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HomeMy WebLinkAbout0278 PARKER ROAD - Health Z78 PARKER RDO\ OSTER171LI:k A = 116 133 t � Mar 28 2016 22:02 Jim The Inspector Man 5085349919 page 18 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "e 278 Parker Road Property Address 1�+ Meryl Beckingham Owner Owner's Name Information is required for every Ostervllle MA 02656 3-28-16 page. Cily/Town State Zip Code Date of Inspection W .A 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 fillip out forms c/ 1160844 ��►1���IIIIr�Uip, on the computer, V ����` �jN DFSS"�i4 use only the tab 1. Inspector: 2� 9cti key to move your cursor-do not James D.Sears =g JAMES ' �' use the return 8' SEKKS Name of Inspector = C :rns key. Capewide Enterprises, LLC *,'•.o� o ICY T� `�• `` � Company Name '��, !E'• •• • G'� i.� 153 Commercial Street ''/i,, INS? it����.�`` Company Address Mashpee MA 02649 Cityrrown State Zip Code 508477-8877 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 F Title (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-28-16: 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 under the conditions of use at that time. This inspection does not address how the system will perform in the future under the some or different conditions of use. 15ins-3/13 - Title S Official Inspection Form:Subsurface sewage Disposal System•Page 1 of 17 �0 Vs Mar 28 2016 22:02 Jim The Inspector Man 5085349919 page 19 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'- Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name Information is required for every Osterville MA 02656 3-28-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I 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 1500 Gal.Tank D Box and two pits. 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. 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): 15ins•3,'13 Title 5 Ofndal Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 t Mar 28 2016 22:03 Jim The Inspector Man 5085349919 page 20 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-16 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 (cunt.): ❑ 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-W13 Title 5 Official Inspection Form:Subsursee Sewage Disposal System•Page 3 of 17 Mar 28 2016 22:03 Jim The Inspector Man 5085349919 page 21 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is Osterville MA 02656 required for every 3-28-16 page. Gity[Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fall unless the Board of Health (and Public Water Suppller, 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 i 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 t bf,a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a Ovate water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50'eet 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, fcr,fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogej is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attachdd 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: o — I Yes No El ® 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 A2 day flow 017-1 15ins•3113- h •r Title 6 Official InsPection Form:Subsurfaoe Sewage Disposal System•Page 4 of V. Mar 28 2016 22:04 Jim The Inspector Man 5085349919 page 22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'r 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-16 page. Cityrrown 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. y ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if 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 16,000 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Mar 28 2016 22:04 Jim The Inspector Man 5085349919 page 23 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 278 Parker Road Property Address _Meryl Beckingham Owner Owner's Name information is Osterville MA 02656 3-28-16. required for every page. City/Town State Zip Code Date of rnspection 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 ❑ ® 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located'on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® . Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 6 Official Inspactian Form!Subsurface Sewage Disposal System-Page 6 o1 17 Mar 28 2016 22:05 Jim The Inspector Man 5085349919 page 24 Commonwealth of Massachusetts. onw I ea t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is Osterville MA 02656 3-28-16 required for every page. Cityrrown State Zip Code Dale of Inspection D. System Information Description: The system is a 1500 Gal. Tank D Box and two pits. 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 Seasonal use? ❑ Yes ® No OGal Water meter readings, if available last 2 ears usage d 2014-119,0 Gal's g ( y g (gp �)' 2015-124,000GaI'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•3/13 - Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 7 of/7 I Mar 28 2016 22:05 Jim The Inspector Man 5085349919 page 25 Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required For every Osterville MA 02656 3-28-15 . page. Cltyrrown Stale Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: NA Source of information: 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 El Tight,tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins 3113 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 8 of 17 Mar 28 2016 22:06 Jim The Inspector Man 5085349919 page 26 Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments 278 Parker Road Property Address Meryl Becking ham Owner Owner's Name information is Osterville MA 02656 3-28-16 ' required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)'and source of information: 2001 Permit #2001 '- 174. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): .. 5411 Depth below grade: teat 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: "feet 3 Material of construction: ® concrete ❑ metal El 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 1500 Gal. Precast H-10 Dimensions: — 211 Sludge depth: 15ins•3113 '" Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Mar 28 2016 22:06 Jim The Inspector Man 5085349919 page 27 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-16 page. Cilyr town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 1, Scum thickness Distance from top of scum to top of outlet tee or baffle 8" 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. Tank at 43" below grade w/outlet cover at 4". In and outlet tee's. No sign of leak age 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 official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Mar 28 2016 22:06 Jim The Inspector Man 5085349919 page 28 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Cisteryllle MA 02656 3-28-16 page. CityfTown 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: t ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons r 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•3112 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Mar 28 2016 22:06 Jim The Inspector Man 5085349919 page 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . '< 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-16. page. City/Town State 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 16"x16"-55" below grade w/cover at 2'. Box is clean and solid w/two line's out. 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: 15ins-3113 Title 5 Official Inspeetion Forth:Subsurface Sewige Disposal System•Page 12 of W Mar 28 2016 22:07 Jim The Inspector Man 5085349919 page 30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is Cisterville MA 02656 3-28-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is two 1000 Gal. precast pit's. Pit#1 camera out. Pit clean and dry-pit under flat stone patio. Pit#2 Dry-pit at 32" below grade w/cover at 2'w/sprinkler line's over cover. No sign in pits of over loading 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System-Page 13 of 17 Mar '28 2016 22:07 Jim The Inspector Man 5085349919 page 31 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s' 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-16 . page. CilyrTown 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 plan): Materials of construction: Dimensions t Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Mar 28 2016 22:07 Jim The Inspector Man 5085349919 page 32 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 278 Parker Road Property Address — Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-15 page. City/Town State Zip Code Date of Inspection D. System Information (cone.) 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 13 ACV R 3 �P, p�fr O a �(� P1 T 4{ O t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Mar 28 2016 22:08 Jim The Inspector Man 5085349919 page 33 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is required for every Osterville MA 02656 3-28-16 page. Citylrown 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: 1 + 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: Ck. Abutting area no G.W.at 12'. Bottom of pit at 8'-6". Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Mar 28 2016 22:08 Jim The Inspector Man 5085349919 page 34 s Commonwealth of Massachusetts u W Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 278 Parker Road Property Address Meryl Beckingham Owner Owner's Name information is Ostervllle MA 02656 3-28-16 required for every 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 05ins-3113. Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION ��- SEWAGE # � ® VIL AGE ®S 1 �+ G ASSESSOR'S MAP &LOT` fld"/ .3 ferF Cork R#9T�ER'S NAME&PHONE NO. I�� Q�1' SEPTIC TANK CAPACITY /01«SO 6 LEACHING FACILITY: (type) (9. L�"��® (size) NO.OF BEDROOMS ,(��- BUILDER OR OWNER P DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ®� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Y i Y �� �,.. ��� �,' ���� '+`�' I l U� �T�'��'4..� . ' � �:�. ���. . ►•� .� . _^ .�_ 7 TOWN OF BARNSTABLE LOCATION hit 1k/�7 YZ SEWAGE # dI1- 1� VII:LAGE (9S ASSESSOR'S MAP & LOT V('1.33 INSTALLER'S NAME&PHONE NO. I`o� �s a 7 -7 ,<—3 7 2 SEPTIC TANK CAPACITY I-Jr6 LEACHING FACILITY: (type) .;f� (size) NO.OF BEDROOMS �l BUILDER OR OWNER S s 0 A4 h^- PERMITDATE: COMPLIANCE DATE: /0—o Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and.Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . .. _� r �I �i � L S _ iy�".} ._ .} � � �,�i � x. .�:. 0 $50 I ! Fee /No. � 1� V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for 30igaar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asse2or'8Map/Farceier R . , Osterv' lle, MA John O'Brien Box 3394 Wa uoit Installer's Name,Address,and Tel:No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service �A P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S a n ri Nature of Repairs or Alterations(Answer when applicable) Pump and remove 1 250 gal. tank, Install new 1500 gal tank, connect to new D—box and 2 new existing 1 000 coal st-c)nPparkPc3, =rPt�a�t* r r)nr_rPta 1 eacb pits- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this and Health. �� 7 Sign _ G► Date Application Approved by 4 Date Application Disapproved for the following reaso s Permit No. Date Issued Of �j y No. , r (��---� 2' ..!= {'� Fee !t r,n I -Entered in computer: THE COMMON IE LTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes 3ppftcatton for ;Dt$pO$a1 *p$tem Cottztrurtton Vermtt Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Asse267'8Ma7/aart'aler Rd. , Osterlle, MA John O'Brien Installer's Name,Address, d et o. f -� Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089 Centerville Type of Building: Dwelling No.of Bedrooms 4 — Lot Size sq.ft. Garbage Grinder( ) Other_ Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Pump and remove 1250 gal. tank, Tnc4 al 1 not, 1 500 gal tank, Connect to nctox D tram and- 3 new axi rstin r gal.stonepacked, precasty concrete leach pt!LW. 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 Certifi- cate of Compliance has been issued by this Board o ealth. SigneA Date Application Approved by i Date Application Disapproved t e�llowing reaso u i Permit No. Date Issued ----- --�-7-- 7---------------1 --- ----- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ' O"Brien Certtfirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(X )Upgraded( ) Abandoned( )by r -68 fir, . r E. n men a i-e�� e '0 �C at _ has beep constructed in accordance 10 with the provlslonI oI It e�an e for t Spoeaf SYystem Construction Permit No. / dated Installer Designer YC . B• ,. . The issuance of this permit shall not be construed as a guarantee that the system will function as esigned. Date Inspector ) ---------------------------------------- No. Fee c}!1 f THE COMMONWEALTH OF MASSACHUSETTS y PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS O"Brien '=t0poga1 bpgtem Con5tructton Vermtt Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( ) System located at -_ 279 P=rker R � OsterVb13A and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co- pleted within three years of the date of t J C Date: ! i Approved by / t % ) V f 17619R NOTICE: This Form Is To Be used For the Repair Of Failed L Septic Systems Only. CERTIFICATION OF 310ETCR AND APPLICATION FOR A DLSPOSAL WORKS CONSTRUcnoN PERUff(WITHOUT DESIGNED PLANS) William E_ Robinson,S y certify that the application f,r&Vosal works conamctiort permit signed by toe dated —� i , concerning the property located at 278 Parker Rd. , Osterville meets all of the Mowing criteria: • The failed is ca umcled to a residential dwelling only. There are no commercial or business um assoc the dwelling. The soil' clas ilied as CLASS 1 and the penalabon rate is less Wan or equal to 5 nun um per inch. There sr no aKUartds within 1Ot)feet of the proposed sepuc atiem — There r no private wells within 150 feet of the Proposed septic seem Them no inc mace in Bow andlor change in use proposed • are no variances requested or needed banom of the proposed Imcdring facility will ago be located less than five feet.above the tttnm adjusted gtonndarater a ble elevation:[Adjust the gruundwater table using the Frimptor when applicabkl the S.-VS.will be looped with 250 foes of arty vegetalcd yam,the bottom of the proposed leaching;amity will Mt be located less than fourteen(14)Wet above the maximum adjusted groundwater table elevation. Please complete the fdkwieV A) Top of Ground Smfaoe Ekvafka(using GIS kdxmratiou) 19 B i G.W.Elevation +the MAX. thigh G.W.Adlusunent DIFFERENCE BETWEEN A and 8 — SIGNED: � DATE: 3 [Sketch Proposed Plan of system on backl. r bmikh rokkr rat 1 1 x ,. .�-."3 i+wa5'^'S 5 •^91s3. +a'% - 'ti*"'7'-c t-•z,r•P�, T.x,,; . c t ��-: it`s-...�'w. �o.:��s�w '�'t'= �, J- ,.t '3�r`',�'*..,c u"� N,rxc�s�Le'�e��'•�."6�°'C'-�`�%v�a�..��+. a''{y �'�'' =" � TOWN OF BARNSTABLE VILLAGE �.� �,e(/�'LL ASSESSOR'S MAP & LOT �� /33 INSTALLER'S NAME&PHONE No. SEPTIC TANK.CAPACITY Z56 ��� 99 ; LEACHING.FACILITY: (type) JdC'b Z (size) NO. OF BEDROO MS ,'BUILDER OR,O;WNER, PERMIT DATE: 0 COMPLIANCE DATE: Separation Distance,Between the: Maximum Adjusted-Groundwater Table and Bottom.of Leaching Facility Feet Private Water Supply Well and Leaching,Facility (If any wells exist :.. on site or within 200-feet of_leac6u facility) Feet Edge of Wetland and_Leaching Facility.(If any wetlands.exist 1. . Feet within 300 feet of leaching:facihty), ' Furrushed`by yl 41 S i COMMONWEALTH OF MASSACHUSETTS ' a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED V MAR 2 0 not TOWty Vr IDArn1N,-IrltSLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:278 Parker Road Osterville,Ma 02665 Owner's Name: Taylor Owner's Address: Date of Inspection: 3-10-01 Name of Inspector: (please print) William E Robinson Jr. Company Name: William E Robinson Septic Inspections Mailing Address: 43 Tomahawk Dr Centerville Ma 02632 Telephone Number: ( 508)775-7986 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000). The system: _x Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �- a Date: 3-10-01 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: System is Title-5 and is like new.. ****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. { f . Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 271 Parker Road Osterville,Ma 02665 Date of Inspection: 3-10-01 Inspection Summa ry: Ch eck A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _z_ _ I have not found any information which indicates that any of the failure criteria described in 310 CUR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is Title-5 and in good working condition. Tank is like new. B. System Conditionally Passes:N/A One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection:3-10-01 C. Further Evaluation is Required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: — Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet.but 50 feet or more from a private water supply well**.Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that noo other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection:3-10-01 D.System Failure Criteria applicable to all systems:N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No _x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than'h da now — Y x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped —x Any portion of the SAS,cesspool or privy is below high ground water elevation. —x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. T —x Any portion of a cesspool or privy is within a Zone l.of a public well. — x Any portion of a cesspool or privy is within 50 feet of a private water supply well. — x 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] no(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no — _ the system is within 400 feet of a surface drinking water supply T — the system is within 200 feet of a tributary to a surface drinking water supply — _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 11,304,The system owner should contact the appropriate regional office of the ts� 3 bf t l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ON FORM ASSESSMENTS PART B CHECKLIST Property Address: 278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection: 3-10-01 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 _x Were any of the system components pumped out in the previous two weeks? _x — 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? _x — Were as built plans of the system obtained and examined?(If they were not available note as N/A) _x _ Was the facility or dwelling inspected for signs of sewage back up? —x Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _x_ _ 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? x_ 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 bas been determined based oa: Yes no x _ Existing information For ocample,a Alai at the Beard oft altli y y l-•� ��Fjy�l(ig3 j{.r w s� _ Determined in the Feld(lf a a tka um 6R iata is P�fS is at issue apptQxltQh Qi distance is unacceptable)[31b CMtt 13.3dz(��(b)j Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection:3-10-01 FLOW CONDITION RESIDENTIAL Number of bedrooms(design):_4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no):no Is laundry on a separate sewage system(yes or no):—no [if yes separate inspection required) Laundry system inspected(yes or no):_ Seasonal use: (yes or no):—no— Water meter readings,if available(last 2 years usage(gpd)): 1999—13,100/2000—14,000 Sump pump(yes or no): —no— Last date of occupancy: COMMERCIALANDUSTRIAL N/A Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_N/A Town of Barnstable Was system pumped as part of the inspection(yes or no): no If yes,volume pumped:gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _x_Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: System'installed`1974 Permit Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection:3-10-01 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:__cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_x_(locate on site plan) Depth below grade:_18" Material of construction: x_ concrete metal fiberglass polyethylene other(explain)If tank is metal list age:_ Is age confirmed by a Certificate of Compliance.(yes or no): (attach a copy of certificate) Dimensions: 1,250.00 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Tank is all clear water in like new condition. 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: How were dimensions determined: direct measurement 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 is all clear water w/pvc Tye's GREASE TRAP:N/A (locate on site plan) Depth below grade:— Material of construction: concrete metal fiberglass. ,polyethylene—other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): i•' a LiF.i� {FT �_..�Yl'7Y 1� * r�� 1 .�7'j\ l� Y1I t�2j1 }.— A� F"'.3 f'y ro_e_a�.x¢s? !a. 1�',I+rt�pcl�l •.y . • 1J17 i..._. SUBSURFACE SEWAk . PART C SYSTEM INFORMATION(continued) Property Address:278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection:3-10-01 TIGHT or HOLDING TANK:N/A (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: x_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): D-box is in like new condition. PUMP CHAMBER: N/A_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Com9 ments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 4 r41 f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Parker Road Osterville,Ma 02665 Owner: Taylor Date of Inspection:3-10-01 SOIL ABSORPTION SYSTEM(SAS):__(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number.2 LP-1000 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Lp-1000 in like new condition w/less than 1'of water and no stain line above. CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of.ponding,condition of vegetation,etc.): PRIVY:_N/A (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.): I'9 10 d€1l I 1<Iv:loaf 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION TIAM. PAR" C SYSTEM INFORMATION(continued) "m perty Address278 Parker Road Ostervitte,Ma 02665 (J ry ter: Taylor IJ 0 a of Inspection: 3-10-01 !a i�ETCH OF SEWAGE DISPOSAL SYSTEM N to vide a sketch of the sewage disposal system including ties to at least two permanent referewe landmarks or I:r.m chvmrks.Locate all wells within l t10 feet:.Locate where public water.supply enters the buil+lung. .01 mid- AS �S R� I Page 11 of 11 ztT �I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 278 Parker Road Osterville,Ma 02665 Owner Taylor Date of Inspection: 3-10-01 SITE EXAM Slope Surface water Check cella r , G Shallow wells Estimated depth to ground water_ 20+ feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: lot is on high ground 6 Y w ,. Town of Barnstable _ > snA F Department of Health, Safety, and Environmental Services ;� �� Health Division 367 Main Street, Hyannis MA 02601 Office: 508-190-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health June 12 1995 Joseph E. Mackie 188 Beacon Street Boston, MA 02116-1367 Dear Mr. Mackie: The septic system owned by you located at 278 Parker Road was inspected on May 5, 1995 by Joseph Macomber/Peter Sullivan a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has passed under the guidelines of 1995 TITLE 5 (310 CMR 15.00). However, the following should be corrected: • Tees in septic tank not extended to center of cover. • No cover provided over distribution box. Please telephone Health Inspector, Edward Barry at 790-6265 within thirty (30) days to discuss your intentions in regard to rectifying these deficiencies. PER ORDER OF THE BOARD OF HEALTH omas A. McKean, R.S., C.H.O. Agent of the Board of Health ASSESSORS MAP NO: 6- PARCEL NO: I Town of Barnstable T � 1 eerwsreeU& •t Department of Health, Safety, and Environmental Services 16"1 � Health Division of 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 llamas A.McKean FAX: 508-775-3344 Director of Public Health June 1, 1995 TO: Merviller � �1'i C' /�Iq Road l �b^02655 Dear W.;Traft:n r 1'Vl��� e ,• c�2 1 , �D 13� `'� The septic system owned by you located at 278 Parker Road was inspected on May 5, 1995 by Joseph Macomber/Peter Sullivan a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has passed under the guidelines of 1995 TITLE 5 (310 CMR 15.00). However, the following should be corrected: • Tees in septic tank not extended to center of cover. • No cover provided over distribution box. Please telephone Health Inspector, Edward Barry at 790-6265 within thirty (30) days to discuss your intentions in regard to rectifying these deficiencies. PER ORDER OF THE BOARD OF HEALTH �a Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health [Installer letter] TO: )A5 ate C 77 C--)s 1 A A- 4 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at '- 770 0464- P—o--v-j was a Massachusetts licensed septic inspected on±Oi5 by `� inspector. The inspection of your septic system showed that your system h s un er Ia �. guidelines of 1995 TITLE 5 (310 CMR 15.00) duet ' g: r L�fed `'cv.V-ecIej 6yv rgzs- Lshy,b6ha' b�k You are re c o hi a lic Town o. arnst eptic stem installer to submit a sketc d' ram of ro ed system to a of Barn able He sion Qttte (T Hall, 367 Street, Hyannis t will bring the ept' stem into compliance ith 310 CMR 00, The State Environmental Code, Title within (14) fourteen days of receipt of this notice. You are a directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. Y u ar er direc aintain the em y iring a licensed a hauler to the s ptic em to pr vent d' arge of sews or�e�ffluW�nto the bui ings, onto e surface he ground, o i surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean,R.S., C.H.O. Agent of the Board of Health Town of Barnstable �"� �,1 o-�, 1 ���s � �r1hC1[r /t/03""'" ' 7s } � ba�- �� _6ver�c►"b'i� r r DATE'_5/5/_95 PROPERTY ADDRESS:_278 Parkex-Road-----_- 02655 ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: A. 1 -1250 gallon septic tank. B. 1 -distribution box. C. 2-1000 gallon leaching pits. Based on my inspection, I certify the• following conditions: A. This is a title five septic system. ( 1978 .Code ) B. The septic system is. in proper. working order at' the present time. C. Tees . in tank should be extended to center of. covers. D. Concrete baffkes in tank be removed. E. cover on distribution box raised to within 12" of Grade. SIGNATURE:' - Name: J.P_Macomber Jr_._______ Company:_J_P_Macomber_&_Son Inc. Address:_Box 66 ____________ Center_vi11e,Kauz ._Q2.b32 Phone:_-R8_-7.2.5=33.3$-_-__-_- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775.3338 775-6412 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 2-1g FaQ.�CL �HO axazvlutr£,Owner's name Date of Inspection Ml'��'S-) Ise PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. AD �ECofLp5 QF VU V k PkiUr- � S'IY� 1CcPpeT �F�� -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 into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility .or dwelling was inspected for signs of sewage back-up. The' site was inspected for signs of breakout'. All system components, excluding the SAS, have been located on the site. The septic tank manholes were uncovered, opened, and 'the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid,.depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. C-0 WA,VVL 4 >Am � 1. {`Q VILOV L. e� a C3 C�+�. rU 9��2. `C �( -V-1 r2J4L-c— L-.c �'E DF S A.S Z. xTE�-t Q '��0 -1 l o'.t LC' OL.T'l_.E7 .�-'` l� ��►t�. f3, 12�c.o Ke&-L 0 Z L5 6i2 0 v 62 "p s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential _ number of. bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no 446 seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available:- g CC Last date of occupancy GENERAL INFORMATION Pumping records and source of information: e r-- System pumped as part of inspection, es if yes, volume pumped Y or no Reason for pumping: T pe of system Septic tank/distribution Single cesspool box/soil absorption system Overflow cesspool Privy Shared system (yes or no ` records, if any) ) (if yes, attach previous inspection Other (explain) ------------ Approximate age of all components. Date installed, if known.n. Source of Sewage odors detected wh en arriving at the site, yes or. no _ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION. FORM PART B SYSTEM INFORMATION continued --' 1AA LC-i �,IS NOT SEPTIC TANK: X (locate on site plan) p 5 c� iz- depth below grade: �` I1z vy ou-r LET material of construction: k concrete metal FRP other(explain) dimensions:__ sludge depth distance from top_of ,sludgd-.to`bottom of outlet tee or baffle uo22GikVcum 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. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) wl1MEftX7 L6,��r r�6 7-� ""i'^ �AFF�G 'CiE t=Mr'i V`� PVL"`r n t ro LE rx t r--T -tam g F rx ,n b�a (Q-m Le r,c -rb�►Y' �'1�P \1`t r N DISTRIBUTION BOX: DL (locate on site plan) �lw(u-T depth of liquid level above outlet invert OtG. Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or�o�t of box, recommendation for repairs, etc.) t " O�z FCC i I PUMP CHAMBER: NC—*4 Z—� (locate' on site plan) b , pumps in working order, yes or no Comments: (note condition of, pump chamber, condition of pumps and a ' '�" recommendations for maintenance or repairs,etc. ) pPurtenances, . , . { 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued ,, SOIL ABSORPTION SYSTEM-.(SAS) : - (locate on site ..p.lan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: k.L A.y�4 i�-t0 ©►..a C P� T �0 2 l f05;P��tcO!� '1�c��Ft�S�� Type leaching pits and number q�'it'S leaching chambers and number leaching galleries and number - . leaching trenches, number., length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, . cre or L41tion of vegetation, recommendations for maintenance .or repairs,etc. CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level 'of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) k4o ; materials of construction ` dimensions i depth of solids Comments: (note condition -of soil, signs of hydraulic failure, • level of .ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) , .2-7 a 112, t CLk 2. iZV 05TEYL.V i u-G 11`��`l S, lg9 S SUBSURFACE ;SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' ` A�C�-r^C��.S DEPTH TO GROUNDWATER 141 + depth to' groundwater lao-T)-om 64-- SAS method of d termination or approximation: 9e ► —%\Aa - OO1 LpL +a C- r er. VC FQ I 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination ��in all instances. If not determined", explain why not) �p Backup of sewage into facility? o Discharge or ponding of effluent to the surface of the round or surface waters? g Static liquid level in the distribution box above outlet invert? 1� Liquid depth in cesspool <6" below invert or available volume< 1/2 .day flow? Kp Required pumping 4 times or more in the last year?e r. number of times pumped Nd Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? 1 Is any portion of the SAS, cesspool or privy: O y. below the high groundwater elevation? Ko . within 50 feet of -a surface water? /vC within . 100 feet of, a surface water supply .or tributary to a surface water supply? within a Zone I of a public well? I�b within 50 feet of a bordering vegetated etated wetland (cesspools and privies only, 1 nd or salt marsh . not the SAS) . . N� within 50 feet of a private water supply A I we 11. Tess than 100 feet but greater than 50 feet from a rivate w supply well with no acceptable water p water p quality analysis? If the well has been analyzed to be acceptable, attach copy..,of well water analysis for coliform bacteria, volatile grganic compounds, ammonia nitrogen j and nitrate nitrogen. NO 4ARNS .IDLE LOCATION � � SEWAGE VILLAG �-� UISESSOR'S MAP & LUT IJcc,, —L INSTALLER'S NAME & PHONE NO. —4R SEPTIC TANK CAPACITY 4-- A --T— L'- �1 AaN.STi4RCt+ LEACHING FACILITY:(typA) (size) NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER-: iDLU4 -+� BUILDER OR OWNER ' - c--r DATE PERMIT ISSUED: l -- -- DATE COMPLIANCE ISSURDL VARIANCE GRANTED: Yes No --- 4/28/1995 0749 508-428-3506 C.-.O.MM. WATER DEPT PAGE 02 ` 7 KEY NUMBER 4 8 9 > NAME <MACKIE, JOSEPH E > B-C 1 B-C 2 S-C 3 a-C 4 STREET 188 BEACON STREET CITY BOSTON ST MA ZIP 02116-1367 REF 1 REF 2 PHONE ( ) - REF 3 REF 4 METER NO. < 4568> DATE READING CONS STREET <PARKER RD N0. 278> 12/31/94 256 53 CITY OST T ST LOC 06/30/94 203 7 " PHONE (508) 420-3752 12/31/93 196 65 06/30/93 131 1 ROUTE NUMBER 12 12/31/92 114 SERVICE DATE 10/24/74 06/30/92 42 METER DATE 09/06/91 12/31/91 23 83 CAPACITY 7 06/30/91 0 17 STYLE T10 SIZE 1 RATE SCHEDULE KEY PIT PLASTIC NOTE RR FRONT RIGHT ADDITIONAL CONS 0 ALTERNATE MIN 0 19 9q 199r3 3s� G!P-0 t 9g t = -4 S g &?D SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART D CERTIFICATION Inspector : Peter Sullivan PE Location : 278 Parker Road Osterville Date : May 5,1995 Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and maintenance of on-site sewage disposal systems.. I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. Please note the summary of recommendations"in the text of this report. Very truly yours Peter Sullivan PE Distribution: Original to system owner Buyer Board of Heath g Of o? KTER SULLIVAN � �g No. 29133 *b ��Q►sTea�� S�ONAI I /V - ¢ xOWIV O' BARNSTABLE \ `? LOCATION X8. _SEWAGE VILLAGE �j'j" � U& SESSOR'S MAP tCz LOTJL-113 INSTALLER'S NAME Q PHONE NO. _ SEPTIC TANK,CAPACITY .� AaNSTe4�LE LEACHING FACILITY:(tgpe) d ' (size) - -_ — NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER V6 LVA BUILDER OR OWNER- A2 s-� DATE PERMIT ISSUED: DATE COMPLIANCE'ISSUFD C VARIANCE"GRANTED:. -Yes i— No --®� ���� °�f. :� �!� .��- �' w �. ar► r No.. ®... .... Fps.... ..: THE COMMONWEALTH OF MASSACHUSETTS BOARD HALT 2 --------------- OF- ........ .... ... .. . .. . ... '-------------------- Appliration -for Diipoiial Works Tonstrurtion Prrinit Application is hereby made for a Permit to Construct (--"),-or Repair ( ) an Individual Sewage Disposal System at • ........... --•--- 4 ............. • •. ........ .................. ............. ._ / �nsta dress ----------------- Address Q Type of Buildii Size Lot....��%� ....Sq. feet U Dwelling—No. of Bedrooms______________________ ________________Expansion Attic ( ) Garbage Grinder (4-r aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures -------------------------------------- Design Flow-___.- _......_:...........___ gallons per person per day. Total daily flow....... �_ __________________________gallons. 1 q P JJ�3 ---g g .....--•-- Width--------- ------ Diameter----- ..... Depth---------------- W Septic Tank—Liquid ca acttd--___-_____.gallons Length x Dis osal Trench—No. .................... Width___._________ T%tal L tl_.._._.___..._..__. Total leachingarea_._-_-______.__-_-__s ft. P T�� DIV 7 ` q . Seepage Pit No.._.__�..._..._.. Diameter........ _ Dept below t e .......___. tal leaching area- sq. it. Z Other Distribution box O Dosing tank Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------------- Depth to ground water_.-_________--_--_-_._.. ,44 Test Pit No. 2................minutes per inch Depth of Test Pit--________________ Depth to ground water........._-_.,-_____.._. W ____________________ _ _ __ ____ _ _ __ _ d ___ __. . e.. 0 Description of Soil­­ -"'--f�'-L = ��� ..Y .. -------�`....��------------A,_ U ------------- �`�'`v ---•-•-+ 11 ------- W -•-••-••------- ---------- _ tz�1 s -------/6-�---- - -?� - "��--=-1 J Z , d _ [t�� U Nature of Repairs or Alterations—Answer when applicable._-__............:......... -_hie. C �... ------------- -----------------------------------------------------------------------------------------------------•----------------------------------------------------------------------------------- Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code--The undersigned further agrees qpVC9 place the system in operation until a Certificate of Compliance has been issued byte o rd o ea h. Sign- - .. ----•------------ __ __ ___________ _______________ t� Date Application Approved By------ ...... Date Application Disapproved for the following reasons-.............................. ------------.......------•-------....-•--------- ---•--......--------- Date. PermitNo. Issued........................................................ Date -- -------------------- ----- No. .74--- Fss. ../ ......✓ THE COMMONWEALTH OF MASSACHUSETTS BOARD n Appliration -for Dig uiitt1 Workii Tottotrw1ion Urrutit Application is hereby made for a Permit to Construct (&-,0,)'or Repair ( ) an:Individual. Sewage Disposal System aA w cation-fddf�ess "" / I + (or Lo _ ,y /may , � er:/� (/yj Own ...................................... 1 dr Installer Address UType of Building Size Lot_..._:_..:�...__.-.._..._.Sq. feet. Dwelling— o. of Bedrooms........... , ............(__-_-_-__--____ Expansion P Attic ( ) Garbage g Gander (�" — - a Other— ype of Building --------•_-••--•-•---• ----- No. of persons............................ Showers ( ) Cafeteria ( ) WOth r fixtures --------- ------------••--- -------------------------------------•------••:---__------_---•._.__....------.._.. + °Y 6- gallons per person per day. Total daily flow._._.....�.��------------------ � W Design Flow_.. = �- g P P P Y Y ;p-----gallons. Dis osal Trench— o._•--_-•--_------_-- Width_--_ '---•--•-------. Width...... Diameter-..------------- Del�tll.._..._.-_••-.-. Septicp 1 g g Tp al Length................ Total lea&,An Area.--_-.-._-__._--__-_s ft. Tank—Liquid ca capacity ...gallons�----- — the l L n r(� ,_.g` q' Seepage Pit No_____________________ Diameter._.._.__.'__.____-_ Depth below inlet._._._._____.____.__ Total leaching area..__:_.-__--.___--sq. it. Z Other Distribution box (A Dosing tank � ems, Percolation Test Results Performed by.............................�_._._. -_____. 17ale'-----•------------_---- ------ a 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........................ a •------•-•-•--•-- j D Description of Soil__ ------------ W ' ,c -------------------------------------------------•--------------------------. V Nature of Re °or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ -------------------------------------------------------------- Agreement " ','The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article.XI of the State Sanitary Code=The undersigned further agrees no o place the system in operation until a Certifi4ca e of Compliance has been issued by h board o lth. t x Signed.._- , '. Date Application Approved BYF f .- - „_. 7 Application Disapproved for the following reasons:----------- .........................................--•••-•- -------------------------------------------------------------------------------------•------•------------------•-----------------------------------------.............................................. Date PermitNo.--••----•--••--•---=-.................................... Issued..............................._......................... ,,. Date $ I THE COMMONWEALTH OF MASSACHUSETTS -- BOARD OF HEALTH .........OF........ � J 40 • Rk. tr�� ler�ifir��r n f�nnt�littttrr • k' T S I 0 CE AFThat the Indiv', al fnstaller Disposal Svsterrr�constructed /J"or Repaired ( ) ` G_bye a� r/� i[C' ----'•- .,:> a. ----------• .................................... ...• has been installed in accortth the provisions of ,Article XI of The State Sanitary Code as described in the application for Disposal Works Congtruction Permit`NQ6...._:__.. dated.- ti $f9E fS$ZAN,1,1 M,,HIS �ERT4FlCATE SHALL NOT BE CONSYR�JED AS A GUARAPITEE T AT T;FJE Slf S7 EM WI L `FUPICTI®N''SA ACsTORY ~` r DATE_ ,� � , BInspector . .. ------------- •-•-- •---•-•------• . ---------....----------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH frk Nd7h .........`:....OF.. ........... ............. Fp i� tt1 nr n n nrintt err . Permisss hereby grant p!�_"".`�-- :. " ... to Co . ruct ( ) or Repair ( ) an Individual ge Di osal Sys + e ' at /',a .......... • �-------- ... .eet - as shown on the application for Disposal•Works Constructi ermi ........ Dated/ Y �/ Board of ea DATE/a '"" Z/� G z` " a 1 ` ---- T -------------------- �`/t FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS* e J r e y � t _..�......�..�.,.�_,..mow-...-«.-,................r ...,...r..:._. .,,.....:,.:_........_.,....,..«,w..r,..,..-.....«....,.>,_... ,..,.,,.........,.-.,,w.,.�-ww-....M,.._:... .,.,..•.....,..._:...,..:,........,....-,.....�..,,.,�-�...,.. ..,....„:.,....w..:....,......... �„awe•.._,.....,......_......_..�.... ,. m.».. _ ,.�,.. .�.,....»....y.....,... 611 t d PDO Li t �� ~_� # � } �\ �"' .yy- .fro•. � �V� "'YYY 777444