HomeMy WebLinkAbout0024 JASON'S LANE - Health 2.4.Jasnn!o$ t-"Vzl
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plitation for Disposal 6pstrm Construftion Vertu
Application for a Permit to Construct( ) Repair(Y) Upgrade( ) Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No. 14 ZTA500 5 G*4045 Owner's Name,Address,and Tel.No.
Z»�'7' PaTEt,�GA (�l��C-7�034etI
Assessor's Map/Parcel i QINUMS7WE E1PFA (V 0 VA
Installer's Name,Address,and Tel.'No. 50 8—141 77 Designer's Name,Address,and Tel.No.
C'i4AGl�slbE Eo1'ezPASf�s "X__ N!A
153 C f1 WfG A1(- 5T
'lope of Building:
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 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Hea .
Signed Date lO — mU PA015
Application Approved by G Date
Application Disapproved by Date
for the following reasons
Permit No. °" Date Issued
No. �_o �� / / 16'IQ a Fee ( `'Ol �-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pplitatlon for Disposal 6pStem Construction Permit
Application for a Permit to Construct( ) Repair()� Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. ;14 UASdNS G#40O Owner's Name,Address,and Tel.No.
05'T PA-0tIVA 7J1GFqE)VO4`W
Assessor's Map/Parcel $ e p RIM E FF�I i/}T(0111 VA
Installer's Name,Address,and Tel. o. 50 Fa-1411 —$'$77 Designer's Name,Address,and Tel.No.
Cs4A6t�t�E E7U`��Pk1SLS �.-c.G.. N fQ
15 Col AE. �" rt4
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heath.
Signed Date ' Q
Application Approved by M mctl-11144aDate ZL /
Application Disapproved by Date
for the following reasons ,
Permit No. Date Issued
----------------------------------------------------------------------------------------------------_----------------------------------
®��\ THE COMMONWEALTH OF MASSACHUSETTS
_M
n BARNSTABLE,MASSACHUSETTS
r Certificate of Compliance
. Cal
THIS IS TOCERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired
n (X) Upgraded( )
Abandoned( )by V�peo g F_ ?�1_ z 4-
at l 4,50a (,41C 0$ j='PV j .(E7 has been cons cte/d,,�t accr ar�ce
with the provisions of Title 5 and the for Disposal System Construction Permit No % ' a d
Installer 0—ApG�—(DCZ 0U dS?P (,(,G Designer ; A
1
#bedrooms Approved design flow ( gpd
The issuance of this pe ��Jsh 1 not be c n trued•as a guarantee that the system will ,ction71as�ydlesi/glued.
Date V I y Inspector j!/J.f f i l/t i n
t - I p W ' +✓ r v - �-
!----------------------------------------------------------------------------------------------- --------r�
No, o � ! � �j� Fee ��V�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction Permit
Permission is hereby granted to Construct( ) Repair(Y) Upgrade( ) Abandon( )
System located at zr As o i _S L4 M; &}, x /u—,g
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 be rleted within three years of the date of this permit.
Date (0 pD Approved by
3) GPI
AsBuilt i Page 1 of 1
TOWN OF BARNSTABLE
LOCATION Z ,ro»�� 6? „SEWAGE #
VILLAGE �(�r-���/ ASSESSOR'S MAP & LOT /a I
. INSTALLER'S NAME PHONE
SEPTIC TANK CAPACITY.
LEACHING FACILITY:(type)rl0(�LD- (size) Gtc�
NO.OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: - Ss
DATE COMPLIANCE ISSUED: 7.- )-,7- $
VARIANCE GRANTED: Yes No �--.
- 1
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t 20, ,2015 21:46 Jim The Inspector Man 5085349919 page 1
Commonwealth of Massachusetts woo
U
Title 5 Official Inspection Form -a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r�.1
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
required on is every
OSterville
required for eve � MA 02655 10-21-15
page. City/Town State Zip Code Date of Inspection 1v0
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
tilling out forms C/ `�puurnnrrrr�r
on the computer, CJ! # /�2�� ``���``�`\�,1N OF;t?Assq,X-
use only the tab 1, Inspector: ��= '•c��.
key to move your '�;' JAMES G cursor-do not ,lames D.Sears =�
key the return Name of Inspector
VQy Capewide Enterprises, LLC
Company Name �, G
153 Commercial Street s„�g,P���`����
Company Address ,
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1823
Telephone Number License Number
B. Certification
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 16.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10-21-15
spector'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.
****This report only describes conditions at the time of inspection and underthe 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,
ISins-3/13 41.
Tills5 Official Inspection Form:Subsurface Sewage Dispose l or 17
,Oct 20 2015 21:46 Jim The Inspector Man 5085349919 - page 2
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner owner's Name
Information is
required
re wiredfiredfor every Osterville MA 02655 10-21-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cant_)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal.Tank D Box and three flow's.
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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements..lf"not
determined," please explain.
The septic tank is metal and over 20 years old' or the septic tank (whether metal'or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent..System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
(Sins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Oct 20 2015 21:46 Jim The Inspector Man 5085349919 page 3
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA 02555 10-21-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
15ins•3113 Title 5 Official Ins peclion Form:Subsurface Sewage Disposal System•Page 3 of 17
Oct 20 2015 21:46 Jim The Inspector Man 5085349919 page 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is
required for every Osterville MA 02655 10-21-15
page. City;Town State Zip Code Date of Inspection
B. Certification Cont.
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 aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.-
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
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
El ® Liquid depth in aleler is less than 6" below invert or available volume is less
than %day flow ei}0111A e'
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17
,Oct 20 2015 21:46 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owners Name
tion isrequirred for every Osterville
MA 02655 10-21-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification
Yes No
® 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a'surtace water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis, [This
system passes if the well water analysis, performed at.a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® 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.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking.water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 . Title 5 Official Inspection Form:SubsuAaoe Sewage Disposal Syste•n•Page 6 or 17
Oct 20 2015 21:46 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
F Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is
required for every Osteryille MA 02655 10-21-15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been don l e. 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?
❑ ® 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) an the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedroomsj: 330
t5ins 3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Oct 20 2015 21:46 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
19 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA 02655 10-21-15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and three flows.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ®' No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 2013-42,000Gals
2014-47,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 6 Official Irspection Form:Subsurface Sewage Disposal System-Page 7 of 17
,Oct 20, 2015 21:47 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA 02655 10-21-15
page. City(Town State Zip Code Date of Inspection
D. System Information (cost.)
Last date of occupancyluse: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 9/22/14
Was system pumped as part of the inspection? ❑ Yes ® 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)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank_Attach a copy of the DEP approval.
❑ Other(describe):
15ins•3l13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Oct 20 2015 21:47 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
6 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA 02655 10-21-15,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Tank and two flows 1979 Permit#779-79- one flow 1988 permit#88-70 10-2015 New D Box
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20
feet
Material of construction:
❑ cast iron ®40 PVC ® other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40& SCH 20_
Septic Tank(locate on site plan):
Depth below grade: 101,
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
-If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth: 3"
t5ins-3113 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Oct 20 2015 21:47 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
F
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required For every Osterville MA 02656 10-21-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cant.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Inlet cover at 10", outlet cover at 8", In and outlet baffles. No sign of leakage
or over loading.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-3113 Title 5 011lclal Inspection Fort:Subsurraoe Sewage Disposal System-Page 10 of 17
Oct 20 2015 21:47 Jim The Inspector Man 5085349919 page 11
�C\_' Commonwealth of Massachusetts
14 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not For Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owners Name
information is every
Osterville
required for eve MA 02655 10-21-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
i
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
r
t5ins•3H 3 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 11 of 17
Oct 20 2015 21:47 Jim The Inspector Man 5085349919 page 12
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA .02655 10-21-15
page. Cilylrown Slate Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
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.):
D Box is new 10-2015. Box is 16"x 1F-16" below grade. One line out w/cover at 6".
Pump Chamber(locate on site plan): .
Pumps in working order. ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 O(fidal Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Oct 20 2015 21:47 Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA 02655 10-21-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number:
3
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: "
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is three flow's. Flow's are 15"below grade. Leaching is clean and dry. No sign of over
loading or solid carry over.
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 ❑ No
(Sins-3113 Title 5 Official Inspecl'on Form:Subsurface Sewage Disposal System•Page 13 of 17
Oct 20 2015 21:47 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
Title 5 CJfficial Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
• s 24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is Osterville MA 02655 10-21-15
required for every
page. Cityrrown State Zip Cade Date of Inspection
D. System Information (cont.)
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 114 of 17
,Oct 20 2015 21:48 Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
A Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owners Name
information is required for every Osterville MA 02655 10-21-15
page. City1rown State Zip Code Date of Inspection
D. System Information (cant.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
f
R E/9 R
6_ � _s�
79 to 2
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Oct 20 2015 21:48 Jim The Inspector Man 5085349919 page 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville .MA 02665 10-21-15 page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N°
Estimated depth to high ground water: 8+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® 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:
Auger T.H. 8' no G.W.. Bottom of flow's at 3' below grade. Bottom of flow's at 5' above T H Depth
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3r13 Title 5 Official Inspeclion Forth:Subsurface Sewage Disposal System-Page 16 of 17
Oct 20 2015 21:48 Jim The Inspector Man 5085349919 page 17
Commonwealth of Ma
ssachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
24 Jason Lane
Property Address
Patricia Diefenbach
Owner Owner's Name
information is required for every Osterville MA 02655 10-21-15
page. CilylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins-3113 Title 5 official Inspecion Form:Subsurface Sewage Disposal System-Page 17 of 17
f
CERTIFICATE OF ANALYSES
Page: 2
� ot3� Barnstable County Health Laboratory
Report Prepared For: Report Dated: 04/10/2001
C&O&Marstons Mills Water Dept Order Number: G0109435
P O Box 369
Osterville, MA 02655
Laboratory ID#: 0109435-02 Description: Water-Drinking Water
Sample#: 09435-02 Sampling Location: 24 Jason Lane Osterville MA Collected: 04/04/2001
Collected by: G Oakley House Received: 04/04/2001
Test Parameters
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:IC Lab
Nitrates 3.5 mg/L 0.1 10, EPA 300.0 04/04/2001
LAB:Metals
Copper 0.6 mg/L 0.1 SM 3111B 04/05/2001
Iron <0.1 mg/L 0.1 SM 311113 04/05/2001
Sodium 14 mg/L 1.0 20 SM 311113 04/05/2001
LAB:Physical Chemistry
Conductance 232 umohs/cm 1.0 EPA 120.1 04/04/2001
p1I 7.0 pH-units 0 EPA 150.1 04/04/2001
Approved By: d l_—
(Lab Director)
�iotlx�d
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
o�=.gin
' Page: 2
CERTIFICATE OF ANALYSIS
!k
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 04110/2001
C&O&Marstons Mills Water Dept Order Number: G0109435
P0 Box 369
Osterville, MA 02655
A
Laboratory ID#: 0109435-02 Description: Water-Drinking Water
Sample#: 09435-02 Sampling Location: 24 Jason Lane Osterville MA Collected: 04/04/2001
Collected by: G Oakley House Received: 04/04/2001
Test Parameters
ITEM RESULT UNITS MDL MCL Method# Tested
LAB:IC Lab
Nitrates 3.5 mg/L 0.1 10 EPA 300.0 04/04/2001
LAB:Metals
Copper 0.6 mg/L 0.1 SM 3111B 04/05/2001
Iron <0.1 mg/L 0.1 SM 3111B 04/05/2001
Sodium 14 mg/L 1.0 20 SM 3111B 04/05/2001
LAB:Physical Chemistry
Conductance 232 umohs/cm 1.0 EPA 120.1 04/04/2001
pH 7.0 pH-units 0 EPA 150.1 04/04/2001
Approved
(Lab Director)
'diilt�u
..Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
TOWN OF BARNSTABLE ~
LOCATION t=s��,e(� SEWAGE
VILLAGE '2 S%� oj'/_(�ASSESSOR'S MAP & LOT /I i-
INSTALLER'S NAME 6z PHONE NO.�S IA�s9-�tiP�',� y� �►
SEPTIC TANK CAPACITY //
LEACHING FACILITY:(type) -jyln �J D_ (size) �d��
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: 5r Sr
DATE COMPLIANCE ISSUED• a, %L-7 ci'
VARIANCE GRANTED: Yes No -
05
.:a
ASSESSORS MAP NO: --
" PARCEL N0: �"z�
No.... .. Fis..... ....2 D._.D.p.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
-----------Town...................O F..................B.ar.ns.t.ab l e...------------------------------------
Applirafivat for Disposal Works Cnomitrurtion truti#
.Application is hereby made for a Permit to Construct ( ) or Repair kXj an Individual Sewage Disposal
System at:
2.4... ------------------------------- ---------•------------................------------------------------------------......------------
Location-Address or Lot No.
irpstre-im----------------------------------------- .................................. -----------------------------•----------------.._.--...--------------------------------------------
Owner Address
WJ._,.P-.Macomb _z...................................k.............................. ........-----..........•.............-------•-•-•.............-•----•--•----...----•---...------
F Installer
� _ Address
UType of Building - Size Lot............................Sq. feet
., Dwelling-XNo. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons ....................... Showers —
a YP g ---------------•----------•- ----------P ( ) Cafeteria ( )
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—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by -------------•------------------- Date.
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rl --------------------------------------------------
....................
.--------
..4 --•-------••-•---•--•-•-•------•-•---......-.-------••_•----------......
O Description of Soil..............................zaxl.d.................................................
U --••••-•••-•-•--•••---••--•-••--••-•-••------•--•-•.....--•-•--•................•--••-----.......----------- =.-...-----------•--••----------•.....------.......---------------•--------------
W . .. .
----------------
--------------
...........
U Nature of Repairs or Alterations—Answer when applicable........1-4 x 8 __f 1 ow d i f f u s s o r
--------------------------------------------------------------------
------------------------------------------------------------------•-------------•---...-------•--•••-•...---
Agreement: `
'I The undersigned agrees to install the aforedescribedM Individual fSewage Disposal System in accordance with
the provisions of iiTl:a. ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by e and of iealth.
Signed
2l Date
{ � ate
Application Approved By.... . --• ....... --•---.•.-
.
Da e
Application Disapproved for the following reasons-------------•------------------•---•--------• ......................................................
........... Date
.._..
Permit No 0_0----------------------------------------- Issued...........................................
.,, ..
Dare
No..F _�.'.� FEE_ ...:a .»lrf....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
To-wn------ -----.....OF................TIa.MRStable.-----------._......---------------------
A firatiou for Dispnga1 Vorkg Tomitrartiun rruti#
Application is hereby made for a Permit to Construct ( ) or RepairX(KX) an Individual Sewage Disposal
System at:
.0. -tom=r�13-a--------------------------•------ --•--•------------••---------......-...-----• ----•---------•---•--.._..----------------
Location-Address or Lot No.
l�t------_------------------------------------------------------------------------------- ..............................................-------•...........................................
Owner Address
aJ.B.M5acomsbe Y
Inslw"er Address
UType of Building 3 Size Lot............................Sq. feet
�-, Dwelling X-No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type e of Building No. of persons............................ Showers
P.� YP g ------------------•--------• P ( ) — Cafeteria ( )
04 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—.\?o. .................... 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
r11;4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -•••-•••-••--- -------------•--•-••••--••-•---••••••••••..........---••..........------...-••-•......_......-•--•---•-----...-----•••-••-......-•--••---••_..
O Description of Soil...........................Sa.n.d---------------
x
--------------------------------------------------------------------------------- ----------------- --------------•--•••---------------•- --------------------------_-----
U Nature of Repairs or Alterations—Answer when applicable...___�___4_ 8___f_lowdi. ussar
.. . .--- ....------•••--••..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T IT LE 7 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h n issueWby, oaard ^ health.
e hSign _ . •-•
•-- ---••--•--•-•---•-a .
WI -11"e
at APPlication Approved BY _ ....
Application Disapproved for the following reasons------------------•---------------•----------------------------••--------•----------......--•-•-••---------.._.._
.............................................................
Date
Permit No....SU._ .... .............................. Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..................... ...... .................................................
%Trrfifirab of Tomplianrr 4
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedX }
----------------------------------------------------------------------------------------------------•---------...--------------------------....•---......-••--....--••-----
24 Jason Lang_ Installer
tJstexv:tZle
at.....................................................................................--•-_...-----••-----••--------•---•••-----••----••----•-••-•-••--•----•--•----•••••-•••-•...--•-•-•-----•-•-•.
has been installed in accordance with the provisions of ate Sanitary Code descr'" the
application for Disposal Forks Construction Permit No..... ~__. ._.... dated_--...<�7 ��p/ ...__.
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... -- 1--7-------•-•.................. Inspector . ...
A� THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
pp�' OF.................................----••---........................_......••-•-........ 20.00
Disposal Vorkv TIuns#r ion rrmit
J.P Macomber
Permissionis hereby grantd...................---•-•----•...............•---•--........_......----•-••••••••-.._.....-------••••...........-•--.................___-----
to Construct ( ) or Repair' an In i idual Sewage Disposal System
�t \'G.._24...Jason Dane s�erv� �e
-• ----------------------•--------------......-•-........•--•--.. -------•--•-••••---•-•..._.........................-
street1_ p
as shown on the a plication for Disposal `'Corks Construction Permi u.'__•. d Date �. 4� --
,,,,,,yy�� 1
...............
•------ __�!___A ..---_•.-_ .._!...............
Board of Health
DATE........................... ---------- .............
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS - ''+
LOCATION I VJ A G E p E Q ti ILT—C3 01.
VILLAGE xc; 73T
INSTA LLEWS NAME a ADDRESS
/2
8 U I L D E III OR OWNER
-'r.i, nj L) ivep-
DATE PERMIT ISSUED -/
DAT E C 0 M P L I A N C E ISSUED
t �
R 12
j • -!rw j
I
2 S-FlPe
No.-� �7� M FEB...II.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEM
-..--------- �.OF--------- ---- --------------------------------------------------------------------------
Appliration for llhip .oal Works Tnntrnrtion Prrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System a
• ----- -6 --- --------------•--•---
....... ....
— La ess Lot o.
- ._.. .. ---•••. .....•-• ......................- -............... '�' r .....................
ddres r
W
a -----•---•..................... ......... dd ..............................................
Instal r Address d (!Typ of Building Size Lot._____.._f—feet
U Dwelling—No. of Bedrooms.....,..................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures . .......... ------•-----•----------...---------------------------------..-----------------•------------.......---------........------.
W Design Flow.........1__?�_j.....................gallons per person per day. Total daily flow.............�1.0...................gallons.
WSeptic Tank—Liquid capacity_ ons Length................ Width................ Diameter--._---_--_-_- Depth................
x Disposal Trench—No..................... W' 1 Lengt _ otal leaching area....................sq. ft.
Seepage Pit No------- Dia >�tle ---..._.. • 11. o al leaching area............:.....sq. ft.
Z Other Distribution box ( ) Dosing to �q J�i7w `�D
Percolation Test Results Performed by._._�._ ,li? ...��:�i�✓. � l0 ' 7' �....... Date. ...
aTest Pit No. I.....��--minutes per inch Depth f Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--
/ - •• .................................
O Description of Soil-----�•---�------------ ---- �'-'•--•(-------------•--=------ -----`�- --- ----•---------------------------......-•--------
x ._
V ....................... -••-•-•-•-•-•----------••--••••--••••••-•---••-••-•--•--•--•--------••--•--•-----•-••-•--•-----•--•••--------•----••--•--•-----•-•-•--••••......•...•-•-•--••---•-•-••--•---••--
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 TITL- 5 of the State Sanitary Cede— 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 ------------------ .................................
Date
Application Approved By `%
Date f�Z
Application Disapproved for the following reasons:-------•-----------------------•----•------------------•-----------------------------------------•---•---------
---------------------•----...----•--•-------•--.....----------........-•--•-•----•----------•-----........._..........--•--------•-------------------------------- ......................................
Date
PermitNo.......................................................... Issued.......................................................
Date
i
-104 77
No................. ... r; FEs..:�!.....! ............
THE COMMONWEALTH OF MASSACHUSETTS {
BOARD OF HEALTH �
..................I fA.4.t AE?n .O F....... •...... ..�' '.
Appfir�i jan flan` Dhipuiiaf Works C ontitrurtiun ramit
Application is hereby made.for a Permit to Construct(40)or Repair ( ) an Individual Sewage Disposal
System at
,t r
Location Address f or Lot No. '� r
� ! Owner �--Addr`ess
Yer v
1
9 Address
Typ f In-stall Building Size Lot.....Z 1 "Sq feet
aDwelling—No. of Bedrooms-----,_.�`.................................Expansion Attic ( ) Garbage Grinder ( )
p� Other—Type:of Building _________________________••• No. of persons....................._._:_........._ ..... Showers ( ) — Cafeteria'. ( )
QI Other fixtures s., ^�'-----------------
-........................................................................................ '.........
W
Design Flow.......... .�....... ..........gallons per person per day. Total daily flow..........._....... ....................gallons.
wSeptic Tank—Liquid*capacitye6 lions Length................ Width---------------- Diameter................ Depth_._.. .........
x Disposal Trench—No. Width _ Total Length-� ... /.....Total leaching area___________________'Sq. ft. .
Seepage Pit No.___... ' " ''�Diameter -_ Deptl ^ �'met"_....cDepth below inlet _ Total leaching area..................sq. ft.
Z Other Distribution box ( ) ' Dosing to !J
Percolation Test Results Performed.by. y_ jYTest
.... Date-__f, ...z�:_.7 ..........
aTest Pit No. 1----- _-_minutes per inch Depth Pit____________________ Depth to ground water.._________.__:......._.
Test Pit-No. 2................minutes per inch. Depth of Test Pit------------- Depth to ground water.........................
......... --- ----------
ODescription of Soil.....' °Z j S � __f. r G, i ..........................................................V ..................•-----•••• = ----•------------•---------------------__..........--•--•-•---- ------.... --•--------- ---- -•-----------.--------------
W -----•--•----• ••----------•........_..•--•...............•-------------- •-••-••-- •......-•-- .
U Nature of Repairs or Alterations—Answer when applicable------------ ... ......................................................... i._:____: .
--------•-•---•••-•-••••••••---•--•--••- i.......................................... --, --- --•- . -----
Agreement
The undersigned agrees to install :the aforedescribed:.Individual Sewage;Disposal.System in Accordance1with
the provisions of TIT1E 5 of the State Sanitary Code The undersigned.furilier agrees not to place•the system in
operation until a Certificate of,Compliance has been issued by the board of health.
Sig ed-------- -- -
Date
Application Approved By------ rd -..: ........... a� '+ .....--
Date
Application Disapproved for the following reasons:_,....................................... .................•---•--- -----_----••,
••..............••-•-----•-•---•--........_........------------•-•-•-------------------. •-•--_.... ...........................
Date
_ Permit No................... ------------•--. Issued
Date (•
1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD, OF HEALTH
�
(11rdifiratr of �Torm .Iiaure
THIS vLS)TO CERTIFY,FTl ai the Indiuidual'Sewage Disposal System constructed 1(a-") or paired (� )
Installer
at --
y has been i lled in accordance, with the provisions of 4r r 7 of The State Sanitary Code as described m the
application for"Disposal Works Construction Permit N __._.7___s,_:.:...... dated /..�_ .3`__��r_ .••••.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......... -------------------- Inspector =
........................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD Oy:F. HEALTH
�S5..
.., ,�
Disposal Works Tons n "Vamit h.
Per is hereb granted. - .......................... .....
. •--•- ......
to Construct ( or Repair O an Individual Sewage/Disposal System
' at.-No
.; at,.No. ••�, l - f. q ,,. �.,',.-...• -t i
71
Street
as shown nheapplicationfor Disposal Works Construction Per nut No ..__ Datal.x
q
...------.
.__... ._.__
Board of Health`
DATE... ,
ji =? FORM 1255 HOBBS-.& WARREN, INC., PUBLISHERS
_ Dt=�IG►.1 T � TA � �,
I..,to GaczsnG� �:tzt atv�1Z r> -__
raat>_� FLow tib x 3 = sso &.F.T7 �pp•oc�
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USA- t OOCU GAL. .
�'jtSPDSAL 'PtT usa✓ tOc�-._.�a�L. _ C'��••IU�j O
tSo SF 4 Z.S • 3`75 G-POD.
'gvT•MAA
TOTAL 'pESIGtJ = .42rj G.FPD. d .�"
ToTotr 't>QtL.>-( P=LDW = 3306.PD. peaP
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