HomeMy WebLinkAbout0123 EBENEZER ROAD - Health - F
f'
-' 0123'EBENEZER ROAD
`A=7123—057
Osterville
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRON' ENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
P)%RCEL
TT T T' LOT
11TLL 5 ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A:.
CERTIFICATION
Property Address: b&J(!�er
Owner's Name: ��' ( :��� FgECE"IED F
Owner's Address:
Date of Inspection: `-� _ i- 3 APR 0 7 2003
Name of Inspector: (please print](.ouglas A.Brown jQ\,,VN OF BA(�P��S�ABLE
Company Name: t7nunhc �► Brown `A�{,
Septic InspectibDa .
Mailing Address: R.O. Box 145
Gentewft-Telephone Number: A 02632
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 Sectio -15.340 of Title 5(310 CMR 15.000). The system:
P
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
a..
Inspector's Signature:. ,4!!:�- Date: 4�1-/
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
'"*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 Ir73r 2
Page 2 of 11
-OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: la 1�) cEac-ll'e
Owner's Name:
Owner's Address:. T
Date of Inspection:-4
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. S,yysteem Passes:
� I have not found any information which indicates that any of the failure criteria described in 310 CUR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments-
f ItMIS ? `:. \ :. ✓ ir^ �.1j. [� a ry
i
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 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
p c tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level.in the distribution box due to broken or
obstructed pipe(s)or due to a.broken,settled or uneven distribution box System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box.is leveled or replaced
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
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:-1' 3hrwz z .e�
Owner's Name: G c
Owner's Address:
Date of Inspection: i (✓�j
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 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
n
"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:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued).
Property Address:
Owner's Name:
Owner's Address:
Date of Inspection: �-1 - -C-°.,
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all his
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
V76ischarge 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
esspool
_ ✓' 'qui 1/2d depth in cesspool is less than 6"below invert or available volume is less than day flow
4L quired pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s).Number
of-times pumped
✓ y portion of the SAS,cesspool or privy is below high ground water elevation.
_✓Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to-a surface
ater supply.
A�nn 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.
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 D>EP 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.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owner.or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the,system in accordance with 310 CMR
Page 5 of l 1
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: E -i �c�
,w d^
re ,�--o C F
Owner:Date of InspPr�l'i0n', t j--���
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
VWere any of the system components pumped out.in the previous two weeks ?.
Has the system received normal flows in the previous.two week period
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
.Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
the site inspected for signs of breakout ?
✓ .lam
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�ortees, material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
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 o
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J
5
Page b of 11
OFFLC _
OFFICIAL
INSPECTION _E C TION FO
RM
RM NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION'
Property Address: l
Owner's Name, �
Owner's Address:
Date.of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual}:
DESIGN flow based on 310'CMR 45.203(for`example: 110 gpd x#,of:bedrooms):
Nurnber,of current residents:
Does residence have a garb
age (yes or no):. p
Is laundry on a separate sewage system(yes or no)`. �if Yes Separate inspection required)
Laundry,system inspected(yes or no)
Seasonal use:,(yes or no): ` C7ci
Water meter readings,if ail able(last 2 years usage(gpd)): .
SumP pump(yes or no) t 0,C° e,P_
Last date of occupancy:
COIV MERCYAL/INDUSTRIAL:
Type of establishment: '
Design flow. (based on 310 CMR 15:203): gpd ,
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 S system(yes or no):
Water ineter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: fjtid
Was system pumped as part of the inspection(yes or no): 1�,
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason to ptunping:
T�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
T Innovative/Alternative technology. Attach a copy of the.current operation and maintenance contract(to be.
obtained froth.system owner)
-Tight tank ` _Attach a copy of the DEP approval
Other(describe):
k
Approximate age of all components,date.installed(if known)and source of information:.
Were sewage odors detected when arriving at the site&es or no);
Page 7 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM i
PART C
SYSTEM INFORMATION(continued)
Property Address:. '
Owner's Name: -ci L
Owner's Address:
Date of Inspection: °-1 j -Q'3
BUILDEiG 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)
Depth below grade: P
Material of construction: W' oncrete_,metal -—fiberglass_.—polyethylene
—other(explain) �.
If tank is metal list age: Is age confirmed by a Certificate of Compliance eves or no (attach a copy of .. =
certificate) ,
Dimensions:
Sludge depth: ,
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 'i tc c .E
Distance from top of scum to top of outlet tee or baffle: .
Distance from bottom of scum to bottoms of outlet tee or baffle:
How were dimensions determined: �p
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,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 FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner's Name:
Owner's Address: r
Date of Inspection: G-1- l —C",
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: —11ons
Design Flow: gallonslday
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Continents(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be.opened)(locate on site plan):
Depth of liquid Ievel above outlet invert:
Comments(note if boa is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage eiinto or you�t�ofbox,etc.):_ `'
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.):
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address;' V
Owner's Name: 'L ,er
Owner's Address: Q
Date of Inspection: 1 —�•
SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required)
If SAS not located explain why:
7Cy_p
leaching pits;number:
leaching chambers,-number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool, number:_
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failuz6,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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address:Ir 6 �,-vr
Owner's Name:
Owner's Address:
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.
n
0
�. 3
Page 11 of 11
OFFICIAL INSPE
CTION FORM—NUT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 eZ 3 T.,nr't-C
MCA
Owner's Name:
Owner's Address: )
Date of Inspection.
SITE EXAM
Slope:.Gear-1 ,.,,;— S/e.J�:�>c c
Surface water%t,,x)-�e d
Check cellar: FJ
Shallow wells Poo
Estimated depth to ground water 1��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 water elevation:
o �
.�
1
4
w0✓ THE COMMONWEALTH OF MASSACHUSETTS1v FRiii
BOAR® OF HEALTH
Q 0 / u3
�3 13 Allp iration for Disposal Workii Tomitrurtiun Vamit
Application is hereby made f Permit to Construct. kor Repair .( I an Individual Sewage Disposal
System at:
... ............ _Y�4
Locatio -Address or Lot No,
...... .��.1..' ........... .W... lOX.... . • `P a/ s t�1.!b•• ..... ......
Owner J� Address
C `
Installer Address
U Type of Building Size Lot____�-� ��� Sq. feet
f.......
Dwelling—No. of Bedrooms..........3............................Expansion Attic V o Garbage Grinder (/u
aa Other—T e of Building .............. No. of ersons.........._...._............ Showers
YP g -------------• --------•------------.P ( ) — Cafeteria ( )
Otherfixtures -------------------------- -----•-•-----------------•-----•-•----------••----•---•----------.......----------•........_••---•
W Design Flow.............5:5..........0®.-__gallons per person per day. Total daily flow............33JO..................gallons.
WSeptic Tank—Liquid capacity-`---_a-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 b --.j �.` /. x_�c!1!� Date...........
Test Pit No. L. °+5 5minutes per inch Depth of Test Pit----- Depth to ground water.. 1_e_ /J
GTq Test Pit No. 2.-1 jkk!z _minutes per inch Depth of Test Pit---------•--___---- Depth to ground
xX-----------------•------------------------......._..-------.......... --------
Description of Soil--•-•------------- =r 2 ...A�Ir� f `' Scaf4------•-•-•--------••-•-----------•-----------•---------------
'� .................................................... j ---
UNature of Repairs or Alterations—Answer when p li ble__ ---------__________ _ ____
� �� S' -------------------------------------------------------
Agreement:
The undersigned agrees to-install the aforedescribed -Individual Sewage Disposal System in accordance with
the provisions of AITLE 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..................... . ........ -- -�
at
Application Approved BY - j . ..........
Date
Application Disapproved for the following reasons:...............................................................................................................
----------------------------••-------••-•----•--------------••-----------•------••------•--•-•----------------------------•----•--•----•-•-............................................................
Date
PermitNo......................................................... Issued.......................................................
Date
pp
No..S�2,J, FE$.....5"'o........
THE COMMONWEALTH OF MASSACHUSETTS +
BOARD OF HEALTH
L.. . ................0F............172... :��� �./,�;.-�l� �
Appliration for Dispnsttl Works Tunstrn.r#ion Prrutit
Application is hereby made for a Permit to Construct,0" ) or Repair ( ) an Individual Sewage Disposal
System at:
r.
....................... -- — --• ..... !..r-}...g.. . ............... ,.......
,......... �r+.------�;•�-r--•--.. .^;... ... - ;✓ /
Location-Address ,� �v 414or:1LOPd o. t {
r-
......................„..........,...._.................................................. ......................._._...................... --- ---•-----------.--
r Ownel`F 0 . ' Addyr�eass
-------•-
{� t�!'//l�l A ddress
d Type of Building '� Ize ot- `.........................Sq. feet
U Dwelling No. of Bedrooms............. .Ex anion Attic Gar e Gr-hdkr
___ No. of persons........................... vers ( ) — Cafeteria
a Other—Type of Building ..................y _.. +�' ( )
Otherfixtures -----------------------------------•------------------••--.......••--•----------••••------------•••-•-•-•-•---•-•-•-••-•......-••-•-.............._..
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—Nod..5............pp Width.................... Total Length.................... Total leach gMI....._......._.____sq. ft.
Seepage Pit No---------_--------- DiarhMO........___.__..... Depth below inlet................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........................................................................... Date........................................
aTest Pit No. 1.............ek.Sinutes per inch Depth of Test Pit.............__... Depth to ground water____.✓.............r-
(i, Test Pit No. 2................minutes per inch Depth of lest fPa E.-z M.F h to ground wate _a ...........
® ------------------------------------------------------------••....... �-�
Description of Soil....." A.. '..' '` '"�'�r/4
x .........................................'�.�._.........��.. '' '` f
w ..........................--------•--•-•-•••-•-------- - r
UNature of Repairs or Alteration nlw when a licab _e_/' ,-------- ,,� ---------------------------------------•------------.
U P � � PP� -----. -
-----------------------------------------------------------•----------------•--•---......------------------....-------------------------------•-----•--------------------------------....•••---••.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
1-rrmr^
the provisions of 11 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-------------------------------------------------------------- .....--
Application Approved By.............. ....
_..._.....-•-----•-- ' -• = .�'�._,t.. .._ .
t
Date
Application Disapproved for the following reasons--------------------------------•----------•------•-•------------------------------------------------------....._
......................................•-......_...-------------------------------------------•----------........--......................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................................OF............................................I........................................
���iifirtt#le laf� ��
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------••..............................._•__.._..._..-•4........................F....._._....____....__•_-___•........_•_......._................................: ..........................
Installer f„j
at- _ -- sit y"_t'' •• ••-- '���� t-`✓= F_/ --- �•---••• ••-......----•--it
has been installed in accor n i rovision. f "�?r" 5 of T e St S itary Code as describedhe
` � .,f. fapplication for Disposal Worksuction Permit•�t�C'o__________________ �ted__...__ -:.`" ' _.__ ? ~'•-•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION S TISFA TORY.
DATE................. ra4....... Inspector... .... ................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�,,.. .�
OF............................................................•---.....................
........ FEE........................
� 1rk Tnimr`�f�' #AfifrAffi
Permissionis hereby granted-------- -----------------------------•-..---•--•---•••••----•••-•-•--•••••-••-••--••--•----••-•--•---•--.....••••--.............._...._.
to Construct ( ) or Repair ( ' ) an Individual
�ap age Disposal System
at No. - ..............
-----.---•-• f E ''r
Street
as shown on t e1•i application fop D�st sal )ygr-ks CQlyit �ionermi.,,,No____________________ D e ___�..__...._._.__.�_ : ,...
,. .
oard of Health �`
DATE-----------•---• •---••-----•-•••---•-•••......••............. .....•--.--•-
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
L0 CATION (� S E\ AGE PE I1IIT p0•
vlLLac -- `
IqS AA ER°S qA E ADORES-S
GUILDER OR OWNER
® A-TE RiAIT ISSUED
M
DATE COAA_Pl1ANCE ISSUED Y
S 1
-
f
• Lain t
:.j
\f� « {✓' ,s, FRS.
I
�' yU /illfcU.tcMO 5"6"'j E
v IV 2�CurzvG-D.pc4r/
":D
<) ti
- . - -�
Z H�C'_�.A cEF. rF-i srsAT �co
r ST vF AM`I K_wc7WLE Dc..L: T-HI=
O rf
FALL. '--l-TH44 I-HE,: PLAi"-
AS -1tiikTlvL.,nt.
u�v�'A,_ E P�Au Fn2 rr Gc'-x.)•r.y
�ATe- ' tro E.MI't a- f14,
r '•
�/�cLal= �(=:.�% �.A. r, tea- Jc "•4crd'._ �5q l ( l�tv e,�c� s, \ of
oaf LBE T-
M R E v No.10951 O
F��SIONA✓/
LEGEND
EXISTING SPOT ELEVATION Ox0 o��`J`tH�f sq�yG CERTIFIED PLOT PLAN
EXISTING CONTOUR 0 --- x, �, �r
FINISHED SPOT ELEVATION H Cc—Ch/ F>�. h'1//�.LE }
FINISHED CONTOUR 0
APPROVED : BOARD OF HEALT E� o IN
�o Sua� SAJI � S fA131 A,NASS
DATE AGENT SCALE, r=40 DATE,
LDREDGE ENGINEER/NG CG! IN CLIENT3��E�
I CERTIFY THAT THE. PROPOSED
EGISTERE REGISTERED J08 N0. B f bz3 BUILDING SHOWN ON THIS PLAN
CIVIL LAND n�" CONFORMS TO THE NING LAWS f
ENGINEER SURVEYOR OR.BY� OF BARNSTABL�E, SS. �cc�nr t
CFI. BY
cl.K a
712 MAIN. ST.
HYANNIS MASS. Z
� SHEETS OF DATE RE.G. LAND SURVEYOR ,