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0282 SEA VIEW AVENUE - Health (2)
2 4 12 Sea iew Avenue OstervilWe, A = 138 --0.08 Town of Barnstable Ft<, TpY Regulatory Services �{• Thomas F. Geiler,Director O . Public Health Division *t ABA; Thomas McKean,Director 9 nss 200 Main Street, Hyannis,MA 02601 ifigq �0 ArFD" Phone: 508-862-4644 Email: health(aDtown.barnstable.ma.us Fax: 508-790-6304 Office Hours: M-F 8:00—4:30 February 22, 2006 Ms.Vera Apog c/o John Skapars 2 Tower Drive Dover,MA 02030 Dear Ms. Apog, Recently a letter has been released to homeowners and commercial business owners regarding the removal of Underground Storage Tanks(UST). When removals, abandonment, and testing of the tanks have occurred, our electronic files are updated. We have found that many files have-not been correctly updated and/or the proper notification was not received by our Department. The tanks we inquired about are listed on Parcel 008 on Assessor's Map 138 and one is registered with the Health Department as tank tag#917 and the other is unregistered. The location of these tanks is at 282 Seaview Ave, Osterville,MA. The Town of Barnstable,Health Department,has completed the research on your parcel and concluded that the Underground Storage Tanks of Fuel Oil were properly removed in January of 2003. We received copies of the UST removal application and permit form from the Fire Department that were both completed by Enviro-Safe Corporation. This information will be placed in your street file and the electronic files will be updated correctly. We thank you for your cooperation in this matter and if you have any questions about this topic or you need further information, guidance or assistance,please do not hesitate to contact the Public Health Division. jomSincerely, as A. McKean, RS, CHO Director of Public Health 03-16=2005 . 04:50FM FROM SW-ETSER ENGINEERING TC it ti U:Y(k3LIE r.el a. - T t� �RO�O�I' NGT0 StI-TICS FROG AS�°BUCIr t N A ..—t . I 'A T-gpARD-OF—'riEAL—TH ASO--- � �l 5 K�y^•xC{^y 'o CDC AV � r LOT AREA — f 1584 t vENUE _ SEA TO -#E-B T OF MY INFORMATION, "'EXISTING" PLOT I' _ _ — BELIEF THE IBARNSTA.BLE, A_ KNOWLEDGE-V..-AND OSTERVILLE) =_ ST f C R SHOWN ON .JHJS PLAN L.C. P _ .. ' : _ HAS B t�MATED ON-J €�.:.G UN DAl'E L 3��105._._ SCALE t- AS FDIC - _ r:.. '" .!` B 6134--00 Cl ENT- - - - MMETSRR ENGINRE -- M GREAT WE=Mf ROAD • PR SIONAI �15:A��::-5�1�#�VEYOR "o s ox 7i� t�uurrs ors. WA MTAL P.01 t�T '01/22/2003 14:51 5088889093 ENVIROSAF PAGE 02/02 aEWr'2;L lr r TAFT 50$7902S85 ^" rAN. 2 003 kwErj) 12 ;42 ,wham r1Npli uon ►u 1ocai rire Department. y Fite Department retains original appllca ion and Issues duplicate as Permit. APPLICATION and PERMIT for storage tank removal and transportation to approved tsink.disposil yard in nrcordanrP wlfh the provisions of M,G.L. Chapter 148, Section 38A, 527 CMP 9 00, application is hereby made by: Tank Owner Name(ptease print) MkDarA ibci rlranrio-.. X Address 2 = aY eW, .e,. qgonaLie. MA sr low. � Removal Contractor Company Name Envjra afe Corporation_ Co.or Individual Envi_ro-Safe Corp# RAW FIMI — Address 14B Jan SebilSticM Dr:.Sandwidh, Mik Address *ESC will, conduct a visual —PM ins 9c permit) ly' %%nature(ff appi i r permit) S' t (It a ly o f i r ,J41FCA tsH4,d OU�ar _ m IF01 CerltHCd C1 I. Other _ • r Tarok Location 282 .Seaview Ave. oaterni.11e, is Ma Cry Tank,Capacity(g ions) 50- 6 , LsLbslance Lase Stored #2 Oil Tank Dimensions diametar X length) Remarks: Firm transportlnfl I to En y i r o-�S a£e_ _�,„ tate tic.fR 3 MA 7 Haxardrn19ws4steLnife-- JW `MAM772,365 Er.P,A.0 _?W983269323_ Apprbved tank dis�osafyard Turner Salvaqe Tankyard# 002 Type of Inert 9 i Frank yardaddresc 35 Cnmmercial Street Lynn, MA I i City or Town Ost rviZla FDJDif ()I C Permit Date of issue ILZPOJ Date of expiration Dig sane approval nLber: 20025CO344 Di ate Watt Pr el.Number-800 322-4844 1 1. Signature I Title of Officer granting permlt I After retnoval(s)send Form PP-MR signed by Local Flro Dept.to t)ST Regulatary Campltance Unit,One Ashburton Place, R oom 1310,l�oslon, 02IO&J818. ly292(revtsod 91s6i � Make application to local Fire Department. Fire Department retains original application and issues duplicate as Permit:--- - �tZ�J?/J?'LQ/12ZCA�Tz2�%IZ � r V 1 - c P �/irlLPiJ2rt l/J�r P/X?IZCUI — � � LIOG cir Cl� w., APPLICATION CATI ON an d PERMIT Fee: $25.00 for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by: • Tank Owner Name(please print) Ska per Is Residence X Signature 01 applying or permit Address e Street MA 0 2 6 5 5 S City Removal • State Zip Contractor Company Na7Jan o—Safe Corporation Print Co.orindividual Enviro—Safe Corp. Address 14ebastian Dr Sandwic Primr Print Address Signature Print 9 C pplying for permit) Signature(if applying for permit) �IFCI-Certi ed Other FCI'Certified fl LSP# Other 7TankCapacity on •Imm Steel Address 5 c"y #2 fuel oil (gallons) — o�U' OD m Substance Last Stored Tank Dimensions is r x len th) Remarks: J Q Firm transporting waste Enviro—Safe Corp. 329 MAM 7 7 5 6 3 5 State Lic.# .Hazardous waste manifest# E.P.A.#. MAD 9 8 5 2 6 9 3 2 3 Approved tank disposal yard Turner Inc. 002 Tank yard# Type of inert gas Tank yard address 235 Commercial Street Lynn, MA City or Town Centerville 01920 FDID# Permit# Date of issue October 7, 2003 October 21, 2003 20033706864 Date of expiration Dig safe approval number: Dig Safe Toll Free Tel.Number-800-322-4844 Signature/Title of Officer granting permit O After removal(s) ("Consumptive Use"fuel oil tanks exempted)send Form FP-29OR signed by Local Fire Dept:to UST Re ulafo Compliance Unit, Department of Fire Services, P.O.Box 1025,State Road, Stow,MA 01775. 9 ry *International Fire Code Institute FP-292(revised 4/97) - A a FindMap/Parcel 138008 Town 6M§brnst4bie " , M,j ; ' Health Depar#ment NealthSystm � x Map/Parcel J138008 x°• <Tank Nbr 01Ta Nbr 00917 Instal ed 10/01/1972 Location B > y -. s v Test Notifcatron Date 6/30/1992' Status K ...... �y Dafe movalNo#ifl�cationflate, AIN Teio �'s 09/10/1992 � an3on 10/07/2003 a i a � AT ' Fuel Stored FO Fuei Stp age Reason H y �� � i 321- a r� �• f Capacity Construction Leak Detection Catil hodic Detection 'SforageT�nks�i�o�02000 SS ���_ 7, r �� �� l.m.I Additio�nal�De#axis �x�Tank removed MM at COMM yr y _ a L a ; 2 q za-Z, d Wpaw1 a 3 Townof Barnstable x Find Map(Parcel 138008 �� M ' Health Department HealthSyst�em y "`' as R 11, 011 MaplParceG 138008MIN Tank`Nb� 02 3 Ta Nbr 00000 Installed h 01/01/1973 Location B �� g � Test NaUfi'cationDate �� � �5fa use �RemovalNofificationDate: �eSt r 09/10/1992 h x , y eE a � Ab ntlon 4 Itemovaf 01/31/2003 3 x � x x r»g FueiryStoed FO FuelStorage Reason H j y aICapacity Construction Leak Detection Cathodic®etoe n StorageTia k Info 000750 ®: a T nk v 0lAdutQxl0AjagFL)etail�r. removed emo ed-MM at COMM f rI IA 01/22/2003 14:51 5088889093 EIA IRUSAF PAGE 02/02 c o oENI1i&JTTT.r "T�g 5087902:85 I SALT. 2� 2005 t�:�ri 1 2 ,vkanc 4tjpf,110" w roc-dI rite Department ry~ Fite pepnrtmerit retains original appllcat on and Issues duplicate as Permit.. APPLICATION and PERMIT , Etr:� for storage tank removal and transportation to approved t,xnk disposal yard in accordanr.P with the provisions of M.G.L. Chapter 148, Section 38k r527 CMR 9 00, applimtfon is hereby made by: Tank owner Name(pteasA pano SaKn 1res jhR t dEMr.p. X , I aTrre perm r . Address a2_geay,ew-Ave POLX -tier-�A. &N a I cry stet° zra Company Name fro-Safo Cotpori 'tion no.or Individual Enviro-Safe Corp.�� - r�inf PQnr Address 14 Jan Sebastian Dr:-Sandwidh. MA ;EESC will conduct a visual PAW Address Signature (if appi iq r permit) S' to It a n'spng# on ozily. ( inn 9 permit) F.I� Ci C - Red Ott�ar .� i`3 ►FCl CenitiCd 0 Leaf*#r fltiiar 7Tankocation Z82 .Seavd.ew Ave. ost`orville, A MW Cny enk apacfiy(g ifons) �� � i ubslsnee Last Stored #2 Oil Tank Dimenslons(diameter.x length) Hernarks: /� Firm transporting I ante ' EnV i r o-.Safe � _ `,ate Lic.#t 329 MA _J Hnz:ardni rs Waste t anlfpgt3: MAW720C5 I~.P,A.#_MAD 9$—5.2 0932.3 4prbveci tank cli%0&uiyard Turner Salyyacfa T2nkyprd4 002 Type oftr,ettsic i 'Crank yardaddroec 235 C'nmmercial Street T;ynnr MA I "or 05t zville FDiO i.S,20:- Purr itP Date of 165uel _ 1 J 11��ta Elate of expiration Dig sale approvzt number- 200250034;1 Di l afa Toil 5r el.Number-304-2 2-4844 Signature I Titlo of ofNcer gra�ting permit l -/x. 0 A Aftar removal(s)sendJForrn FP�2,90R e►grted by Local Flro Dept.io UST Ike_Outatory Compliance Unit, One A-shburton.Place, Boom 1310,1.3oston, i A 0210s-1d18. Fmd Map/Parcel 138008 Town of Barnstable # t , Health:Depaitment Health System MaplParcef 138008 `, - •..- ;; Tarik Nbr 02 Tag Nbr' 00000 lnstailed'' 01l01/1973 Locatign rB r z TesNotificationStatus Date Removal NotificatjonDate �— . Test'° rP 09/10/1992 Abandon tr Removal 'i 01/31/2003 ' zt F t Variance ' � '` - r' FuetStored FO ' "; Fuel Storage reason r f, �� Capacity-;E onstruction ' L"eak Detection Cathod a Detection y "Stora a TankInfo 000750 ' 9 J33 � u SS '- "Atld►ffo PDetails Tank removed MM at COMM g ,� p <k r I Town of Barnstable Find Map/Parcel - 138008 �, „ Healtfi.Department Health System � ; N hY 3 K Ma' P 4/Parcel 138008 Tank Nbr 01 T,ag Nbr oo9l7 Installed 10/01l1072 Location Test Notificatwn Date 06/30/1992 k Status Date Removal Notific atton Date ,�— Test" IP 09/10/1992 - C Abandon r r T 3- Removal F .r 10/07/2003 EVarianCe.. YFue!Sfored FO r Fuel Storage Reasonf � tf xRCapacrty Ggrtsfruction Leak Detection Cathodic Detection i r47 � S Forage Tank Info,002000 SS r t Additio al Defails Y Tank removed MM at COMM a , PIT 6Y i z t Make , applica tion ion to Local Fire Department.Fire Department retains original application and issues duplicate as Perlmit_•::: p .. t.��i -T r--�I i 0/C)Y- C7�P/X(1LCP/J — // (i -- r APPLICATION and for storage tank removal and transportation to approved tank disposal d in acco PERMIT Fee: $25.00 of M.G.L. Chapter 148, Section 38A,.527 CMR 9:00, application i herebymade byrdance with the provisions a Tank Owner Name(please print) Skaper s Residence — X Address Signature(11 applying W permit • slreel e MA Q 2 6 5 5 city Company Name Enviro-Safe Corporation Co.orindividual Enviro-Safe Corp. Address 14B Jan Sebastian Dr Sandwic Pri"1 Pdnr Address Signature(if PPiyin9-for permit) Signature(if applying for permit) rl IFC1-Certi ed Other__ �!IFCI*Certified n LSP#v_ _ Other Tank-Location Slaet Address - 5 Tank Capacity(gallons) _ ��'j cityOQ Substance List Stored #2 fuel o i 1 Tank Dimensions is �r x length) Remarks: / Firm transporting waste Enviro—Safe Corp. MAM 7 7 5 6 3 5 State Lic. 3 2 9 Hazardous waste manifest# E.P.A.#. MAD985269323 Approved tank disposal yard Turner Inc., Tank yard# 002 Type of inert gas Tank yard address 235 commercial Street Lynn; MA City or Town Centerville 01920 FDID# Permit# Date of issue October 7, 2003 October 21, 2003 20033706864 Date of expiration Dig safe approval number. Dig Safe Toil Free Tel. Number-800-322-4844 Signature/Title of Officer granting permit After.removal(s) ("Consumptive Use"fuel oil tanks exempted)send Form FP-29OR signed by Local Fire Dept, to UST Regulatory. Compliance Unit, Department of Fire Services, P.O. Box 1025, State Road, Stow. MA m77F C�iV ED -AP � i`�� JAN 18 2005 "ARCEt. TOWN OF BARNSTABLE O ` - .. HEALTH DEPT. DATE 12/23/04 PROPERTY ADDRESS 282 Seaview Ave Osterville Mass 02655 On the above date,_the-*optic system at the address above was Inspected. .. This system consists of the following:. 1 . 1 -1500 gallon septic tank. 2. 1 - Distribution Box. 3. 12- Infiltrators. Based on inspection, I certify the following conditions: 4. This- is a Title Five Septic system ( 95 Code) kin order at the resent time. 5. The s etic system is in proper working P P u-P 4 SIGNATURE Name: Robert A. Paolinl Company: Joseph P. Macomber &Son Inc . Address: P._0. Box 66 Centerville, Mass 02632 Phone: 508-775-3338 or 508-775-6412 • J4SEPH P. MACOMBER & SONv. INC� Tanks-Cesspools-Leochflelds " Pumpgo .&•.Installed Town Sewer-Connections P.O. Box 66 Centerville, MA.026.32-0066 775.333� . 7.5.6412 t ,per �•\ COMMONWEALTH OF MASSACHUSETTS £XECU'i'IVE 0FVi0KOF ENVfR©NM NTAL AFFAIRS DEPARTMENT OF VNV11VDNMTAL pROTCTION x. TITLE 5 OFFICIAL INSPECTION FORM—.NQT FOR.VOLUNT"Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART•A CERTIFICATION Property Address: 282 S e a v.i e,,) _4 ve Owner's Name:E,s.ta to Ole V e z'a 41200 Owner's Address: 2 7 W e lt D z i v e' Dove2 Na 02030 Date of Inspection: 1210 3_/h,� - Name of Inspector: (please print)4?a_4 e? Company Name: .a: P.AacomAgt• .Sion Inn, Mailing•Address: Un eitv.c e, a,37.•02632 . Telephone Number: 5 0 8—7 7 :3 3 8 CERTIFICATION STATEMENT I certify thatI have personally inspected the sewage disposal system,at this address and that the-Wormationreported below is true• accurate and complete as of the time of the inspection.T e ins•cetion-was erformed based on m P P The P. P y trainingand experience in-the proper function and maintenance of on. ite sewage dis•osal systems.I am a DEP p P P & g p Y approved system inspector pursuant fo:gtction'15:340.of•Title 5(31.0 CMR,15:000). The system: XXX Passes -Conditionally Passes Needs Further Evaluation.by the Local Approvin&Authority Fails, Inspector's Sign,attre: Dater 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,shatecl sy4i m or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shaIrsubmit the report to the appropriate'regional•office of the DEP.The on final should be sent to g 'tlne.system ownez aid copies sent to the buyer,'�f i4ppiica6le,and the approving authority. Notes and Comments ""This'report only describes conditions at the time of inspection-and under the conditions of use at-that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT:FOR O- LUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM_INSPECTION.FORM. � PART A CERTIFICATION (continued) Property Address: 282 Seaview_ Ave Osterville M Owner:Estate Of Vera Ap©Q Date of.Inspection: 1 2,12 3%Q 4 Inspection Summary: Check A;S;C,D or.E/ALWAYS<complete all of Section:D A. System Passes: NO 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: Septic sys Pm i Q in =rnpnr w.nrki z4g er•eleE at -the presen B. System Conditionally Passes: described in.the"Conditional need to be replaced.o.r stem components.as NO One or more system 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. NO- 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-pproved 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: \ NO 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. . obstrtcton is removed distribution box is leveled or replaced ND explain: Y v NO 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 ND explain: Page 3 of 11 OFFICIAL MPECT.ION FORM-NOT VOR VADL•UNTARY ASSESSMENTS SUBIStjRFACE SEWAGE DISPOSAL` SYSTEM INSPtCTI6Nf0RM PART:A . . CERTIFICA'HON'(6ontinued) : Property Address: 282 S e ay i,Pw AvA Osterville Ma Owner:.Estate Of via ApQg Date of Inspection: 12 C. Further Evaluation•is.Requited by the Board of Health: NO Conditions.exist which require further•.evaluation•by.theBvardiofHealth;in-order..to:determine ifthe system is failing to protect public•health,.safety or the environment. 1. System will;pass unless Board-of.Health determinesdn accordance with 310-CMR 15:303(l)(b)that the system is not fuactfoning i$.a•maniier-which mill.protect public health,safety•an:0•the..envirohment: \� no Cesspool or privy is within,50 feet of asurface water no 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 mariner that protects thepnblic health,safety and environment: _noThe system has a septic tahk and soil absorption'system-(SAS).:and the SAS is within 100 feet-of a surface water supply or.-tributary to asurface water.supply. The system-has•a.sepfic tank and SAS and the:SAS is witbin a Zone 1 of a-public watensupply. no The system has a septic tank and.SAS:and-the SAS is within'-50 fet t of a private water.supply wen. noThe system has aseptic tank and SAS and the-SAS is less than 100 feet.but 50 feet or-..rAore front a private water supply well". Method used to determine distance- visual **This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic coriipounds indicates that the w.ellis.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 P .: failure.criteria are triggered.'A copy of the analysis must be attached to•tbis form. z r 3, Other: a r Page 4 of 11 OFFICIAL-INSPECTION FORM NOT:FORVOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION:F.ORM PART A CERTIFICATION(continued) Property Address: 282 Seaview Ave Osterville Ma Owner: Estate Of Vera Apoq Date of Inspection: 1 2 ;3/"u D. System Failure Criteria applicable to all systems:. You must indicate."yes"or"no"to each of-the:following,for all-ins ectio= Yes No . Backup.of sewage:into fez lity.:or.systefr component.due..to.overloaded:or clogged SAS...or.cesspool _X_* Discharge:or ponding of effluent to the.surface..6f the:;gcound or..surfface: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 hiquid depth in-cesspool is less than.6"below invert or available volume is less than May flow 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 Ariy.portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion:of a cesspool•or.privy:is within,a:Zone!1•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 lessthan 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 colifortn bacteria and volatile organic.compounds indicates:that the well is:free from pollutloA fr..om:.titat,factlity 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€orb.] k NO -(Yes/No)The system falls.Ihave determined that.one or.more.of.the:above,failure�criteria exist as described in 310 CNIR 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:systtm, must.serve.a=faeility with a.design flow of 1,0100.0 gpd to 15jQ00. 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 — g thesystem is within 400'feet of a surface drinking-water supply X the system.is within 200 feet of a tributary to a surface drinking water supply _ X the:system is located In a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have-answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner-or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional.office of the Department. 4 Page 5 of 11 OFFICI'AL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS WBSURFACE SEWAGE DISPOSAL: YSTEM INSPECTION]FORM PART B CHECKLIST Property Address: 282 seayiew Aya Osterville MA Owner:Estate Of Vera Apog`' Date of Inspection: 12/2 Check if the following have been done You must indicate"yes"or"no"as to each.of the following: Yes No _X Pumping information was provided V the owner,occupant,or Board of Health. — 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? X Have large volumes of water been introduced to the system recently or as part of thisinspection? X Were as built plans of the system'obtained and examined?(If they were not available hote is 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? X Were all system components,,,xcluding 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 froth 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.11as been determined based on: Yes no ` d of Health. X Existing information.For example,a plan at the Boar — _X 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(3)(b)) v 5 _ Page 6 of 11 OFFICIAL IN- SPECTION:FORK-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM,INSPECTION:FORM � PART.0 SYSTEM WORMATION Property Address: 282 geaview Ave Osterville Owner: Estate Of. Vera Agog Date of Inspection: , 12 12 3 I_D 4 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): ::6.. : dumber of bedrooms(actual): 6 DhSIGN`:flow based on"310 CN&15.203'(for exa4le: l IO gpd i#-of bedrooms).-6 6 0 Number of current residents: .: 2 Does.residence have a garbage grinder,(yes or no)_ �s Is laundry on a separate sewage.system;(yes or.no):,no [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use:(yes or no): no 2 0 0 3= 4 7 9, 0 0 0= G.PD=1 31 2. 3 3 �. Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 4= 333, 00 0 =91 2.3 3 GPD Sump pum (Yes or no): no Last date o�occupancy: present COMMtRCIAIAM,USTRIAL Type of estalLJint: NA. , Design flow.4i*� on 310 CMR 15.203):. NA gPd Basis.of d41 n*flow(seats/persons/sgft,etc.):, NA Grease tra '•resent(yes or no):.E& PP 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: Lastdate of occupancy/use: . OTHER(describe):. . GENERAL INFORMATION Pumping Records Source of information: NA Was system pumped as part of the inspection(yes or 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 ob_tained 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: Installed 12/7/95 Were sewage odors detected when arriving at the site(yes or no):no 6 _ l Page 7 of 11 e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTA RY RY AS SESSMENTS MENT SSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: iea�7; eTg A�,o Osterville Owner:Estate Of Vera Apog Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: 2 4" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.).- Joints are ti ht no evi n \ SEPTICTANK: yegocate on site plan) 1500 gallon tank. Depth below grade: 14" Material.of construction: .X concrete metal fiberglass—polyethylene other(explain) — — If_tank is-metal list age:_ Is age confirmed by a Certificate of Comp certifiicate) liance(yes or no):—(attach a copy of. Dimensions: 1 0 ' 6"L X 5 ' 8" W X 51711 L Sludge depth: t r a c e Distance from top of sludge to bottom of outlet tee or baffle: trace Scum thickness: trace Distance from top of scum to top of outlet tee or baffle: t r a c e Distance from bottom of scum to bottom of outlet tee or baffle:tX&C How were dimensions determined: mea s, I ed Comments(on pumping recommendationinlet and outlet tee or baffle condition,structural as related to outlet invert,evidence of leakage,etc.): integrity,liquid levels Pump tank annually G baa Di �nncnT tCCD are In Plac ructural) RpniTank i rntt j t- s sound. GREASE TRAP:Nglocate on site plan) Depth below grade: NA 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 orTaffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,li uid level as related to outlet invert,evidence of leakage,etc.): .Q s Grease trap is not Titles C Tnet�ranfinn T7 ci�nnn 7 IL Page 8 of I I OFFICIAL IN.SPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS :S:' 1 ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continues}) Property Address: 282 Seayiew Ave Osteryijl.P.Ma owner-..Estate Of Vera Ap g Date of Inspection: 12/ ,3/'C14 TIGHT or HOLDING TANK:NO (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 g g y Alarm present(yes or no): Alarm level: Alarm in working.order(yes or no): Date of last um ping:P Comments(condition of ai.arm and float switches,etc,): Tight Qr- holding �anjai —are—n6t Ares I TRIBUTION BOX: es if resent must be o ened locate on site Ian D S ( )( plan) X__ P P 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.): Box is level - R bag d l Afp-rals N6 , Quid®nce �;E solids carry over. No leakage in or out , of box. PUMP CHAMBER no (locate on sife.plan) Pumps in working order(yes or.no): Alarms in working order(yes or no): Comments(no.te condition of pump chamber,condition of pumps and appurtenances, etc.). Pump chamber is not prQsen v 8 Page 9 of 11 OFFICIAL INS PECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS --. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 282 Seaview Ave Osterville Ma Owner:.Estate Of Vera. Apog Date of Inspection: 12 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located see page, 10. Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: _X leaching trenches,number,length: ' 12 Inf i 1 t r a t o r s. 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 pond.ing,damp soil,condition of vegetation, etc.): or ponding. Sandy soil. .No CESSPOOLS: NO (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 ofponding,condition of vegetation,etc.): are not resent Cesspoolsi PRIVY:No (locate on site plan) Materials of construction: . Dimensions: Depth of solids: 1 Comments(note condition of soil, signs of hydraulic failure,level ofponding, condition of vegetation,etc.): Privy i 9 Page 11 of I 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 282 Seaview Ave Osterville Owner: Estate Of AIonra Apog Date of Inspection: 1 2,.2 3/6 4 A SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 9 C feet `.\ Please indicate-(check)all methods used to determine the high ground water elevation: -NO Obtained from system design plans on record-If checked,date of design plan reviewed: 4 CObserved site(abutting property/observation hole within 150 feet of.SAS) Checked with local Board of Health-explain: www.tpwnbarns tabl e.mA Checked:with local excavators,installers-(attach documentation) Accessed USGS database:explain: �—, You must describe how you established the high ground water elevation: used;Gaherty & Miller model 12/16/94 ground water e1PVat'ians _ used;USGS observation well data .7une 1992 used; Technical bul — — wa er a eva ions. Leaching Pit -9 eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per FsLimpteg Method 0(i'� Therefore,the vertical•separation distance between the bottom of the lead}ing pit and the adjusted groundwater table is / feet: 1p • t1 e f • Page 10 of 1-1 OFFIGiAi�INSPE "TQN F`O�RM>_ NOT FORVOLU ARV ASSESSMENTS SU-89UREACE'SEWAGEMISPOSALSYSTEM "'INSPEC'T'ON:FQRM ,— PART C" SYSTEM INFORM ATTION(conthitted)` Property. Address: 282 SPavi Pw Ave. Owner:Estate Of V Apog Date of Inspection: 1 2/.)3LO—�— SKETCH OF SEWAGE•DISPOSA,L SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permaneAt reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters.the building. r t � , w - 10 -- nr+•-nl•rs*-'1'1-•rn-rtRnTi'n nr�.nn+r.m�rr.•rr•rsrv�*t*rv*snm+rm's'W*'R�.T� '110WN OR Bar�nstal�le WARD OF HEALTH SUBSURFACE SFNAOF I>1SPOSAL SY3TF:M INSPECTION FORM - PART D•- CERTIFICATION I rnnn•�errtRa>TT*T+rr't�nt+.rrr•r•,. -•. �:•••TI•I•T•••:• -T,IIM1^.T.TT111 T'RI'q:TRl Tllr llPCtltR'�R71+�51 T•{IfTT>t IITRiQr'TR� �� ' -T9PC OR PRINT GIEARL1'- PI?OPERTY INSPECTED STREET ADDRESS 282 Seavie.w Ave ' ASSESSORS MAP , DOCK AND PARCEL # 138-008 OWNER' s NAME Estate Of Vera Apog PART D - CERTIFICATION NAME OF INSPECTOR Robert Paolini COMPANY NAME Joseph P. Macomber & -Son Inc COMPANY ADDRESS Box 66 Centerville Mass 02b32 Street Tovn or Clty State E I P COMPANY TELEPHONE ( 508 ) 775-33.38 FAX ( 508 ) 790-1578 ni Cf,RTI FICATION. STATEMENT I certify that I . have personally inspected the sewage • disposa7 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 . Check one ; XXX System .PASSED The inspection trhich I have conducted has- not found any information which indicates that th.e system fails to adequately protect public 1jealLI, or, the environment as defined i.n 310 CMR 16 . 303 . Any • failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . , System FAILED* The inspection which I have condtlbted, h.as found that the system fails tc protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 3Q3 , and as specifically noted on PART C - FAILURE CRITERIA of this inspector. for at Inspector Signature . I1 e i ;ne copy of this c�rc.ification must be provided to the OWNER, the BUYER ,"( Where applicable ) and the 130ARD OF HRA74'rll, * .If the inspection FAILED , the owner or "op.crrator shall upgrado ' the vyetem within one year or the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 1513,051 partd .do( 1 TOWN OF BARNSTABLE IOCATION,,�29-, SEWAGE# `IILLAGE 69.S11-LI-»1/l ' ASSESSOR'S MAP &LOT 0© V INSTALLER'S NAME&PHONE NO. Y)') COS 6 /, 5.6 P7 x-m C ` SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS .� BUILDER OR OWNER 0 PERMITDATE: A,—, COMPLIANCE DATE: /A— 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 3 i �-�. ! I i � . � '"� �-C�� �`� `� �r01�� �v `G/ I _r� �.� �� '� l � (!k� �C �, ' �- .. ---� 'No A'��..� /`d�' �,� �J/ Fee 30. 00 . THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS Zippficatiou. for Mi5pogal *pgtem Cougtruction Permit Application is hereby made for a Permit to Construct( )or RepairXX)o an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 282 Seaview Ave Osterville Mass . (/ Vera A o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J.P.Macomber Jr. Box 66 Centervlle,Mass . 02632 Same 4 Type of Building: Dwelling No.of Bedrooms 5 Garbage GrinderAO ) Other Type of Building Res ; No.of Persons 1 Showers( ) Cafeteria( ) Other Fixtures Design Flow 550 gallons gallons per day. Calculated daily flow 5 X 1 1 Q gallons. Plan Date 12/5/25 Number of sheets 2 Revision Date IAA Title Description of Soil Loamy sand to medium sand Omitting cess " Nature of Repairs or Alterations(Answer when applicable) p Q O l s . I n s t a 11 i n g- 1 -1500 gallon tank. 1 -Distribution box, 12 infiltrators packed in stone. Date last inspected: NA 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 a d not to place the system in operation until a Certifi- cate of Compliance has been issue I by this BparQbof Walth. Signed U • 4 Date 12/5/9 5 Application Approved b — Application Disapproved for the fo owing reasons Permit No. — i -,r Date Issued 00 No. "'-.." p, Fee$ 3 0.O 0 t THE C0MM®N1IVEALTH OF MASSACHl1SETTS e PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS � `.iJ -_ar .. a 1. + l f •v•\.. . . . r •.f.. -. ..a . n� • icatiot for og t pgtent Cor�6trurtion errrYit ti w 4Application is hereby made for a Permit to Construct( )or Repair Kp aneOn-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. \l.:ill lV 11 '1V.:.il 0i l , .• u. •• , •, 282 Seaview Ave Osterville Mass. M Vera A o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. "J:P:Macoiuber"Jr. Box 66 Centerville,Mass. 02632 Same Type of Building: k Dwelling No.of Bedrooms i15 Garbage GrinderQ ) Other Type of Building&-e s ti No. of Persons 1 Showers( ) Cafeteria1 . ( ) Other Fixtures Designngw 550 gallons gallons per day. Calculated daily flow 5x1`Q gallons. Plan Date, 1.2/5/9 5 J07 Number of sheets 2 Revision Date—ig A Title ill Description of Sou Lpny sand to medium sand Nature of Repairs or Alterations(Answer when applicable) Omitting cessp6_01s. Installing 1`:1500`-9a11oif tank. 1-Distribution box, 12 {infiltrators packed in stone. Date last inspected: NA 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 a not to place the system in operation until_a Certifi- cate of Compliance has been issued=thisZarof H lth. J;Signed ( Date Application Approved b — Application Disapproved for the fo owing rea ons \ P Permit No._T: � Date Issued t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-- BARNSTABLE, MASSACHUSETTS s f Certifirate of Compliance THIS IS TO CC.F�f�3,�aY,that he On-site Sewage Disposal System installed( )or repaired/replaced(X)l on 12 5 95 by J.Y.Mai�om er Jr. for Vera Apog as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. — S dated Use of this system is conditioned on compliance with the provisions et forth below: ------� :7— No. . LI Fee $ 30. 00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS ,. i!6po�ar -&p�teM Con5tructiou Permit Permission is hereby granted to T.P_ 4Tg.nomhar Tr. to construct( )repair(KX)an On-site Sewage System located at 282 .S`eayiew Aye 0AtArirJ 1 1 A MA R4 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. All construction /1must be completedithin two years of the date below. Date: T� Approved by N-M CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) i I, Joseph P.Macomber jr., hereby certify that the application for disposal works construction permit signed by me dated 12/5/9 5 , concerning the property located at 282 Seaview Ave Osterville meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is,4 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : i 6 DATE: 12/5/9 5 LIC D SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. Lac&.T- O.N GS— _ 5EW6,61E PERMIT MO. -VILLAGE LWS-T-AL-LE_R_'S-WAME_�_AD_DRES.S �,a3UI_LDE_R_S—tJ.A1�lE__ _AD-DRESS ��C �Or o.--_.1-. F'�$..1..�................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Q _ ... ......... .......OF..................................... .................------..---- .. .---------- Apphratinn -for M-4 uiitt1 Workii Tomit.rnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at --- ---------------------- - ----- Locati Address or Lot No. wn I Address W I taller Address QType of Bui din Size Lot----------------------------Sq. feet U Dwelling No. of Bedrooms.._:_----- ----------------,-----------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures . _.;________________ __ _ --• d ----•------•-------------- ----------- •----------------- ............................ W Design Flow................. -------------- lions per person per day. Total daily flow___--__-/----.__.�------______-._-.-_-gallons. WSeptic Tank IL-Liquid capacity/,V—V- Ilons Length------.-----_- Width.............. Depth-----.--__------ x Disposal Trench— o..................... Width-_�__-_____________ Total Length________ l tal leaching area._:----------------sq. ft. ._--_-__ Diameter.._:_______ al leaching<trea------------------sq. ft. Seepage Pit No.._. Depth below inl .�t! Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY------- --------------------------•---•'--...................•............ Date.......................... ------------ ,4 Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water.----------------------- G14 Test Pit No. 2----------------minutes per inch Depth of Te-t Pit.................... Depth to ground water-_.-_-.----_-___-_.__... •- r- - o Description of Soil ---- -------------- x � _ tc, " .----- V Nature of Wpairs or Y_r ations—Answer when applicable...-__-______________________________________•-•.____-.-_--__-__-_-.._.-____-----_-._._____----- -- ----------------------------------- ------------------------------------------------------------ ------------------------------------------------------------------..-._._----------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i hued by the oard f health. 1 Signed 7 Date AA � --- -- - - --- , 7 �_- -- Application Approved B Y' 4 �~' -_ ........Date Application Disapproved for the following reasons---------------------------------------------- ------------------•-"-••....-----------------•---""-•"--"-•"'"•- .."---"---•-----------------•--------•-----"--•-----"---------"--------------------"--......--------••-"•.---._......-----------------------------.........:"•------- ------------------- �- - ' PermitNo......................................................... Issued-"------ ....--"------ -----••-'-......_...•_-•e-• ...... . Date 10� THE COMMONWE TH OF MASSACHUSETTS BOARDS EALTH . ....... -------.OF..................................... ................................... Application is he'reby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System Locat'•m-Address or Lot No. .. tGJ Owner Address /- -✓? -is•�..'----------- ------------------•----------------- --- Installer Address Q Type of Bu lding Size Lot----------------------------Sq. feet U Dwelling L No. of Bedrooms..-._-!•/....................................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building -..---_-.--_______________ No. of persons---------------------------- Showers-(—)-—Cafeteria, ( ) dQ' Other fixtures ----------------- ---------•-------------------------------- - ------ W Design Flow------------------- _....�..._•--------gallons per person per day. Total daily flow-------1_U�___... ��.�_._._gallons. WSeptic Tanker Liquid capacitjr_h__ Ilons Length................ Width................ Diameter_.____..._______ DeI�X��._-----__.._.... i x Disposal Trench— o..................... Widtli..�__._.-._-----_-_ Total Length_..____, tal leaching area.-------- if I. s/sq•1 Seepage Pit No Diameter-�-------------- Depth below inle � fal leac]ing area v_1_.sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolations Test Results Performed by------- ----------------------•-••--•-•.....-•----•-••-------•--•-•--•-_. Date------------------- ---------,--_- Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to grf and water.. I...... f4 Test Pit No. 2---_------------minutes per inch Depth of Test Pit.................... Depth to gr and water....______.._ W ��� l -.. D ----------------- escrt ton o Soil.__. - %--1 --------- -. _. � ------_-_------------------=------- --- U Nature of Repairs or Alte Answer when applicable-----------------------------------------------------------------------------------------------. ----- Agreement. The undersigned a ree stall the aforedescribed Individual Sewage Disposal System in accordance with ✓t the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in jr o eration until a Certificate of Compliance has been issued by`the board-of health. Signed. I --................ f --- - ---- ---------------------- -------------------------------- /. Date /Application Approved By...... _� .. � (/ �j� /.- -- ._ ... `{ Date pp icatio I Disapproved for tlTe following reasons______________________________________________________________ ...............--•---------••--------------------•---•-----•-•--•--•------•--•------•----•---•--•-••-•------•-------.........--•----•-------•-•------•--......----------........---------------••-- Date PermitNo........................................................ Issued........................................................ Date v THE COMMONWEALTH OF MASSACHUSETTS BOARD IF HEALTH . ...............OF.......i.........a_l... :'"t.................................................... Trrtif irate of TIMp aurr IS TO CEIi IFY, That the Individual Sewage Disposal System constructed �) or Repaired ( ) b Cl�Ls,. Installer at...............-'--•--•-•----•--•' --- -- -------- --- - has been installed in accordance with the provisions W-Ir c1 XI of The State Sanitary Code as descried in the ,,d2applicationIfor Disposal Works Construction Permit ..........1 ................. dated. ...............................___........... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................OF..5 .-----..........................---........................ srl No......................... FEE/45)................. �i��n��tt1 grk� �>a�,�tr�rti�at �er�tit Permissionis hereby granted.............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................ ---------------------------------------------------------------------•------------ Street as-shown on' the application for Disposal Works Construction Permit No..................... Dated.......................................... ---------------------------------------------------------------...................=.................... - Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS II ��� Lt C ��P �` �� ��% D� � � � ',� �, �: �. L� ��