HomeMy WebLinkAbout0069 CRYSTAL LAKE ROAD - Health 59 Crystal Lake, Road;
Osterville P
140 194
-\ COMMONWEALTH OF NLASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5 �
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESS ENT'S~ �;
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ca
PART A rn
CERTIFICATION
Property Address: G1-y,ftul /4j(? /?J
Owner's Name: �r�,;r nv Qs"1, L L.C.
Owner's Address: PO, ,&A �-n
Date of Inspection: $ /2 -D q
Name of Inspector: please print) TO`,*t Ir �u
Company Name: joi,�lease
/ to ,46c oe So.✓��
Mailing Address: !�;2 11.A 1nw - j
/1/1,7/t, // odd y
Telephone Number: -5Pg-L/,2i-7779,
CERTIFICATION STATEMENT
I certify that I have personally Lnspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
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 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 Tz, ,y a, -ee- CvrT/,C a ti c:� o� �{,a sys i... /�f,wy I 1
i 'e.oI r S G�cJ 9 !�rl c� h Gi3 I►O/I� pa'�i, u S s'c� �c CG¢N 3 rl D h f 1 a �3FR n
****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
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT:OOR'VOLUNTARY ASSESSMEN-'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 6 9 Cr. it
Os rvi o /y/
Owner: /,I C
Date of Inspection: $— /.2—O 4/
Inspection Summary: Check A,B,C,D or E/ALWAYS complete'aH 4S&Woc.vt.
A. System Passes:
-ZI 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 faihue 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:ouj.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
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION.(continued)
Property Address: 0 Ct jt l Lake Rcr
j-1rf r✓j- l: M/1
Owner: 4,s1 gi; oxi.,,il 7 s C
Date of Inspection: 400
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ 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
Z. 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 front 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 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:
t
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOTJFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAUSYSTEM INSPDMONXORM;,'':
PART:A
CERTIFICATION.(continued)
Property Address: b 9 C.,, 3t J
O Qrvi/7 o —
Owner: ,5�st &I ds oy✓i o e
Date of Inspection: X— /2=Oil
D. System Failure Criteria applicable to all systems:.
You must indicate`yes"or"no"to each of the following for all inspections
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
v Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ __Z 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.
�i Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
z/ Any portion of a cesspool or privy is within a Zone I of a public well.
y' 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 theAve0 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.l
N0 (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 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"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—I WPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large.system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 Cry l ?�
/�
Owner: 0'4o /�.ay �s7. 4 i
Date of Inspection. $
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
V 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?
V _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up
_ Was the site inspected for signs of break out?
-Z _ 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
Page 6 of I 1
OFFICIAL INSPECTION.FORM—NOT FOR'�OLtJNTAAY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTElV1F.INFORMATI ON
Property Address: 69 crysf l 44.1 Ad,
Owner: Afr �iy �rvi 1> j G
Date of Inspection.
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): l/ Number of bedrooms(actual): M
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x tt of bedrooms):
Number of current residents: o
Does residence have a garbage grinder(yes or no):.1/0
Is laundry on a separate sewage system(yes or no):/ t0 [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): iVo
Water meter readings,if available(last 2 years usage(gpd)): /Vone
Sump pump(yes or no):_o
Last date of occupancy: Pee— goo/
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): QDd
Basis of design flow(seats/persons/sgft,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:
Was system pumped as part of the inspection(yes or 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:
Were sewage odors detected when arriving at the site(yes or no):
6
I '
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 69 Cr St l lab e
D' S e,vill.,, N ty
Owner: AOsT Bay 0.17rc 11, L.i C
Date of Inspection: -/2—O'>
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron i 40 PVC_other(explain):
Distance from private water supply well ors on line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: 2/
Material of construction: concrete metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: x 5-
Sludge depth: No
Distance from top'of sludge to bottom of outlet tee or baffle: h o
Scum thickness: {1/dhz
Distance from top of scum to top of outlet tee or baffle: Non e
Distance from bottom of scum to bottom of outlet tee or baffle: dyz
How were dimensions determined: Tu.k' was OQ4.,1- 17 du t
Comments(on pumping recommendations,inlet and ottlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
1Hk �ovhs �� cfo�� s��rre
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 11
OFFICIAL INSPECTION.FORM.-NOT-MRVUUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM.INSPECTION FORM:
PAR'Y'C. : r
SYSTEM INFORMATION(continued)
Property Address: 69 C. s/u j 4 1 Rot
Owner: fiGst Osftryi /, l:L C
Date of Inspection. .S—/2--o ti
TIGHT or HOLDING TANK: (tank must be pumped at time of iirspe - nklatate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
.Design Flow: Qallons%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: t"(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.):
r r 4IAfs Ae~' qkaoft_
PUMP CHAMBER: (locate on site plan)
Pumps in working (yes order Y or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,eu.X
R
Page 9 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE:DISPOSAL SYSTEM INSPECTION FOPJ4
PART C
SYSTEM INFORMATION(continued)
Property Address: t C.I sr Aj
05 Owner: " t O �y �
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): V (locate on site plan,excavation not required)
If SAS not located explain why •� Q
__ /7f I7ui�� p��ra �ra.n ,/skin �f/7tarws7ab�� .'a�✓rvsg L/!a�'l�r,t�vJ w.Pr.0 �S�lI��4C.sn�it✓ 9-?5%-y3
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
t/innovative/alternative system Type/name of technology: 41o, �h %7r�fors
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction-
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
f•9 _ 7�•,.. p
Page 10 of 11
OFFICIAL INSPECTION FORM--jWFOR VOLUNTAAY ASSESSMENT S
SUBSURFACE SEWAGE DISPOS&SY;;TEM INSPECTION'FORM
PART;:C . ' ' � •
• SYSTEM INFORMATION(continued)
Property Address:
Owner: f 1514 s rv-1 t L:LG,
Date of Inspection:
,
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate'all wells within.100 feet.Locate,where public water supply enters the building.
PNb��c l✓AL[r t.r/!r .A�..fr,4y c, `ion SC
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Page 11 of 11
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBS,URFACR:SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address' 6 y Cr4 5
Owner: 6a t Osrr w,1 ,
Date of Inspection: —/2-49
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water ?S y 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)
i/Accessed USGS database-explain: 5 Iqt H
You must describe how you established the high ground water elevation:
ud i&4 ed r JOw^N 4`<e lr cohTscr i3 4f �' /tvw ion•
3
hr M..+Ks .p Kul ZS, i1 -4zl' .1- tvK-• u�a <r
G TOWW OF BARNSTABLE
LOCATION ,1 �I�t fK 4 /`P SEWAGE
VILLAGE�� ✓ / ASSESSOR'S 'MAP;& LOT
4
k
INSTALLER'S NAME & PHONE,NO- -aya3
SEPTIC TANK CAPACITY O 0
LEACHING FACILITYAtype) `��' �� �` T )
NO. OF BEDROOMSPRI,YATE WELL OR PUBLIC WATER
BUILDER,OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: -------------
VARIANCE GRANTED: Yes No
i
� 1
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BAXTER, NYE & HOLMGREN; INC.
Registered Professional Engineers and.Land Surveyors
812 Main Street,Osterville,MA 02655 (508)428-9131 FAX:(508)428-3750
November 11,2002
Mr.Thomas A_McKean,RS,CHO
Director
Barnstable Public Health Division
200 Main Street
Hyannis,MA 02601
Re. 69 Crystal Lake Road,Osterville,MA
Existing Septic System Capacity
Dear Mr.McKean:
Please accept the following verification of existing septic system capacity at the above stated property. The existing
system was installed in September of 1993. Therefore,the analysis herein was based upon the 1978 State
Environmental Code—Title 5. As detailed on the attached plan,the existing system was determined to have a.
capacity of 467 gpd. This capacity will allownp to a 4 bedroom house per the design flow requirements of the
Commonwealth of Massachusetts Department of Environmental Protection,State Environmental Code,Title 5,310
CMR 15.000
Based upon research at the Barnstable Health Department,no records of the design for the existing system could be
located. The septic installers card,Permit#93-510,shows four(4)infiltrators installed with no other detail
information on the soil absorption system. A telephone call was placed to Mr.Walter Lewis,the installer of the
existing system,in which we were told that four(4)feet of stone was placed around the infiltrators. Therefore,the
assumptions used to determine the existing system capacity were as follows[please refer to the attached plan for
assumptions,calculations,and details]:
• 4-STANDARD INFILTRATORS(as Manufactured by Infiltrator Systems,Inc.)—[see attached
infiltrator detail as specified by the Manufacturer] ,
• 4 feet of stone placed around the infiltrator units[yielding a trench size of 33'x 10.83']
• INFILTRATORS set directly on undisturbed ground[no stone below the bottom of the
INFILTRATOR—yielding a 6"effective depth for sidewall calculations]
[As a first order of work,these assumptions must be field verified by the Owner/Contractor. If
these assumptions are found to he incorrect,the Owner/Contractor must notify the Engineer for
a re-analysis of the system:]
Please do not hesitate to contact me if you have any questions or need additional information. Thank you for your
time.
Very Truly Yours,
Baxter,Nyeen Inc.
e � e Holm l�'Y
eewddy,P -
Project Manager
Cc: Mr.James Crocker - . . . . .:
File
Land Surveys • Subdivisions • Septic Design Wetland Filings • Site Design
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Cerfified Plot Plan in Opferville MA.
Prepared For Monno Recity
Assessor's Map MAP: 140 PARCEL: 194 Baxter, Nye & Holmgren , Inc.
Community Panel Number 250001 0016.1)
C Registered Professional
F.LR.M. Mop Zone ,
Engineers and Land Surveyors
Plan References L.C. PL. 2664-78 — .LOT 87
Plan Book 371 Page 96 Lot 87A 812.Main Street, Osterville, MA 02655
Deed Reference : Certificate of Title: 139,638 Phone - (508) 428-9131 Fox - (508)-428-3750
Owner : James F. Shields, Jr. Job Number. 2002-088cp .dw Scale 1" = 40' Date 10-15-2002
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PER INSTALLER'S CARD LINE BEARING DISTANCE F
PERMIT.# 93-510 L1. S 13'36'00" E 20.01'
FOUNDATION' LOCATION 9-17-02 ' L2 S 13'35'00" E 28.43'
'• I CERTIFY THAT THE EXISTING•STRUCTURE IS LOCATED ON THE GROUND AS 7� NM )44
SS't
SHOWN HEREON, IS LOCATED IN RELATION TO THE MONUMENTS SHOWN, AND JOHN
IS NOT LOCATED WITHIN A SPECIAL FLOOD HAZARD AREA.
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COMMONWEALTH OF MASSACHUSETTS
dy
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION 9
J •
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM �
PART A E,VE®
CERTIFICATION
:. NOV 2 6 2002
Property Address: 9 s
CJf v P • �1/�7. TOWN OF BARNSTABLE
Owner's Name: 1-1.1; Ir S s HEALTH UEPT.
Owner's Address: 49 �C.*w-I J X olfe ovgf
Date of Inspection:
2)
Name of Inspector: (please print) 94
Company Name: -jo4— 1-44 1 3�vv��;.
Mailing Address: 152 Woblo, ' SI �l MAP 9
Telephone Number: 5-O� -`f2 8- 7779' PARCEL t Q
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.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Tit1e.5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: o •Date: '- 361 vim•
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 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
• i ,
****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 I '
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT:00R'VOI UNTARY ASSESSM NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'. :,
PART A
CERTIFICATION(continued)
Property Address
Owner:
Date of Inspection: -,2 —Oz
Inspection Summary: Check A,B,C,D or E/ALWAYS completeaili otSs�don•D
A. System Passes:
y 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.
Answe�'r yes,no of 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 of not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is immineaL System will pass inspeWan 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 Comphi mce
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or breakout or high static water level in the distribution box due to broken or
pipe(s)obstructed or due to a broken settled or unevenSystem r distribution box.S w•!1 pass mspectron if( . .
wrth .
approval of Board of Health):
broken pipe(s)art 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
f
Page 3 of I 1
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM
PART A.;
CERTIFICATI ON;(continued)
Property Address: 69 Cryjt J 4e Ry
Owner
Date of Inspection: 2-1 G-01
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order,to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:.
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 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 tribu`tary,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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
J -
1
3
Page 4 of I I ,
OFFICIAL INSPECTION FORM—NO'TJ OR VOLUNTARY ASSESSMENTS X;
SUBSURFACE SEWAGE DISPOSAI*`SYSTEM INSPECMONY- ORr.-.
PART.A
CERTIFICATION(continued)
Property Address: h4XI-1 4f
Owner: ja„wts .S/h.,A
Date of Inspection: `/- 6— uL
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
r/ 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.
v' 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.
i ✓ Any portion of a cesspool or privy is less than 100 feet but greater than'50'feet'from-•private water
supply well with no acceptable water quality analysis. [This system passes if tlheaveu 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 faib=criteria
are triggered.A copy of the analysis must be attached to this forte.[
NUJ (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 Systems: }
To be considered a large system the system must serve"a facility with a design flow of 10,o00 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 II of a public water supply well
If you have answered e t an question in Section E the system is considered a significant threat or answered
Y "yes" o any Y �
"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: 9 Cr �`,/ L a��! RDA
Owner: lv"15 f, S /s/es
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information'was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period? :-
t,' Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓_ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out? '
Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location'of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information. For example,a plan at the Board of Health.
_ jZ 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 , a
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR OLUNTAY ASSESSNiEP`'TS ,
SUBSURFACE SEWAGE DISPOSAL.'SYSTEM INSPECTION FORM
PART.C
SYSTEM-INFORMATION
Property Address: 4k e A71
es 4,07
Owner: Jurris J� Sti�RJ�s
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x It-of bedrooms):
Number of current residents: 0
Does residence have a garbage grinder(yes or no):Vo
Is laundry on a separate sewage system (yes or no): lw [if yes separate inspection required]
Laundry system inspected(yes or no): �
Seasonal use: (yes or no): nic ) ,
Water meter readings, if available(last 2 years usage(gpd)): 1'O°" /Yy'�'`� 2C i) /9i G vd
Sump pump(yes or no): Ao
Last date of occupancy: 4kc, a 0o/
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/persons/sgft,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 ;
6
Source of information: °r+ w� �/ �3 v 9q S`l2.0-Q4
Was system pumped as part o the inspection(yes or no): d/o
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.Attaiti'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 compgrients date installed(if known)andsource of information: J�
9 pA„-s .77 srl�i� g� �" / J:IS.aL�7CYa f°:vH C f //llrhj/if4j�
Were sewage odors detected when arriving at the site(yes or no): A/v
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.. PART C
SYSTEM INFORMATION(continued)
Property Address: �/ C,,�;l� lake
Owner: jyo*v1S S .4,c s
Date of Inspection: y. Y- O2
BUILDING SEWER(locate on site plan) i•=
Depth below grade: 2 f
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)
Depth below grade: �� \
.Material of construction: concret_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) ,,. , x 5-
Dimensions:
Sludge depth: IUo
Distance from top of sludge to bottom of outlet tee or baffle: Alves t
Scum thickness: None
Distance from top of scum to top of outlet tee or baffle: lVoi-
Distance from bottom of scum to bottom of outlet tee or baffle:
Alves c
How were dimensions determined: ro,�Srvy,.to /y si�•y /J�a��£� o�•`f " _. .
Comments(on pumping recommendations, inlet and outlet tee or baffle c6nditiolf,structural integrity,liquid levels
as related to outlet invert, evidence of leakage,etc.):
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.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT:FORVOLUNTARY_ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION FORM:
PART-c'
SYSTEM INFORMATION(continued)
Property Address: /I
5 vi
Owner:
Date of Inspection: — r'OZ
4
TIGHT or HOLDING TANK: (tank must be pumped at time of il�nkiarate an 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: (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.):
N
�ihJ�'es�4 s y p. /3d y 3 va iZ�7f`�• ' e 3V/ Ad-w.�ka' 4e
PUMP CHAMBER: (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
Pege 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: F 5,kee-415.
Date of Inspection: 1
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS
n�not
``located e11xplain//wfhy: k //y) L
lnsrw/i�� a e"'M�vTe7 aadgf 9_ 2,1 - Y3
Y
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number: a
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology: A'j�ruT rs
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic.failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction: e
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOP.VOCUNTAILY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 6�f5 Rot
Owner: Sh�E�lc�s
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
[,6,,A .4 4,,,
3 3>r
� 3
y
M
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
. SUBSURFACE:SWAGE DISPOSAL SYSTEM INSPECTION FORM
�:.. PART C
SYSTEM INFORMATION(continued)
Property Address: 6 Cr >Z
Owner: James r SSea s:
Date of Inspection: 9_-2g_oz
SITE EXAM
Slope
Surface water _
Check cellar
Shallow wells
Estimated depth to ground water Ys,y 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: .+muds a Ba ,r! ,,� k4,/tt,
You must describe ow you established the high ground water elevation:
YOu N p•• CZ val-a., /'s
11
C TOWN OF BARNSTABLE
LOCATION SEWAGE 0 �� /
VILLAGE //t' _ ASSESSOR'S MAP;& LOT
INSTALLER'S NAME & PHONE NO,22 A
SEPTIC TANK CAPACITY O 0
LEACHING FACILITY:(type)
NO. OF BEDROOMS PRI,YATE WELL OR PUBLIC WATER
J�
nUILDER,OR OWNER
DATE PERMIT ISSUED:
C� 5
DATE COMPLIANCE ISSUED:
i
VARIANCE GRANTED: Yes No
�04
m � � �
S
jw
C, TOWN OF BARNSTABLE
LOCAl-ION62 (Tk- Sf d A-f SEWAGE
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO,/�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) I!�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
9
DATE COMPLIANCE ISSUED: a�
VARIANCE GRANTED: Yes No
r'
V
V e
�o� � �,
,.
�� �
,, � ��
��
�� ���
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��
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IY6 -
Y _-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
APPROVED TOWN OF BARNSTABLE
Cwmrvation Dey rtmeitt
dfa (RiAor Diaivajial Workii Ta imtrnrtion f ernti
Application is herebyDmaade for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: ,
f
.......---------
Lo lion-: trc or Lot No.
. .... ---------------------- • --•---••-•---------•---t ...................
Installer Address
d Type of Building Size Lot............................Sq. feet
V 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.
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 ( )
Percolation Test Results Performed by.......................................................................... Date........... ............................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 .....-•-•--•.._.........•------•--------••---•----------••••---•--•--••-----•--••-•--••---•..................•----........................................---
0 Description of Soil........................................................................................................................................................................
V
W --- ........................................................ ---------------•--.....----•-•-------
U Nature of Repairs or Alterations—Answ when applicable_..... _ .._, lam.-.. .. .._._,S__.� .:..._...—......•............. ;
` +...�� \. P s r
dd 1 .... ......0-,F•---------------• �ifJ� G>�r..gJ_
Agreement: c/
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
ehhas
been i ued b� he board f health.
Signed ... � �... � ���
..... .. ......... . ..........................
Dare
Application Approved By ......... .. �............................ ......... ... .�..�- .-...1......
Application Disapproved for the o� reasons: .......................
.. ............. . ................. . . ....................................................................... . . ...................................-- ......... .. ........................................
T Dace
� .`. ..................
Permit No. .......... ....�r...�......... - -- Issued .. - ----- �'..�.�-..�..,r..
Dace
V `�..3 r w c-'fr-..-.'�."v u "�.�"'-��.'•y�.1 n u7+-. �,,,,r"�...-�2� -.e� •r.,.. '..i�?= v�' �_.
NO.13-.51.tn Fim �.....CD Q)
THE COMMONWEALTH OF MASSACHUSETTS
1 BO.ARD OF HEALTH
TOWN OF BARNSTABLE
A. V0irtt af? or viripim ll Works Towitrnr#inn rnmit
Application is hereby made for a Permit to Construct ( ) or Repair (� Individual Sewage Disposal
System at:
Location-A19,dress a or Lot No.
P ..........!`. P (J. ........... ----•--------------•----. --•-.......... .........-•-.........--•--..........----•-•.
Owner A/dvcss
Installer
Address
Type of Building - Size Lot............................Sq. feet
... Dwelling—No. of Bedrooms--------------------------------------- ....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a
d Other fixtures ..... •...•--.....••--------• ---------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity-_------___gallons Length._............. Width---------------- Diameter._---._.-.-_---. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-------- ------------ Diameter____.-_--_----_._- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------- --------------------••-•-•--•••------••-•---•--•-•---•--...---•_. Date........................................
1.4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Li Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •------••--------------------------•----••--------......--••----••-•••-••••--••-•--•.......•----•-•--...-•••-••-•-•-............--•-•-••-•---••......_.......
0 Description of Soil.........................................................................................................................................................................
W
V ----------------------------------
------------------------------------------
........-------------------------------------------------
-.---------------------------
-------
-----------------------
UW •----•------------------------------------------------- ; ----------------...-----•----.....--------------- .....-------- � --------- r .....................................
Nature of Repairs or Alterations—Answer-when applicable_--_-_ 2._._.._.—....................
.....e!� '' --•----•......C�`" '7 t
Agreement: t/ J t y
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 y f health.
Signed .. /<... 1 �..:f�j �`
Dace -.
Application Approved B �..¢ - c(
PP PP y ............ � ..-.. 1
............................................................. ...........
Application Disapproved for the following reasons: ...... . .... . .... .. .................... .... ......:................................................
........................ .. ............... ................................................ ........................................................................................ . ............ ........................................
r Dare
Permit No. ...7.-. .-..r�- ..C3............................... Issued ............... ..-..1.:.V..s..... ."?3........
Dace
------------- ---.._g.=--s -�—art....®.- ----_._..--.-----_..._--`'-.— ,.-----__.,.._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-TOWN OF BARNSTABLE
J < Y� , �kPr"fifiCMtQ of CII>rYCl1YiFIri.CE .
THIS,'IS TOCERTIF `, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .............................................., i......-------- ----------- .--...............--------------.... . . . ..--.....---------------------------.---
at . (fir" / .l!... f .fL... = ---- -'l aEnvironmentaln
......;.....1................. .. .._........J.,-..., ...............................
has been installed in accordance with the provisions o TITLE 5 of The State Code as i
application for Disposal Works Construction Permit No. ....._��'�� �/- }........ dated ......... .............-------------
the ...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
q �p �
DATE....._ ----------------- -l-..--a' .....1,�............._--------------------------- Inspector ---- .:... -- ------------------........-------------- ---_
-----------__--_®_ - ---_---_._.___-- --� --- �----
THE COMMONWEALTH OF MASSACHUSETTSr (//)
BOARD OF HEALTH
/3 �� TOWN OF BARNSTABLE -0 0 U
No...,.__ - • -•--- FEE...I... ............
Difillnlitt1 Vor,-s Tom r ion rrrmit
Permission is hereby granted------`.... ; �'�
to Construct ( ) or Repair (Z an Indiv•rlu l Sewage Disposal System / � lJ
�
as shown on the application forpisposal Works Construction Permit NO.-7-3`�10_-_ Dated.......
Q ,�
Board of Health
--•................................
DATE._..._..---�-'--�--`��-:..---•.�
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