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HomeMy WebLinkAbout0069 GUNSTOCK ROAD - Health 9 GUNSTOCK IMA�D, 09TERVILLE r TOWN OF BARNSTABLE f LOCATION SEWAGE # VILLAGE ASSESSOU MAP & LOT��-q�v� 13 �I �ZVZf C/ :5 NAME&PHONE No V SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (;-/ (size) NO. OF BEDROOMS BUILDER 0 OWNE PERMTTDATE: 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 ``ti r • ; , �� � ._ o S � � �� � \ . i TOWN OF BARNSTAIE ILE LOCATION ��� r,����� r.V SEWAGE# ao 7 A 3 of � VILLAGE ASSESSOR'S MAP&PARCEL 13 INSTALLER'S NAME&PHONE NO. 5[ r U k C-k SEPTIC TANK CAPACITY e y(S.+ f o U o ®� LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3' 6 X �C`�'�`^' � OWNER Qp,r,C, Scv4t Lo Cr s, 0 A PERMIT DATE: 9,19 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4 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 �- -7 1 �S A a✓ ®. , Qk-:: DCox No.,;� c(—7 Fee /c THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:—�L PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftpfltation for Misposal bpstem ConstCUttion Hermit Application for a Permit to Construct( ) Repair(%,)`-upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. G� (Yv(v&3Z CA �-k Owner's Name,Address, 1and �Tel.No. mAssessor's Map/Parcel \a 65 v 1`� w`cY F -t-r Installer's Name,Address,and Tej.No.o` w r!� 3, Designer's Name,Address,and Tel..No. �V, 3 Y V` \ Type of uilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons .Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Q C S [ o Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) `( �, �cC�tC�6 �; � A V Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board 95ealth. Signed Date(r1 J S Application Approved by Date Application Disapproved by Date for the following reasons Permit No. "D �� Date Issued No.� u—7 Fee ._ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Misposal 6pstem Construction Vertu Application for a Permit to Construct( ) Repair(\,)"'Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. �j �V�S�6t✓� Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel `\t 1vCAJ`CY �� Installer's Name,Address,and Te kNo, `d c,r M0 kt_,V Designer's Name,Address,and Tel.No. Ck otD Ci Type of uilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided "- gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank p X S q Q G Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) .�`G[.-�_ �eS r\- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board, Health. j Signed Date S~'`l 1 1-7 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. c� t kM Date Issued . . --- ----------------------------------- ------- - - - --- -------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(L/ Upgraded( ) Abandoned( )by Srn�l M V-c-�/" ` - - at- L G Q d 0 y 6\V2__ -- - has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.,q.,:a /3�dated r•l'!/ Installer �,, C0� M �r,�/� Designer #.bedrooms• Approved design flow _ gpd The issuance of this permit shall not be construed as a guarantee that the system willefu hon`as"designed. Date 5/ f l Inspector No. � Fee S` f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i3ermit Permission is hereby granted to Construct( ) Repair 1U�pgrade( ) Abandon( ) System located at ko Cs (7-U nst [) nn t r_V i�d ©S .rV i N k_-e and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must b°e�completed within three years of the date of this perm' . Date I ' t / Approved by "' � t iq BORTOLOTTI CONSTRUCTION, INC. 11N 45 INDUSTRY ROAD, MARSTONS MILLS, M. 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE, DISPOSAL SYSTEM INSPECTION FORM PART A" CERTIFICATION Property Address: Date Of Inspection y O Inspector's Name:. O ner's Name and Address: 696 c 11h (0,19 SSA 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- t .. posal Systems.T e system: LL t Passes Conditional)Conditionall !yPsses , Needs Fu Eva atio y the Local Approving,Authority. Failur Inspector's Signature a Date: �/�7/ cgj 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: t;.{ A) SYST>yIGI 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 exffl- 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): Y 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 it' 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 SYSTEMIS,F;UNCTION- "ING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND TH E 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.dueito an dver'Ioaded or clog- ged: :SAS.Or,CesspO,0, Liquid,depth.in cesspool] less than G"below.invertor.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 - lie, +; Sl1BSURFA( •SFWA(:E'1 )ISPO) XC SYS`1•teM- INS'l FC 1•ION FORM PART A CERTIFICATION(continued) Any portion of the Soil Absorption Syslem,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 I 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 coliform6bacteria,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`I+eet•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 Welihead'Protection Area (1WPA)or a mapped Zoue tl;of'Vp 61i' 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 following have been done: ✓Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two 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. The 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. ` All 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- L.speeted';foe condition of baffles or tees,material of constructionI dimensions,depth'of liquid,. depth of sludge,depth of scum. t'lie 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 �F p too[• SUBSURFACE .SEWAGE,DISPOSAL SYSTEM"INSPECTION FORM PART B CHECKLIST(continued) V•1'he facility 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 - FLOW CONDITIONS RESIDE ua Design Flow: U gallons Number of Bedrooms:_ 8 Number of Current Residents: Garbage Grinder: Laundry Connected To System: Seasonal Use: 211;- Water Meter Readings,if aflable: Last Date of Occupancy: — COMMERCIALAND T Type 41'Establishment: r.=. ., . Design Flow: gallons/da Grease Tra Present: es or ho ,'- ' " "`^ Y p (y ) .... 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: 2 1 System Pumped as part of inspection-�',Iz If yes,volume pumped: gallons Reason for Pumping: TYP"F SYSTEM:` t/ Septic'Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if.any) - Other(explain): -A TROXIMATJEAGE.of all com f ents,date installed(if known)and sourceof information.; F ' Sew lie od rs'detected when arriving at the site: - - - -4- SUBSURFACE SEWAGEA SPOSAI. tiVSrl`E,M IN'SPECTUON FORM . PART C GENERAL INFORMATION (continued) SEPTIC TANK: !/ Depth below grade: Material of Construction: ✓ concrete metal F'RP Other (explain) Dimensions:g 5 'a'w'XS' Sludge Depth: j/�P1X�_ Scum Thickness: 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 tees or baffles,depth of liquid level in relation to outl invert,structural integrity evidence of leakage,etc.) / oI/t GREASE TRAP: Depth Below Gra e• 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 pumpin condition of inlet.and ooutlet tees or baffles;,depth of liquid level„ _ in'relation to"outlet Invert;'structural integrity;evidence of leakage,"efc) TIGHT OR HOLDING TANK: Depth Below Grade: Material 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:�,[�{1/) 0 Comments: (n if level an distribution is equal,evidet of so 'ds carryover,evidence of leakage into or out of x,et box, � --PUMP CHAMBER: Pump-is--in working, rder: y .';ets: ( = - Commennote`condition of pump c,l►ainber,condition of pumps,and appurtenances,etc.) S - ar.Y .i. .4 if .,.. ..., «s�. • - S 1113 . SURFACN'SN WA(.N DISPOSAL SYSTEM 'INSPECTION•.N FORM, 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: y Leaching chambers,number: Leaching galleries,,number: Leacabing trenches,number,length: Leaching Gelds,number,dimensions: Overflow cesspool,number: Comments: (note conidtion of soil,signs of hydraulic failure lev kof ponding,conditioji of vegetation etc.)_ Q� " CESSPOOLS: Number and xoA figuration: 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) Continents:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.) PRIVY: Materials.of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation, etc.) . .. .b;l,€,`'., •. . . _;,�`:4, « .. k`�tA.a.�_�,_. ..t t,.t; .... `_".,rat_..._ - 6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM•INSI'EGTIUN FORM PART C. SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references,landmarks or benchmarks. Locale all wells within 100 Feet. r 4z -33 ,f a�• Y.„� .r A"i.r. t `� 1 E �4i •___,. _. .. ' -x+` ,..Pt .'i.Fir �'i:'t I .irk � F t �.3 gyp.;{.� .i ���`'' � DEPTH TO GROUNDWATER: Depth to groundwater: - / Feet P -Method of Determination or'Approj�imation:. /" /6 /2�ftj' ,� THE-COMMONNWEALTHCOFUMASSACHUSETTS BOARD � �-� �I ✓ .....OF........ ..... . ........... ......................................... i Appliratiou for %gpviiFal 10orkii Tomitratrtiou frrutit Application is hereby made for a Permit to Construct P<�Ior Repair ( ) an Individual Sewage Disposal Sys at: -•--Locatio - M or Lot No. »». ... ---•----------------------- .. ........ % �Ow r Address W '. ------------------------•••-• -------------------------- -------- Instal Address Type of Building Size Lot.. __ / _ ___0___/� q. feet Dwelling—No. of Bedrooms............................................Expansion !tic ( ) Garbage Grinder ( ) �_l Other—Type e of Building No. of persons............................ Showers — Cafeteria G4 YP g P (�1. ( ) p-' Other fixt Design Flow.............. - ------•• .. ----..gallons per person peK day. Total dajl f --------3.3-0--------------- to �r W �' W Septic Tank—Liquid capacit/.O.C..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 ar ..sq. ft. Other Distribution box ( ) Dosing tan Z Percolation Test Results Performed by____________............ __ .__.__._.____ Date ............ Test Pit No. I 15�' .._2�-�minutes per inch Depth of Test Pit.................... Depth to ground water..................... Test Pit No. 2...4?_.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptio�f Soil_____® ` Z_ "� Z' � iot --•----•-------------------•-------=------•-------------•---------------------------------.-----...... U W •--•---•-------------•-••-----..............._..------••-••---------•-•-•••-•---•-••--•-•••--•-'-•••=---••----••------------•------•'--•-•--••----------•••••••---••---••---•......•-••--•--.._.._•--•-- UNature of Repairs or Alterations—Answer when applicable.___________________•____.--________----__-____------.--__-__-__-_------._•--__--_--------- '---•••••-•-•••••----•••--•--•••----•-•-•-••-••-•-•-•••------•-•••-••••••-•-•--•-•--------•------•-•--•-•-•-...•---•----••--•-••-----•--•---••-•-------•••----•••••••-•••-•-•"-•-•--••...............•. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:T i p 5 of the State Sanitary Code—The undersigned furth re s not to place the system in operation until a Certificate of Compliance has b ed by the boar ea - 3 Signe --------... Date Application Approved By--•.. --• -- •-••-•........... ------••--•'---------•---••-•---' "�'"-............... Date Application Disapproved for the following reasons:_...................................... -•'•-----'-•••---................................................... ----•----------------------------•--•----------'--------------•-------------------------....----•---•---•-•--•---•-•-•--•-......•-•......•--••-••---'•-•••--•------------•--•------••--••......------ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ,_...-..----- BOdeRD OF HEAL. ._I� Y- r , .-...OF...... ' Appliration for ElWpoiial VorkB Tomitrurtion Famit Application is hereby made for a Permit to Construct ), or Repair ( ) an Individual Sewage Disposal Syst a / ; ;� 0::Z��", , / r Locatior ddress:. or Lot No- _._. ,•....................... '' .-+-. -....... ....................••••-•-••-.........----•-• W .. At Ow er Address a -°Z��•- •`r 1......yJ°e�...•-----• -•-------------------------------------- Insta Address I r Type of Building 'i Size Lot_....... feet U a Dwelling—No. of Bedrooms____________________________________...._.Expansion�. Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers Cafeteria ( ) Otherfixtu esm-----------------------------------------------------------------------------------------------------•----- -----------------_-____-_____---- WDesign Flow.............!�L_ ___________________gallons per person per day. Tota ilpow------- _-_Xtr�__.................... o- 1f W Septic Tank—Liquid capac>t ____gallons Lengthc,��-=-3�---__ Width------- Diameter----............ Depthl______ - x Disposal Trench—No_ ____________________ Width.... Total Length.................... Total leaching area..... .= , sq. ft. Seepage Pit No--------------------- Diameter_/_t`�__....•..... Depth below inlet..-_�'�__.._.,,Total leachWgar _ t ->-_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) j _ / Percolation Test Results Performed by___________ __________________________ .___:_:__.. _ Dat .._..__________.._._.._-. Test Pit No. 1s .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........................ Description of Soil..... - = -- -17 °t `= W ----------------------------- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------------_.................... --------------------------------------------------------------------------.-•--------.......------------------•---------------------------------------------------------- .............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f-1 I:T/'1'' the provisions of T 5 of the State Sanitary Code— The undersigned furtker y gr- s t to place the Vsyste;mioperation until a Certificate of Compliance has been j-,sted by the board-of4 e`°lth. Datep� Application Approved By........... _ ^' Date Application Disapproved for the following reasons_______________ _____________________________________________________________________________________•--•...___ -•-•................•-----------------------•------•-------------•---•--------------•------•-•---•----------•----------•------------•-•---------•---•----•-----•--------••-----------••--------•-------- Date :Permit No.-----•----•.....••-------•-•--•------------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD._OF HEALTH______ (9rdifiratr of Tontpltanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed .; ) or Repaired ( ) ,._...^ •--Installer �r�,/ --•-- .. has been installed in accordance with the provisions of T rr pf The State Sanitary Code as described)n the application for Disposal Works Construction Permit No. ....r ..s______________ da.ted_-_ _._'X. _"___..�-------- or— .____.__._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................••••..........�,^\ Inspector----, THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HEALTH�--j�""� NoFEE........................ Disposal J orko (9jawitnirtion runfit Permission is hereby granted_..__! '!-''`" ........... �"" .�--- . :--•-- --------•------------------------------------------------•----- to Construct )--o Repair ( ) n Zndi-,dual Sev, g Disp stem �,� _ Cam" ---- at No. ...---- •_.. _...__ ._ r Street _ j as shown on the application for Disposal Works Construction Permi o___________ _______ Dated. 3_'"-............... 1�DATE---------.:r._'�----+�-�--------------------------------------•-•---- Boar of Health FORM 1255 HOBBS & WARREN- INC., PUBLISHERS !,` � 1 + r CC J 9 103 ' r. � �, C��` �1�, Dart• i �r ,`, 0 r� i N - N 1-A'4S' 00 r, ps- SST -: -.•. ' .. .. .....n -_.-. - .. - -- _ .- _. . -+r. —r. - '_3 x 'i' b LEGEND CERTI!1E,D PLOT PLAN EXISTING SPOT ELEVATION OAO �'�hOFAf4ss - EXIISTIING CONTOUR --- p'-- - -- r �� o`y ROBERT yc � :l1WSHED SPOT ELEVATION 0 0 ,F, ��P. FINISHED CONTOUR -• 0 UNiKi �, IN�1PPR4VED,t BOARD YOF. HEALTH � � ,�i$# 1A P ag,AASSDATEAGENTSCALE: i > DATE CDREDGE ENGINEERING CO /N CLIENT UsF ��%� I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED p���f� . BUILDING SHOWN UN . THIS PLAAI tV J06 N0. --- CIVIL ' LAND CONFORMS TO THE ZONING LAWS DR.BY _ - OF BARNST�. LE MASS. ENGINEER SURVEYOR I 712 MAIN ST CH. BY —u— I t' - HYANNIS MASS. SHEET)-- OF — DATE REG. LAND SURVEYOR i 1 "s?® FT. /°'//N N07 E /F F/TN�'R THE SEP.T%C TANk DR L,EficN/,,vG P/r AjRE MORE. :THA/V /BffBELON/ /N. -- -GRAO�, f� 24.0/AN/ET.ER •COI►rcRET�' C'OliEa 5tlALL EE BPDU SIT TO 6/�A�E.�.4N EXTR/4 q'PYC ®/PP NEAVy CAST /RO/Y GoYER SiN.4LG. DE 41SE.0 CONCR@T@ .: AWN. 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