public Health,Safety and the Environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or Privy.is within 50 Feet of 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a Septic Tank and Soil Absorption System and is within 100 Feet to a Surface Water Supply or Tributary to a Surface Water Supply. The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public . Water Supply Well. The System has a Septic Tank and Soil Absorption System and is within 50 Feet of a Private Water Supply Well. The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50 Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform bacteria and volatile organic compounds indicates that the Well is from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS:_ I have determined that the System violates one or more of the following Failure Criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overload 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 clog- ged SAS or cesspool. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped - 2 - ti SUBSURFACE SEWAGE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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.. If the well has been analyzed to be acceptable,attach copy.of well water analysis for coliform bacteria,volatile,organic compounds,ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 ggd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 315 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the fo owing have been done: Pumping information was requested of the owner,occupant,and Board of Health. -/1Qone of the system components,have been pumped for atleast tw6 weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been / introduced into the system recently or as part of this inspection. V As-built plans have been obtained and examined. Note if they are not available with N/A. he facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. Il system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- s ected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. - 3 - r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ate; PART B CHECKLIST(continued) ZThecility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ti. > FLOW CONDITIONS RESIDENTIAL: Design Flow:-? gallons Number of Bedrooms: 3 Number of Current Residents: 4? / Garbage Grinder: Laundry Connected To System: Seasonal Use:/l� Water Meter Readings,if available: .Last Date of Occupancy: COMMERCIAL/INDUSTRIAL•1�16/� Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: (Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS any source of information: System Pumped as part of inspection: „ If es,vol a pumped: V gallons Reason for Pumping: TYPE OF YSTEM: eptic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): APPROX51ATE AGE of all components,date installed if know i)a id source of information: -�� / Sewage odors.detected when arriving at the site:_ r� -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: // Material of Construction: 1/ concrete metal FRP Other (explain) Dimensions:?,5`.Y&'j Q5 Sludge Depth: ('" jr Scum Thickness: oa' Distance from top of sludge to bottom of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: `® Comments: (recommendation for pumping,conditioin of inlet and outlet es or baffles,depth of liquid level in relation to outl invert,structural integrity,evide a of leakage,et . 1" GREASE TRAP Depth Below Gr de: Material of Construction: concrete metal FRP Other (explain): Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity;evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: M� aterial of Construction: concrete metal FRP Other (explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: �! ` Depth of liquid level above outlet invert: Comments: (n level and distribution is equal,evidenc o solids carryover,a�idenc of leakage into or out of box,etcZlyze. 1 ! "4 PUMP CHAMBER: Pump is in working order: Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc.) - 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r: , . PART C SYSTEM INFORMATION(continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan,if possible; excavation not required,but may be approximately by non-intrusive methods) If not determined to be present,explain: Type: Leaching pits,number: Leaching chambers,number: Leaching galleries,number: Leacahing trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: nments: (note conidtion of soil,si s f hydra 'c failure level of ponding,condition of vegetation,etc.)_ i CESSPOOLS Number and miguration: 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(cesspool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: Material of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) - 6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locate all wells within 100 Feet.. III �t Q P a' q4 DEPTH TO GROUNDWATER: Depth to groundwater: Feet Method of�Determination or ppro imation: le ' Gr✓' - 7 - z o -pj ✓, k COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE-OF ENVIFONMENTAL AFFAIRS C DEPARTMENT OF ENVIRONMENTAL PROTECTION � k TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSENSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FO ; PART A 1 C." -� CERTIFICATION m. , :;�1 1 _71 Property Address: // (5 P v"I - a; . t-,i./A ? Owner's Name: Owner's Address: N 7>� r Date of Inspection: (4Q,�C;57�4)OpS' © m Name of Inspecto please print) G N,�-J, .t' '11t�l Company Name• Mailing Address: u p Telephone Number: I WI: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. Th_inspection was performed based on my training and experience in the proper function and maintenance of on sit-- sewage disposal systems. I am a DEP approved system inspector pursuant/to Section 15.340 of Title 5(310 CMR 15.000). The system: �✓ Passes Conditionally Passes Needs Further Evaluation by-he Local Approving Authority. ]Is Inspector's Signature: - Date: �i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner shall submit the repo.-tto 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 aed 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 I Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: u. rk r ea A � Date of Inspection: �,� 7 �S Inspection.Summary: Check A,B,C,1 or E./ALWAYS complete all of Section D A. System Passes: 'I have not found"anyiriformation which'indicates'that'anyof the failure criteria described ii 310 CMR 15:303 or in 310 CMR 15.304 exist.Ar_y failure criteria not evaluated are indicated below. Comments: R. 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 cf 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.(wheiher metal or not) is.structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System w:ill'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 yars 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,setded or uneven distribution box. System will pass inspection if(with, approval of Board of Health): broken pipe(s)are replaced ob3nction is removed distribution box is leveled or replaced ND explain: The system required pumping rr_cre 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 Page 3 of 1'l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: ,L 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 i5.303(1)(b)that the 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,A�etland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a,manner that protects the public health,safety and environment:.. _ 'The system has a septic tank and soil absorption system (SAS)and the SAS is within.100 feet of a surface water supply or tributary to a surface water supply:. _ The system has aseptic tank and SAS and the SAS is withir a Zone I 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 30 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 well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to cr less than 5 ppm,provided that no other failure criteria are triggered. A-copy of the analysis must be attaced to this form. 3. Other: 3 Page 4 of I I OFFICI'AL.INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION.,FORM PART A CERTIFICATION(continued) Property Address: Aw M PAJ� Owner: /V/ 11(744.4 ' Date of Inspection: 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ 9/ Backup of sewage into facility or system component due to overloaded or clog oed.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 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. -7 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 I of a public well. Any portion of a cesspool or privy is within 50.feet of a private water supply well. V 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 nitrcgen.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.]' (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.330,therefore the system fails.The system owner should contact the Board of Health to determine what w.i- be necessary to correct the failure. E. .Large Systems: To be considered,a large system.the system,must serve a facility with a'design flow of 10,000:gpd to 15,000 gPd•. You must indicate either"yes or"no"tc 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 ILof 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 f Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Ile Pe_dt Owner: `'l•�l Date of-Inspection: Check if the following have been done.You must indicate"yes"or"no" a_to each of the following: Yes No _ Pumping.information.was provided by the owner, occupant,or:Board of Health -6z-Were.any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large.volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined?(If they were not available note.as N/A) _ welling inspected for signs of sewage backup Was the facility or d 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 imerior 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 owne-)provided with information on the proper maintenance of subsurface sewage disposal systems?. The size and location of the Soil Absorption System (SAS)on.he site has been determined based on: Yes no Existing information. For example, a plan.at the Board of Heal:h. _ Determined in the field(if any of the failure criteria related to Fart C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 • Page 6 of 11 OFFICIAL,INSPECTION=FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner N• Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 1 . Number of bedrooms(actual): DESIGN flow based on 310 C R 15.203 (for example: 11:0 gpd x#of bedrooms) ' Number of current residents: C (Q,�Z Does residence have.a garbage grinder(yes or no ;11 Is laundry on a separate sewage system.( s or no):�.[if yes separate inspection required] Laundry system inspected- ,(y/' )/ es or no): Seasonal use: (yes or no Water meter readings; if av -ilable(last 2 years usage(gpd)): 30 z� 3� m� Sump pump(yes or no)/ ' Last date of occupancy: ��'6 / COMMERCIAL/INDUSTRIA��j(t) Type of establishment: Design flow(based on 310 CMR.15.2-03): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):— Industrial waste holding tank present Cyes 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: ' Was system pumped as part of the ins coon es.orno i..- If yes, volume pumped: gallons--How was quantity pumped determined? Reason'for.pumping: TYP F SYSTEM eptic 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'ofthe DEP.approval Other(describe): Vxi,m tea e of all cQjnponents; fe ' stalled(if known) and source of information: 6/ Were.sewage odors.,detected when arrving.at the site(yes or no): Paze 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: e � Owner: Date of Inspection: 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: - Comments (on condition of joints, venting,evidence of leakage, etc.): SEPTIC TANK: locate on site plan) I/ Depth below grade: _ Material of construction: ncrete_metal_fiberglass co _polyethylene —other(explain) If tank is metal list age:_ 1s age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) a Dimensions: k,Lla,X' Sludge depth: Distance from op of sludge to bottom of''outlet tee or baffle: Scum thickness: to �f Distance-from top of scum to top of outlet tee or baffle:=3 Distance from bottom of scum to bottom qf outlet tee or baffle: / How were dimensions determined: L Comments (on pumping recomme ations, let and outlet;tee or baffle condition,structural integrity, liquid levels eawelated to outlet invert, evi e ce of leakage, etc.;� ): J 42 ea rz � s .� , GREASE TRAP/,')locate on site plan) Depth below grade:— 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.): 7 Page 8 of 1 I OFFICIAL:INSPECTIONFORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM[ PART C SYSTEM.INFORMATION(continued) Property Address: Owner:. Date of Inspection: — TIGHT or HOLDING TAN (_ank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of consmiction: concrete, metal fiberglass polyethylene other.(explain): Dimensions- Capacity: gallor_s Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of Iasupumping: Comments (condition of alarm and float.switches,,etc.):. DISTRIBUTION BOX: (if preser:t 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, kage into or out of box, tc.): ' I r. CL PUMP CHAMBE locate on s toplan) Pumps in working.order(yes or no):. n Alarms in working order(yes or no): Comments (note.condition of pump chamber,condition of pumps and appurtenances,etc.): ' 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- 0 l wner: Date of Inspection �/�r`��'� 7, a60(j 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: e'enh�ing mg trenches, number, length: fields,number, dimensions: overflow cesspool; number: innovative/alternative system Type/name of technology: Comments(note condition of soil; signs of hydraulic failure, level of pording, damp soil; condition of vegetation; iF / �eff 6f7 CESSPOO (cesspool must be pumped aspart of inspection)(16cate 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 pondirig,conditiion of vegetation, etc.): PRIV U(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.): 9 Page l0 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. > Owner: Date of Inspection: z6i C)OOS 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 TOO feet. Locate where public water supply enters the budIding. -EGh --fan(/ 10 t , Page 1 1 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .Property Address: Owner: IV, p Date of Inspection: e SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water I feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date 'of design plan reviewed: Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) /Accessed USGS database=explain: You must describe how you established the high ground y g g o nd water elevati 11 F*armit Number: Date: Completed by: i`7i HIGH GROUND-WATER LEVEL COM?UTATION Site Location: > �� 9 e— j � �l/jl�� Lot No. Owner: Address: Contractor: 4/fy/ J Icelf 11-177 Address: tj� I. Notes: STEP 1 Measure depth to wafer table to:a Parest 1"/1 oft. ......... . .................... .Date yl�71 l month/day/year STEP 2 Using;Water-Level Range Zone and Index Well Map IDcate site and determine: OAppropriate index well.................. Z CWaterdevel range zone ........................................:..........:. i STEP 3 Using monthly report"Current Water R esou rces.Conditions" determine current depth to water level'for index wellwell ©J ........................... ; month/year STEP 4 Using Table of Water- evel Adjustments for index well (STEP ?A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) 'determine water-level adjustment ........................ ! STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) _......................................................_.. �� ' Figure 13.--Reproducible computatior.form. 15 1 X Z i ,I I • i I r.. j-LOT NO. : // ADDRESS:_ OWNERS NAME: SEWACE PERMIT NO. : NEW: REPAIR: .-I DATE ISSUED:_ - DATE INSTALLED: vi "I INSTALLERS NAME: INSTALLATION OF: WATER TABLE: FINAL INSPECTION BY: DRAWINC OF INSTALLATION ON REVERSE SIDE: Li 6-P Rl No..... 1, :©........ THE COMMONWEALTH OF MASSACHUSETTS APPROVED 8ernstable Conservation Departrr'ent BOARD OF HEALTH 10,TOWN OF BARNSTABLE L Appliratiol or Dirpotial Wnrk,i Toutitrud-unn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .............. ............................ ...............................a..................................................................� Loc:�ion-:\ddnss or Lo No. Oa ncr Addreu Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons___-_____-_______--_-_._-._ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------------- - W Design Flow............................................gallons per person per day. Total daily flow-----------------_..........................gallons. M Septic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---------------_ Depth................ W Disposal Trench--No. .................... Width.................... 'Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch. Depth of Test Pit.................... Depth to ground water........................ L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •---••-•••----------------------------- ..................................................................................................................... ODescription of Soil.....................................................................................................------•-••------••••••---•---•-----.............-----•---......_.. x U ----------------••-•------------............----•-----•...-•---•••••-••••---•••----•-••••.........--•----•-••-------•-••--••--•--•-••-----•------•---------•--••---•--•••--•-•-......................... W ----•----------------------------------------------------------------------------------•-------•---•--------....----------------------------•--------••-----•-••---------------••--•••-•-•----•-•---..-- UNature of Repair r Alte tions—Answer when appli ble............... ............................................................................... ----------------------------------------------------------------------------------------------- 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 isVd by the board of health. Signed - Due .._... . Application Approved B Application Disapproved for the following reasons: .................................. ................. ........................................................ .............. ................................... ................................................................... ........................................................... -- . ................................... r Date Permit No. ...........CJ. - ........_,� .7---C.............. Issued . .................... Date ————————————————--———————————--————————————————————————---—————————————— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE vlertifi ate of C�oraptianee THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) b in stall cr at ............j.[.. .. ._..�:)-(................. ................--------------------------------__------------------------------------------- .................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ------- 3_ _ ----- dated _.......................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.............. ..._................. .......- - ---- ---- Inspector ..... .................. ...._.........:---------.......----------------_....----.._... No.... FEB.......� . ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �; /'J /0.jTOWN OF BARNSTABLE rA- pplirativlt for Diripniul Wurkw Cnvastrurttnn rumit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at ..............// l.r /� ,�� Location-Address ? or Lot No. l/" _Z / � �e a �/ /-� u�-�C�e _5V . C>"iS � .O«.ncr......•... ..........................v.................................. .......... Address ......_......... a ...._rJ----------------- r1/................::!.... . .................. � Installer Address U 'type of Building Size Lot............................Sq. feet ... Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building ............................ No. of ersons.-.-_--_---_--...___--_.---- Showers Other—Type g persons ( ) — Cafeteria ( ) dOther fixtures ------------------------------------- •----•----------I--------------------------------- -----•--- ................................................... W Design -Flow............................................gallons per person per day. Total daily flow...........................:................gallons. WSeptic Tank—Liquid capacity............gallons Length---------------- Width-------------------- Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter-------------....... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1.4 Percolation-Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ L% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 Description of Soil........................................................................................................................................................................ x U ..............•--••••....••••••••-••-•....----•--•-----•--•--------------•---•---••------•----------••-----.•---••------......--------•----•••--•--..................................................... w - ----------------------- ----------------------------------•--------. -•-------....-•••••----•--------•----••---------------------------•-•--•-•--••--------•-••-•-•----•-•••..........._._.._...•..... U Nature of Re 'Fa _or Alterations—Answer when applicable---------------- i/ O. ...rzpt�nP�� = `c '`"� v Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ... ,�11/ ..... ...................................... .- G O;3. .:...... � Dare Application Approved By ............ J. ..4�..t a� .........................................................................:. ....-.� --`f mw Application Disapproved for the following reasons: ................................................................. .............................. ................................... . .............. . ................................... . ..... . . . . -- ........................------.......................... ........................................ Dare PermitNo. ..........7 3 �.7./.............. Issued ......................................................... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�e>r#ifi a e of C11omplian>re THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ......................:bn... =1?_----- p.;± .,._ a,-,,...._.............. ................ . ................------------- at ............. .. ........1 . c ' ` ---..h, ue.... ...........................-----------------------------------------....-_-----------------------.------------ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .........✓-3.. L7/.... dated .......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- ------------------------------------------------- ----------------------............ Inspector ...._--------------------...................:... ......_._.........._..._.................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No...ATOWN OF BARNSTABLE //, :..� / FEE -•.................. Disposal Worb To1notrudwit vermit Permission is hereby granted................:---`:- --_-.-.r,!�:-.o--^^_-�: �� to Construct i( ) or Repair (k) an Individual Sewage Disposal System f at No............. _ ry Y?-14, ,0 a-,— i � n•�, , _,, ��(� (J `� Street ( h_��/ as shown on the application for Disposal Works Construction Permit No----/_--,:__.- Dated........................................... l v Board of Health DATE =....../.(.....- --• ............................. FORM 36508 HOODS a WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE t LOCATION SEWAGE # �rI- �CO " VILLAGE ASSESSOR' MAP& LOT rj 13 I NAME&PHONE NO. SEPTIC TANK CAPACITY oOd Qnt(- �QP �. !C oL• �C LEACHING FACILITY: (type) Sown e f7E 18 (size) NO.OF BEDROOMS \� BUILDER OR OWNER ,&t e!.c.eA PERMIT DATE: 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 leaching facility) Feet Furnished by . D � - lb `IL L M1 TOWN OF-BARNSTABLE LOCyATION P S 1, SEWAGE # s ' VILLAGES ASSESSOR'S MAP & LO INSTALLER'S NAME & PHONE NO. �ts'/�/ /� lC f SEPTIC TANK CAPACITY l 6 LEACHING FACILITY:(type) �,('�"=�I C>A (size() X 16 NO. OF BEDROObIS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER dip 5�°-P DATE.PERMIT ISSUED:��i3d1✓ c� I/9- DATE iCOUPLIANCE ISSUED::/0-4-1 / VARIANCE GRANTED: Yes No �/ ` �,� jog ,�w��� � � '�- ............................. THE COMMONWEALTH OF MASSACHUSETTS I BOAR OF HEr-*%A T ..............1D---6047................orl/ A..' 1;,�7 ........... ..................... lit tw- Vptiration for Dispaiial Works Tonstrurtion 1hrmit Ap do is hereby made for a Permit to Construct or Repair Z,)-an- Individual Sewage Disposal ys at: ---- _.... �................... ..........0---5� .4r . .......]),Ite..................................... do AddreA or Lot No, Lol. ........ ........................ jfhzal��_o... atil .............. ........o............................. ................ Owner 'Iddre.r W. ......................................... le..................................I................ Installer Address Type of Building Size Lot............................Sq.-feet U Dwelling No. of Bedrooms..... :............................Expansion Attic Garbage Grinder P4 Other—Type of Building .......................�.., No. of persons................----------- Showers Cafeteria 04 Other fixtures ......................................................................................... ............................................................. Design Flow............................................gallons per person per day. Total daily flow----------...........I.................------gallons. 9 Septic Tank—Liquid capacity............gallons ,Length................ Width........_.....__ Diameter.....•.......... Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No..................... Diameter._......._...._..... Depth below.inlet.................... Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by.......................................................................... Date-----------.....---------- . Test Pit No. I.................minutes per inch Depth of Test Pit.................... Depth to ground water---------------------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.__.............._.. Depth to ground water..................... -----------------------................................................................................................................................ 0 Description of Soil.......................................- .......I......................................................................................................................... --------------*-----------------------------........ ....................................................................... ------------------ ------------------- ----------------- ............................................................................................................. ................................. U Nature -,f Repairs or Alterations A wer when applicable------ P7 hf rv �----4.,9 - A ......knp Z .... ..... V—----- -------- Agreement 0 X X The. undersigned.agrees to install ,the aforedescribed Individual Sewage Disposal System in accordance With the provisions of TL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been_issVd o-rd of heal Sined... . .... ........ .. .... .......... Date 2, .......... Application Approved By.............................. I................. ...................... ..... .. ....Date-- Application Disapproved for the following reasons:..............................................................11=.............................................. ......................................................................................................................................................................................................... Date PermitNo...... ...... --------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARP---,OF HEALTH —2)P Applira#ion for Bi-qpuoal Workii Tonstrnrtiun .errant Application is hereby made for a Permit to Construct ( ) or Repair (iri an Individual Sewage Disposal System at: -•-••• - ----.... - ___.... La�io, -Addr s's3 � � or Lot No. ' �_'._ _ %:_ ....._ ...-___ 4. _ .: =`` ---------------------------•-••-•-••. •-••____..••••--......-•••----__........___..... Owner a C.�'r..c__ �; - <`_r --------------------------------------------------- Installer: dress r._.__.. ,:..... �.. Address Type of Building Size Lot---------------_____________Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ;(-. Other—Ty e of Building ............................ No. of persons........................... Showers ( ) — Cafeteria a p " ! Otherfixtures ....................................................-........................................-----•-----•--••••-••------•--•--•••-•-•--•--........_ r Design Flow____________________________________________gallons per person per day. Total daily flow____._._.____.__._.._...,...................gallon: W - :.- 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------------------------ 114 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 •---------------------------------------- •...... ••............ _--------------- •......... •------------ -------- •---------------------- •••----------- -••--------- 0 Description of Soil........................................................................................................................................................................ x V -•--•-••••-•---••••---••---••••-•--•-•-••••-•••-•---•-----•-•••-----------•---•••-------------•-•-----...--•••--•------••-•..........•.•••-••-•---•---•--•---•---•---•----•---•--......•-••--------.... UW =---------i...I-------•---------- ----- .Nature of Repairs or Alterations—Answer when applicable 9t� f�r'r�C r�� �: I. A ........................._ ......... ___ <. _y:{- ._..._. t„S° J< __. ..- .X..! ....-4.�f___.�...___. 7��.'. _ _�y_ .a P Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'TTLE 5 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 health. Signed' ff r •F' is ✓ r .............— "`. - ApplicationApproved By...........................-_� ........................ ............................... - Da� Y Date .1 Application Disapproved for the following reasons:-----•--------------------•----------------------------------•-----------------•----------------......---•--... ...................---------- •.....-•----•--••------••--••••--•-----•--•-------••...•-----•---•-......-•----------••---••----- •-•-••-•------•--••••••--•------••---•••---------•••••.....-•--- _ _ Date PermitNo....... ............��- 0---------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS �w BOARD OF HEALTH ....... - _1.. '.............0F.... r✓' . .. ................................................. Tntifiratr of Tuntpliatta THIS, S TIO/CERTIFY, That tho Individual Sewage Disposal System constructed ( ) or Repaired (c:-I r ......................... . ' p , ________________Installer ,#r ` r ry at € of .J --•------------ --- . i_x 1._, ......... `rtit fhas been installed 54 i accordance with the provisions of TITLE 5 of The. State Sanitary Code as described in the application for Disposal Works Construction Permit No _`�____ _.____ dated-------- `f�-- --?� ;.�................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE — .._-__.1.3..-.5s 2___.......:. Inspector. A..,- ................................. r THE COMMONWEALTH OF MASSACHUSETTS . - BOARD` OF HEALTH 4141 I' No. FEE...--2..n?.••-•--- �i��rrr��1 � flitnn��rUan. rrrttit Permission is hereby granted..._ f l! `''.... ••• ---------•-------------------------- •...... ........._._.. to Construct ( )for Repair, ( ",I--an Individual Sewage Disposal System) -7- ---� � - - -- �T" J••-'Street ' f i- • `~ �/� 1 as shown on the application for Disposal Works Construction Permit No._•.-�....•.... ^ Dated.._.•............. --...... L �� ti Board of Health DATE.�', --••-- ° "�'er y ts �, d r FORM 1255 'HOBBS & WARREN, INC., PUBLISHERS ti i REVISIONS BY AX tj RF EC P o i c) a / ��?• Ate` ,q�y L`:.k;t;•�. � .i \ � ;r, �y (�` �� \ • L��-%L--�j v�..%i Vim.. "� 1`L� (L� d t� �_ 1. ... . �) l 'Q1-1 \ --r`:,_t lG�, "!�'� �.��'�:���.1T� ,�►V ,�C.TUr'��,,, �Ut�.V� �'�E � �.,, MA05 ✓? 745 GPZOL>40 TO 77hS l tC�.AFL TAN OARC) L+� �,1i?�3u4c5 DRAWN .�� CHECKED DATE � * SCALE JOB NO. SHEET !o ti OF SHEETS �o�