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0076 MILNE ROAD - Health
76 MILNE ROAD, OSTERVILLE A= 118 022 1 � o i Q ° i i s, i 0 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE Q����C6/����� ASSESSOR'S MAP& LOT i I INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) 0, (size) NO.OF BEDROOMS BUILDER OR OWNER LM . =%C DATE: CgI�IA4`, COMPLIANCE DATE: Separation Distance Between the: B Ma ximum Adjusted Groundwater Table an I 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 f et o leac��hi�n�g�facility) Feet Furnished by �JJ . 1 7 1 1 '1 TOWN OF BARNSTABLE LOCATION 74. w,L+j€- 1A� SEWAGE # lcy- ���J VILLAGE O,TJ—Z**—viLAUC ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Lv t� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) _;4-/0 NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER BUILDER O OWNERS DATE PERMIT ISSUED: /�a / 'p/ DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� (JV W SLR 00 F),Mun 1413 03:34p r... p.1 trte� s� �m Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is psterville required for every MA 02655 155-12-13 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forn>e; may not be altered in any way.Please see completeness checklist at the end of the form.' Imngout forms n A. General Information filling out muter, �F10F rrlb{q�p�i� on they use to the move to 1. Inspector: .� �. kty your Y cursor-do not James D.Sears = : .JAMES N use the return = key Name of Inspector sSEA ;y CapewideEnterprises LL_C : f . p Or'Qr Q 6. ..... Company Name 153 Commercial St ��� r5�INS4EG����`��\ Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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 15.340 of Title 5(310 CMR 15.000).The system: gI Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6-12-13 actors 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 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. 15irw 3M3 Titla 5 spection Form:Subsurface Sewage Disposal System•Pape 1 of 17 Jun 1413 03:34p p.2 � commonwealth of Massachusetts Title 5 Official Inspection Forum Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is Osberville required for every MA 02655 6-12-13 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D- A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist, Any failure criteria not evaluated are indicated below. Comments: B) System conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. if"not determined,' please explain. R 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 Wiiltration 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): 45ins-3M 3 T¢te 5 Mciat mspecteon Forth Subsurface Sewage Disposel System•Page 2 of 17 Jun 1413 03:35p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required fnr every Osterville MA 02655 6-12-13 page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes(coat.): ❑ 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 t5ins•3/13 Title 5 Olfidal Ins pet:Ucn Form:Subsurface Sewage Disyordl System•Pie 3 of 17 Jun 14 13 03:35p p 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Osterville MA 02655 6-12-13 Page.. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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: 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 ❑ ® Liquid depth in Is less than 6" below invert or available volume is less than Y2 day flow?' t5ins•3113 Title 5 Official rrmpeaion Form:Subaaracs Sewage Disposal System-Page 4 of 17 Jun 14 13 03:35p p,5 Commonwealth of Massachusetts Title 5 Official Inspection Form _: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Osterville MA 02655 6-12-13 page. CityfTown State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well_ ❑ ® Any portion of a cesspool or-privy is within 50 feet of a private water supply well. ❑ ® 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 How of 20009pd- 10,OOOgpd. ❑ ® The system fails. 1 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 ❑ Q 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 If 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. ESira•3/13 Title 5 Offic7al Inspection Form:Subsudace Sewage Disposal System-page 5 of 17 Jun 1413 03:36p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name inrbnnation is OSterville required for every MA 02655 6-12-13 page. Citylrown State Zip Code Date of Inspection C. Checklist 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 Q Were any of the system components pumped out in the previous two weeks? Q Has the system received normal flows in the previous two week period? ❑ 0 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 NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ 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)1310 CMR 15.302(5)) C. 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 bedrooms): 330 Gins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 17 Jun 1413 03:36p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Osterville MA 02655 _ 6-12-13 page. cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1ODD Gal.tank D Box and pit. Number of current residents: 2 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 reading's, if available last 2 ears usage d 2011-36,000Gais g ( y g (9p )�' 2012-25,000Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatstpersonsfsq.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: f9fns.3n3 hue 5 official Ins pattion Forth:Subsurface Sewag®Diapoaal System-Page 7 of 17 Jun 1413 03:36p p g Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is for every Ostervillewire MA 02655 6-12-13 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 94113. Was system pumped as part of the inspection? k El 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): t5ins.3113 TWO 5 Official Inspaaion Forth:Subsuftce Sewage Disposal Systen•Page 8 of 17 Jun 1413 03:37p p,9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Osterville MA 02655 6-12-13 .page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 1994 Permit # 94-745 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' Depth below grade: 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 Septic Tank(locate on site plan): Depth below grade: 14" 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 Sludge depth: 151ns 3/13 Title 5 ORdel lion Form:Subsurface Sewage Disposal Syssam•Pepe 9 of 17 Jun 14 13 03:37p p.10 N Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner owner's Name information is required for every Osterville MA 02655 6-12-13 page_ City/rown State Zip Code Date of Inspection D. System Information (cunt.) N Septic Tank(cont.) Distance from top of sludge to bottom of.outlet tee or baffle 29" 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 18" 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. Tank and cover's at 14" below grade inlet tee,outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: seer 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-3/13 .Title 5 Official Inspection Fmw Subsurface Sewage Disposal System•Page 10 of 17 Jun 14 13 03:37p p.11 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Osterville MA 02655 6-12-13 page. Chyrrown State Zip Code Cate 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 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 t5ins•3773 rnW-s Official trupac6on Farm:SuCsurface Sewage Disposal System•Page 11 of t7 Jun 1413 03:38p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name required for is Osterville MA 02655 6-12-13 required for every page. Cityrrown State Zip Code pate of Inspection D. System Information (cola.) 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 16"x16"-22" below grade w/one line out. Sox is clean and solid. No sign of over loading or solid carry over. 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 official insp ection Famr.Subsurface Sewage Disposal System•Pape 12 of 17 Jun 14 13 03:38p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd_ Property Address Esmaii Ghorbani Owner Owner's Name information is Osterville MA 02655 6-12-13 - required for every page_ Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ 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 one 1000 Gal.precast pit. Pit at 50"below grade w/cover at 8". 4" water in pit w/stain line at 12". No sign of over loading, solid carry over or high stain line 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 t5ns•113 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 13 of 17 Jun 1413 03:38p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Fonm-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is Osterville required MA -q red for every 02655 S 1 2-13 page. Cityrrown State Zip Code 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 plain): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5irs•3113 Title 5 Official Instectlen Form:Subarace SeWsga Disposal System•Page 14 of 17 L Jun 1413 03:38p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Ostervllle MA 02655 6-12-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 � �A) '6-X= �3 -3 -3 y4-6 Q_ 3—s'7 ' � - y=33'„ ISin6.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 OM ' . Jun 1413 03:39p p.16 N ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name information is required for every Osterville MA 02655 6-12-13 page. CityfTown State Zip Code Date of Inspedion D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water a ❑ Check cellar ❑ Shallow wells v fe eett Estimated depth to high ground water. 3 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: y Lot and area high 30'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15irts•3113 TAe 5 Official Inspedion Forryr Subsurface Sewage Disposal system•Page 16 or 17 Jun 14 13 03:39p p,17 • ' Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewa ge Disposal System Form-Not for Voluntary Assessments 76 Milne Rd. Property Address Esmail Ghorbani Owner Owner's Name i don is re equir wired for every Osterville MA 02655 6-12-13 page. City/Town 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 Mile 5 Official Inspection Forst Subsurface Sewage DIsposer System•Page 17 o117 s� • CO` MONO%EALTii OF MOSSACHt SETTS . OF E?�ti'IRO�'�iE�TAL AFF 4r�RS�F?:ECL'TIVE OFFICE OFE'�ti•IRO�NIF UAL PROTT�ECMN A„ DEPART. IE. T . .:_ �o ONE WINTER STREET. BOSTON. A1A 02105 61►-_S_•S:{'G Se.: • AAGcO PALL CELLI'CCI Comtrissianc LLGov�_=i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM^ PART A CERTIFICATION - Address �O z l"N e:.: �`:1 .. Address of Owner. . "t- .._ GS Property t _ :(If different)of Inspection: (Q( 2Aa,� : ,., Name of Inspector. Me: Q'o +' ►1 E� C�� - - - am a DEP ap roved system inspector pursuant to Section 13.340 of Title 5 C310 CMR 15_0001 Company Name o Mailing Address: 2O Asmx P 1, f�SNO�tZ- 2E(�q Telephone Number. e- 4-_9-5` CERTIFICATION STATEMENT 1 cenif that I have pe•scnally ir.speced the sewage C:s*asal syster at this address and tha: the information re:one-' be',ow• is true. accurate and comote:e as of the time of inspe:,o-. The tnspec:on was pe-�arrner' bases on my training and experience to the ;rape: funds:: and rnamtenance of on•s•te sew•aee dtsposa: systems. The system.: _ Passes _ Concu,onai;% Passes 1,eecs Furthe- Eva!uatic- Gv theJAcal Approving Authonn Fa . Inspector's Signatur . Date: �O T:ie S%•sr:e^ Ins:e_o• sha" submr• a copy of this inspec,cn recce to the Apprcving Authcnt� within thin (301 da}s of compie:ing this inspeoen. It the systern is a shareci s\•stern a• has a des-gn flow of 10.000 gx or greater, the tnspe=r and the system owner sFbll subrrut the repo-. tc the a:oropnate res,oral o ,ce of the Depanment of Erivircnmenta' Frote^nicr., The erigma! should be sent to the system, c,ne- and copes :-n:to the buyer, if applicable. and the ap-.roving autharin INSPECTION SUMMARY: . . Check A, .E, C, or D Aj SYSTEM PASSES: . . I have not found any information which indicates that the system viciates :ny of the failure criteria as define' in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. . COMMENTS: BJ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, upc completion of the replacement or repair, as approved by the Board of Health, will pass. , Indicate yes, no. or not determined (Y, N.cr NDi. Describe basis of determination in all instances. If'not determined-, explain why not. The septic tank is metal, unless the owner or operator has provided the system tnspec;or with a copy.of a Certificate of Compliance lanachedi indicating that the tank was Installed within twenty (20) years prior to the date.of the inspection; t the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar. failure is imminent. The system will pass inspe^.ion if the existing septic tank is replaced with a conforming septic cnk As_zoaroved by the Bo rrd of Health. g e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-M PART A tFRTIFICATION (continued) Property Addcgss: Owner: _ ... . . . Date of Inspection: 81 SYSTEM CONDITIONALLY PASSES tcontin.rrd- _ •_ . -; Sewage backup or"breakout or high static water level observed in the distri ution box is due to broken or obstructed pipe- s) or due to a broken. SeRW or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken"pipes) are rep aced : ). _ _ .. . o7. bstruction Is removed a k. distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipesl.:The system will pa<s inspection if twith approval of the,Board of Health); - broken pipe!sl are replaces `._ • _. _..-.. ._ _. _..: .. obstruction is removed C1 FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH. Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the s-stern is failing to protect the public health. saie-.--and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE;0AINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cessooel or pri.'t is within So feet of a surface water - _ Cesspoo! or prn-,• is within So feet of a bordering vegetated wetland or a sat marsh. 2) SYSTEM WILL FAIL UNLE55 THE BOARD OF HE•k.LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIOti11G 1N A MANNER THAT PROTECTS THE PUBLIC HEALTH AND.SAFMr AND THE ENVIRONMENT: _ The sys;ern has a septic tank and soil absorption systern (SASi And the SA-5 is within 100 fee:to a surface water supply iace water ,tributaryto a s ur supply. p. ly. ' within a one 1 of a public water su .n V we!I. _ The vstem has a septic tank and sail absorption system and the SAS is t Z p P s p rp Ys _ The syste•n has a septic tank and soil absorption system and the SA_5 is within 50 feet of a private water supply well. The system has a:septic tank and soil absorption system and the SAS is less thar. 100 feet but 50 feet or more from a t organic compounds a private water supply well, unless a west water analysis for coliform bacte.ia and volatile org c c pounds indicates th � from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equa l to CT the west is free f o pa u ty p g less than 5 ppm. Method used to determine distance (approximation riot valid). 3) _ OTHER (rsvi••t 0�:73/7"I tags 2 of 10 " ti SL!BSURFACE SMAGE DISPOSAL SYSTEM INSPECTIO% FORM - PART A . CERTIFICATION (continued) Property Addrpss: w ' Owner: �- Date of Inspection: -• DJ SYSTEM FAILS: You must indicate either "Yes' or'No- as to each of the following: 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..Jhe Board of Health should be contacted to determine what will be necessary to correct the failure. _.. :. . Yes No ' ._ Backup of sewage into facil,n or system component due to an overloaded or clogged SAS or cesspool. _ ....,Discharge or^pond,ng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or. cesspool. Static lioud levei in the d,stribition box above outlet invert due to an overloaded or clogged SAS or cesspool. L,cu,d depth in cesspool is less than 6- below invert or available volume is less than 1/2 day tlov. Required pumping more thar. 4 times in the last year NOT due to clogged or obstructed pipes . Number of times pumped— Anv portion o'the Soil Aesorption System, cesspool or priv,)• is below the high groundwate• eievat,or. Anv por,:on o-a cesspool or privy is w,th,r. 100 feet of a surface water supoly or tributan• to a surface water supply. Any por-,,on of a'cess000' o�.pn.-• is%,thin a Zone I of a pubic well. Am peso- o:a cesspool or pricy is within 50 feet of a private water supply well Anv por,,or. o- a cesspool or privy is less than 100 feet but greater than 50 fee: from a private eater supply well with no acceptable Ovate- qualm analysis. li the Weil has been analyzed to be acceptable. anach cop,.- of well water analysis for col,form bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: - lrou must indicate either "Yes` or "No" as to each of the following.. The following criteria appiy to large systems in addition to the criteria above: The system se ves a facihrt with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public hea!th and safety and the environment because one or,more of the following conditions exist. 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) . The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. . y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARZ B ' ;CHECKLIST Property Address: Owner: Date of Inspection: Check if the following have been done: You must indicate either 'Yes`or'No'as to each of the following: e� No . . Pumping information was provi _. .. •. . _.. ded by the owner, occupant, or Board of Health. None.of the system components have been_pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced info the system recently or as part of this inspection. x As bwlt plans have bee obtained and examined. Note if they a.re�not available with N1A. ' The iac.la% or dwelling was inspected for signs o.sewage'baa-up•• _ Tne system does not receive non•sanitan or industrial waste flow. The site was inspected for signs of breakout. All iy terra components. excluding the Sool Aosorption System, have been located on the site. r The septic tank manholes Mere uncovered. opened. and the interior of the septic tank was inspected for condition of_ baffies or tees. materia; o• construction• dimensions, deptn of liquid,depth of sludge. depth of scum. The size and location of the Soil Absorption Svstem on the site has been determined based on- _ The iac•lw, o%%ne• nano occupants. if dirteren: from owners were provided with information on the proper maintenance of 1 Sub•Suriace Disposal Svstem. Existing information. Ea. Plan at B.O.H. --111 Determined in the field tr am of the failure criteria related to Part C is at issue, approximation of distance is unacceotabie 115.3013!tbil - SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTIO'v FORM PART C SYSTEM INFORMATION Property Address: � l k0A, Owner: Date of Ihspectt n: FLOW CONDITION'S RESIDENTIAL- Design flow ` 6 :o.dhbedroom for S.A'-S Number of bedrooms : Number o'current residents Q Garbage g•v der (yes or noi:_h=3 Laundry coy-ected to system (yes or no!. _.. ..... __.:.. _... .. ...:_.._....__ _._ ._ .—_-- _ •--- -,,- __ Seasonal use (yes or no!: Water meter readings. if available (last two f21 year usage tgpd): ,�+ Sump p Pum (ves or not _ : ..- Lac-- date c°occupancy COMMERC;kL'INDUSTRIAL: Type of establishment Design Go%%•_galionsida% : Crease trap present ryes or no Indus-.ria! \taste Holding Tank present. Ives or no 'kon-sanitan waste d-scnargec to the Tine 5 system. Ives or no \later meter readings. d availabie Las:gate o: o c�;z•tc. OTHER. .Describe last care of occuoa-ic. GENERAL INFORMATION PUMPING RECORDS and source of rniormanor. ... taco � - 4 w `1lnc� oWT�. - • System pumped as par, ct inspection: (ves or no,_ _ If yes, volume pumped- ¢allons- Reason for pumping TY,P,E OF SYSTEM "`J'(}'— 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) VA Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 2112 Sewage odors detected when arriving at the site. (yes or no)�� . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM 1KFORMATIO% (continued) Property Address: Owner:��sSr�nQ1 Date of Inspection: �t Z�qC. BUILDING SEWER: (Locate on site plan) Depth below grade. ._: - - Material of construction. cast iron _40 PVC _ocher (e+cplain) Distance from private water Supplywell or suction Ir-: •---- " - Diameter Comments: (condition of joints, venting, evidence or leakage, etc.) t . t SEPTIC TANK: g - (locate on site pl --- - --- Depth below grade-- r.Saterial of construction oncre:e _rne:a _Fioerg!ass _Polyethvlene _othertexplain If tank is me:al, lis, age _ Is age con:irmec w CenJica:e of Compttance _(lies"No Dimensions pvf Sludge depth Distance from top o: s!udge to bonorn of outle: tee o• ba le Scum thickness- Distance _•, �...__ .._.... from top of scum to top o'oi;ile:tee or ba-ie �t Distance iron bottom of scurn to bo-o-+ o;outie: to e• ba�;*•e l` Now dimensions vvere determined Comments. trecommendation for pumping, rondition of inlet ar�d outlet tees or baffles. depth of liquid ley relation too tl t invert, truaural i try egr evidence of leakage. e:c.t 603 — (� e 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: . . .. _. (recommendation for pumping, condition of i!ilet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION (continued) Propert. Address: 76 Nf l Owner:~�'�i�►7ill�l Date of Inspedion:�/�Ig� TIGHT OR HOLDING TANK: 'Tank must be pumped prior to,or ai time, of inspections = ;. (locate on site plan, , 'Depth-below grade- Material of construction.--concrete _metal •_Fiberglass _Polyethylene other(explain) Dimensions Capacm-. galions ""— Design flow gallons da. -- ----' Alarm level Alarm in wonting order—Yes._ No Date of previous pu`nping _ Comments (condition or inlet tee. condition o- a!a•n: and float switches. etc.) -- ------ -- - DISTRIBUTION BOX:L�S (loca:e on site pa- Depth of Iiouid level a00%.e ouue: m.e^ U Cap G Ed Comments mote i!I vel and stribut r is oua' vid ^ce of solids ca n•over. •idence of le kag tnt o�out of box, etc.J -- PUMP CHAMBER:-" - --' 1locate on site plan:___ ._.......-•.--._... Pumps in working order; (Yes or No' Alarms in working order (lees or No Comments:--__.__. (note condition of pump chamber, condition of pumps and appurtenances,-etc.) --"� - - - - C, v SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr-ss:16 Owner. Date of (nsPecuon: SOIL ABSORPTION SYSTEM (SAS): (locate on stteplan, if possible: exca% ion not required, but may be approximated by non-intrusive methods;. y •• If not determined to be present, explain: - Tye; __... .... .....lic -- leaching pits. number. leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensio^s overflow cesspool, number Alternative system -' Name of Tecnnotogv Comments. ►not con cion f soli. igrs o'hydr tic fa lure, le•e! of pondino cond o egetat)on, et -- - - - - - 1, CESSPOOLS: hU (locate on site p ar. Number and configura:.on Depth-top of liquid to inlet Inver, Depth of solids lave• Depth of scum layer. Dimensions of cesspooE Materials of construction - Indication of groundwate• ` inflow tcesspool must oe pumpeC as par, of inspection' 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.) (revised 04/25/97) _ Daaa et 10 u SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IN-FORMATION (continued; Property Address: � j.I N� Owner: r ' Date of napection: . SKETCH OF SEWAGE DISPOSAL SYSTEM: _ - include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) a r , A" 33 3c, 'a-3 ri Ll10 4Y,33 -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C � SYSTEM INFORMATION (continued) Property Addres- Owner: Date of Inspection: III • r Depth to Groundwater ` Feet Please indicate all the methods used to determine High Groundwater Elevations Obtained. from Design Plans on record Observation of Site (Abutting property. observation hole, basement sump etc.) Determine it from local conditions Cneck with loca! Board o• nea!,r Check FE.mA Maps Chect. pumping records Check local eacavato•s installe•s L se L SCc Da:a r. Desciibe in voi, o%%* v.oras r.o•.% %o:: es:ab!tshed the l-iieh Groundwater Elevation. (Must be completed: 1C V � -75 /Yu z THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Mirpoiittl Workii Tontrnr#inn ramit Application is hereby made for a Permit to Construct ( ) or Repair (P<Z an Individual Sewage Disposal system at: ..................................... ---------------------••-• --- ocation 1d r s A^ t L� Lot No.ZVA �� f /! I Ad Installer Address d Type of Building Size Lot............................Sq. feet U1-7 Dwelling—No. of Bedrooms------------________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther.—. 'Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------- ----------------------_------------_---------------_............................................................... Design Flow---------------- ................gallons per person per day. Total daily flow----------------:�__..............gallons. WSeptic Tank—Liquid capacityJ Cgallons Length---------------- Width---------------- Diameter---.------------ Depth................ x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq..ft. Seepage Pit No...../............ Diameter-----/U.-------- Depth below inlet..__6..._....... 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........................ fX4 Test Pit No. 2................minutes per inch Depth of Test Pit---______-_--__--_ Depth to ground water........................ 9 -------------------------------------------------------------------------------••-----------................----•------•---------------....----••......---... 0 Description of Soil.......................................................................................................................................................................... w U Nature of Repairs or Alterations—Answer when�pplicable__/!�'3 IJ. _.. -_./ © .................:.L. ?f j .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance s en 'ss by e board of health. Signed ... +__ ........................ ............................................................... ...... ........ .....-.....:...... Dace Application Approved By ---------- ID... . .. e C Application Disapproved for the ollowing reasons: ........................ ... ..----.... ..................... .... .................:............................. ----------------------------------------- ------------- -------------- ace' PermitNo. -------- --------- Issued .........................................................D.- ..... Dace I[g t DZ•Z No..�y: Fxs.... .U. .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , VVftratiott for Dig oott1 World Tatuitrurtiott 1rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: ..........-Z r----- .��a2 .L ocation• -\ddr• s Lot No. -----•----- ........................................... .................................... Owner Addrx IN ------- - � Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms______________�_-----__________-___-__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures .--•-•--•--------•------•-•------------------------•--------------------------------- ..._.._...__... W Design Flow.................��_____._...____.__gallons per person per day. Total daily flow.__..........__ �d..._____.__...gallons. WSeptic Tank—Liquid capacity.f'6d_galIons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length._-___......�...... Total leaching area....................sq. ft. Seepage Pit No.... ............. Diameter...../0........ Depth below inlet----&........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_...-:.-.__--__---____-- 9 .-•-•----•-•----------------••------•-----------•--•--•••------•----------------•••-------••-•-----•................................ 0 Description of Soil........................................................................................................................................ W 1 --- U Nature of R�airs or; Altenitions—Answer when applicable.._ 5.!..._ : -__. __./GUO a. --�� 7 C_._�. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental`Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h• s en 'ssue 7by e board of health. 1,2 Signed .......... ...._._.- . . .......................................... ....... Date ApplicationApproved By ................... .........�--- --------------------------------------------------------------- ce Application Disapproved for the ollowing rearonf- ------------- ----------------------------------------------------------------------------------------------------------------------- ........ -----� ~ ...--- '................... Date Permit No. e}1 �/ y Issued -�^y------------------- Date l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C'Ie>`tifi ate of CZompliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) y f�Ct it (—�•Vr <c..".) mstauet at ..................._...................... ... ... .. ... 76. ......... /cN ���d CAS% �/L.CC -.... ... --------- f has been installed in accordance with the provisions of TITLE 5 qof The State Environmental Code as described in the application for Disposal Works Construction Permit No. .__./-- ...-..7. ......_ dated ..........................................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. n DATE......... .- ..... p............. >... ------ --- ----- Inspector--7�. ; 5/...._..... - - l/ ---------P-----------------,---_.-_----------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE..•......d............ �io, tt1 or�� �utitrtiori hermit Permission is hereby granted....... ............ cf Lv-!! -_---_-.0 5_ tiG?! ,� .. .................. .................................. to Construct ( ) or Repair an Individual Sewage Disposal System atNo......................................... ........... 0 - �.......................`. �---- ------��5"T.�1/r l ..E Street q1 as shown on the application for Disposal Works Construction Permit No .- l/: 71/-r Dated.._.��.-� :�~.�C�........ -------.................---•- o --•-------------------------------------••••- oard of Health DATE..........I-- - FORM 38508 HOBBS 6 WARREN.INC..PUBLISHERS a r