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0011 SOUTH STREET - Health
1 TSoutr. Street Osterville A= 117-180-001 E E t 8 1 r JPT BORTOLOTTI CONSTRUCTION, INC. 48 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508428-9926, FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION ` Property Address: —/ oo Date of Inspection: /S� �'� Ins ec is Name: ,i Own 's Name and Address: CEBTIIICATION CTATFM NT• = I certify that I have personally inspected the sewage disposal system at this address and that the informs-z lion reported below is true,accurate and complete as of the time of inspection.The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage: disposal terns. The System: , 4Passes Conditionally Passes Needs Further E lion B th ocal Aproving Authority Fails , Inspector's Signature: Date: The System Inspe ohall submit'a copy of this inspection report to the Approving authority within thin-, ty(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 andrthe system owner shall submit the report to the appropriate regional office of the,Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION 4i1MMARY• A)SV I ,92 PASSES: ' 1/ I have not found any information which indicates that the system violates any,of the failuie criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system upon comple- tion of the replacement or repair,passes inspection. Indicate yes,,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why,not. , The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or .,,exfiltration,or tank failure is imminent. The system will pass inspection,if the existing sep- ,dc tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or,breakout or high static water.level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box: The system will inspection 'if(with ,P� th approval P� oval of. ( The Board of Health):PP ea th I - {�, � A .� ,a< 'i�:r_ a��£ Ca 76�'Sa S'�$ n.�rS''�� t 11+',�.:.. L{���{� �`fi x+`'r''r� ..x y�L c.=..�'yt� x,R4�� � ,r�; :..�•�'-4 R'�.�r, � 7 -(l, S( !N:.• 1::�:: ��.:�x. F1��7� s �, :5:'� 44( p1'�9. r� ..r i .r h r' EC TION FORM $YS'fEM iNSP , • ' �SUBSURFACE SEWAGE DISPOSAL_. ,,. h, .. , PART A CERTIFICATION;(continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of The Board of Health): 1 Broken pipe(s)are replaced Obstruction is removed - -" C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if ; r the system is failing to protect.the,public health,safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE . , Y MIS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE S STr PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within,50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a.salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE.).DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ; The system has a septic'tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. i The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. i The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 }F Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from;pollution from, the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as dined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health t should be contacted to determine what will be necessary to correct the failure. Backu of sewa a into facility or system component due to an overloaded or clogged SAS p g or cesspool. �e surface of the round or surface waters due to an . t Discharge or pondmg ofefluent to U g overloaded or clogged.SAS or cesspool. e distribution box above outlet invert due to an overloa Static liquid level in th dedyor clog ged SAS or cesspool' �, a :. R 1/2 '` 1 is less than 6"below invert or available volume is less than i" Liquid'depth in cesspoo r. day flow, Required pumping more than 4 times in the last year NET due toged clog or obstructed pipe(s). Number of times pumped -2- 'SUBSURFACE SEWAGE DISPOSAL'SYSTEM+INSPECTION,,FORM = PART A CERTIFICATION (continued) ' Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. i Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 Feet of a.private water,suppiy well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. if the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic_ compounds,ammonia nitrogen and nitrate nitrogen.' E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: ) The design flow of a system is 10,000 gpd or greater•(Large System)and the system is a significant threat to public health and safety and the environment because•one or more of,the following, conditions exist• ' The system is`wrthin 400,Feet of a surface prinking,water.`supply, , a }Tile systerii ry;t iswithin.200 Feet of a tributao a surface drinlung`water supply The system is located in a nitrogen sensitive area Interim Wellhead.Protection'Area` + IWPA or a ma Zone 11 of a public water su 1 well .. ( )� ` PPS P PP Y:The owner.or operator of any such system shall bring the system and facility into full complianeewith-the groundwater treatment program requirements of 314 CMR 5.00 and 6.00.- Please consult the local ., regional office of the Department for further information. ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST ... ; L:....;s- ^*•.<`...5 e.:. v r•, 4y 4i. ,':r".Y' °#^s. ..`•.,^ F3+n. `r.te yr-"r,,. ... Check if a following have been done: Pumping information was requested of the owner,occupant,and Board of Health. ;f None of the system components have been pumped for atleast two weeks and the system bas+a a 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. t ,Y,. As-built plans have'been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up The system does not receive non-sanitary.or industrial waste flow. i The site was inspected for signs of breakout. -t J, L4.1All,system components,excluding the Soil'Absorption System;have been located on site. The septic tank manholes were uncovered,open�d,and the interior of.the septic tank was to ; ` Wed for condition of baffles or tees,material of construction,dimensions;depthsof liquid; �, , �•,s depth of sludge,depth of scum. r„ „• _ 'J. . ' The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated_by non-intrusive methods. N s -3_ .. t .h Wi St� I ... FORM � :'• -INSPECTION •. ' SUBSURFACE SEWAGE DISPOSAL SYSTEM PART B CHECKLIST(continued) Vl�e facilitY owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM L PART�C.- h SYSTEM INFORMATION FLOW CONDITIONS O Ions Number of Bedrooms: r� Number.of Current Residents: Design Flovvt Garbage Grinder:_.AQ0 _ Laundry Connected To System: Seasonal Use:/26 Water Meter Readings,if table: Last Date or.Occupancy: . .COMM •_��s.,,r. - ..,. o. r •. .. c,.t .j",t 4,r. r.''.d. a" _ °3 Type of Esfabhshinent:t i lonsa GreaseTra' Present: (yes or no) A s. Design Flow�1 /dY' p , Industrial Waste Holding Tank Presents- Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings,If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERA INFORMATION PUMPING RECORDS and source of information: /� ped: 'moo System Pumped as part of inspection: C� If yes,volume pum _ , Reason for pumping: . TYPE SYSTEM: � tic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other(explain): r A ` APPROXIMATE GE'of all co pon nts,date installed(if known)and source�of-mforma Wh 9 e /Y'JiY Sew a odors detect in arriving at the sit -4- i q_p;- ' )I +� .¢" 7dth•.�' I' Y 4-k W' �-0'4 i< � Y� :3.5 ' ! � --��,,�� W. , ��i✓.'Yd` ^g+c-. ! .V�' �,�5` 'i 4, ,: .,pi'µ t ;�.'k.+d s7 'aY•�++ a, ,�lJfihVR rM .»',St �§uyh s U�t kph alk "_ , I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART`C ; ,GENERAL,INFORMATION (continued)' SEPTIC TANK: Depth below grade:- Material of Construction: concrete ;metal, FRP Other,.; (explain) Dimisions:/D,'S')f 'X S' Sludge Depth: ' Scum Thickness: Distancejfrom top of sludge to bottom of outlet tee or baffle: Distance,from bottom of scum to bottom of outlet tee or baffle: 3 '' Comments:(recommendation for pumping,condition of inlet and outlet lees or aBles,depth.of.liquid Ie31VI in relation < outlet invert,structural inte rit evidence of leak ge.etc. 21 /i GREASE TRAP:_ Depth Below Grade: Material of Construction: concrete ' metal FRP- Other (explain)I Dimensions: Scurn Thickness: Distance from top of scum to top of outlet lee or bltfle: tvr,x,, Comments: (recommendation for pumping,condition of inlet and outlet tees"or bales,depth of,liquidr level in relation to outlet invert,.structural integrity,"ev.idence of leakage;,etc.) TIGHT OR HOLDING TANK: . Depth Below Grade: Material of Construction:__concrete_metal_FRP_Otiter(explain) s Dimensions: Capacity: gallons Design Flo%% gallons/day Alarm Level: `Comments: (condition of inlet tee, condition:of alarm and float switches,etc.), DISTRIBUTION BOX: Depth of liquid level above outlet invert: . Comments: (note if level and distribution is equ I,evidenc of solids car over,evidencF of ge Into 0 out of box,etc. PUMP CHAMBER. /)!) '~ w _ Pump is in working e , . Comments'(note condition of pump chamber;condition of pwnps and appurtenances,etc.).'' _g "t Tit P- rF. 'E ' SUBSURFACE,SEWAGE DISPOSAL'SYSTEM`INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):_k (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: _ . Leaching pits,number: Leaching chambers;number: Leaching gallefies,number:• Leaching trenches,number,length: Leaching fields,number,dimensions: Overflow cesspool,number: / Commen : (note condition of soil,signs of hydraulic failure leve of pondin conditi n of v geta on, etc. Jo 62 Y CESSPOOLS:4,2,� 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 soilk,signs of hydraulic failure, level of ponding,.condition of vegetation, etc.) PRIVY:4-L Materials of construction: .Dhuensiong: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) i -6 yi�'a �4 �}- ly �n �i-�^.�'''�Y . + SUBSURFACE SEWAGE DISPOSAL'SYSTEM-.INSPECTION FORM PART C -•SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references; landmarks or benchmarks. . Locate all wells within 100 Feet. `eccv , _ 95-:. t '�•;+ t"yr 'e�.�,,. �. :.e9,a '.+IJ� � y,�� +� x '~ !/ 7�. o 0 0 0 DEPTH TO GROUNDWATER: Depth to groundwater: Feet , Method of Determination or Approximation: ' No. "� SZ Fee (y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: cam-.. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppfication for ]Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System R Individual Components Location Address or Lot No. t �Q ' QbUI ner's Name,Address,and Tel.No. Assessor's Map/Parcel Install s<Narg, resannd Tel.N``3 `j ll �eigner's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o alth. Si Date Ila Application Approved by Date 3 Z Application Disapproved by Date for the following reasons Permit No. ( �1 Date Issued ' 3 Y 1 No. 0S2 Fee IU� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: /PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes a 0[pplicatlon for Disposal *pstrm Construction Perron Application for a Permit to Construct( ) Repair r ' Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. SQ 05kTA ner's Name,Address,and Tel.No. Assessor's Map/Parcel NO— �j t )5, Install e N Address s e . igners Name Address d �c� `rw and Tel No..t.�. \\3 , v 1d �c,,Mo� �� ' ,an Tel.No. Type of Building: /� Dwelling No.of Bedrooms ilk Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd *' Plan Date Number of sheets Revision Date Title V Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: Tae undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o alth. / r Signe Date Application Approved by ki f5n=2 ��e Date 3 { Z Application Disapproved by Date for the following reasons - -Permit No: Date Issued ... <-------------------------------------- _-�- -- --------_-------------- - ---- - --- ----_--------- j=---------------_--`--- .. THE COMMONWEALTH OF MASSACHUSETTS i (vice- (J ,h�� ��n u��� BARNSTABLE,MASSACHUSETTS (certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( t Upgraded( ) Abandoned( )by C� tt �77 c-z�^vim at k`{ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. I� ` dated 6LL Installer �C-O C\ JqF(�Vim.. Designer #bedrooms J J}- Approved de gn\flowX &/ ✓� gpd The issuance of tilts er t hallfnot be construed as a guarantee that the system' will`p g y lunctro as designed; Date Inspector --------------------------------------------------------------------------------------------------------------------------------------- No. p 0 � � d�� Fee A)0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(� Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction 'ust be completed within three years of the date of this permit4 Date 3 2 Approved by '�/" e1 • _ Barnstable T own of Barnstable A A"meica ciw SHE Tp�y e arvices Department Rul tory Se ► . � g BARNSfABLE• ' Public Health Division 2007 i63 . no Main.Street, Hyannis annis MA 62601 rfor 't Thomas F.Geiler,Director Office: 508-862-4644 YY' Thomas A.McKean,CHO - FAX: 508-790-6304 -- CERTIFIED MAIL-4 7'011,0470 0001 4525 5563 February 2, 2012 Ms. Susan Kingman 11 South Street Osterville, MA 02655 J . ORDER T O COMPLY WITH STATE ENVI120N1VgENTAL CODE,TITLE 5 MA wa's last inspected on Osterville, , The septic system located at 1 nSa cert f eduth septic inspector for the State"of 1/18/2012,by David B. Maso Massachusetts. ; The inspection of the septic 'system showed that the system"Conditionalll Passes". 5 TITLE 5 (310 under the guidelines of the 199 CMR 15.00) due to the following.- • The pipe.from the D-Box to the SAS needs to be replaced. You are ordered to repair or replace the septic system within one (1) year-from the date you receive this notification. re air lace the septic system with the deadline period will result in future Failure to p p enforcement action. PER ORDER OF.THE B ARD OF HEALTH F cKean,R.S. CHO • Agent of the Board of Health ; tic Inspec Q:\SEPTIC\Letters Sep tion Failures\11 South St.,Ost..doc _ l � �- ��e � � � Q � '�, � �l �� d�o �� Commonwealth of Massachusetts Title 5 Official Inspection Form p Subsurface Sewage Disposal System Form - Not for Voluntary707 °M 11 South Street Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is required for every Osterville MA 02655 January 10, 2012�-1/1-8L12-i page. City/Town State Zip Code Date of Inspection 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 filling out forms A. General Information on the computer, lv 11 q use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David B. Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 ' City/Town State Zip Code:. "- 508-367-1617 S1287 Telephone Number License Number B. Certification fi�r1 �-a°m°m I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).,The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Revised January 18, 2012 Inspector'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 same or different'conditions of use. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 i �� i f � i o- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10 2012 rev 1/18/12 required for every rY page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. 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): The Distribution box is full to the top over the outlet pipes. Further investigation determined that the Distribution Box is at a lower elevation than the cesspools and leach pits that it feeds. The cesspools and leach pits are dry showing minor ponding of effluent. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M s 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every rY page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ® Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ❑ Y ❑ N ® ND (Explain below): Distribution box is at a lower elevation than the cesspools and leach pits that it services creating effluent as observed to be to the top of the distribution box. ❑ 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 q ed 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts f Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10 2012 rev 1/18/12 required for every , page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every ry page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10 2012 rev 1/18/12 required for every rY page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts . Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage See Below 9 ( Y 9 (gpd))� Detail: #13- 10,000 gal in 2011 and 9,000 gal in 2010, #15- 15,000 gal in 2011 and 15,000 gal in 2010 Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every rY page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Truck gauge Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 11 South Street(Also Known as 13-15 South Street) Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10 2012 rev 1/18/12 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Newest Pit is dated 9-20-95 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10 for town waterfeet Comments (on condition of joints, venting, evidence of leakage, etc.): No issues observed that are observable Septic Tank(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Typical 1500 tank Sludge depth: 8" t5ins•11/10 Title 5 Offoial Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every n/ page. City/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 30" Scum thickness 7" Distance from top of scum to top of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Scour stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Portions of tank that are observable appear in good conditiorr 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owners Name information is Ostervill r�/e MA 02655 January 10 2012 rev 1/18/12 required for every , page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10 2012 rev 1/18/12 required for every rY page. Cityrrown 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 6" 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.): Dbox is 18 inches below grade. Box was full and outlet pipes were not observable. 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: The Leaching pits and older cesspools were opened to determine issue with dbox and it was determined that the leaching pit and cesspools were empty with evidence of past ponding in the pits. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is rY Osterville MA 02655 January 10 2012 rev 1/18/12 required for every , page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 1-24' ❑ leaching fields number, dimensions: ® overflow cesspool number: 1 ❑ 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.): No damp or ponding soil above system. probing area of system in stone indicates dampness. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 ,i' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every rY page. City/Town 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 Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): z t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title '5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M , 11 South Street(Also Known as 13-15 South Street), Osterville Propery Address Sue Kingman Owner Owner's Name information is ry Osterville MA 02655 January 10 2012 rev 1/18/12 required for every , page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 11 South Street(Also Known as 13-15 South Street), Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every rY page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 25 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: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: gourndwater contour map and septic designs in the area Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 11 South Street(Also Known as 13-15 South Street) Osterville Property Address Sue Kingman Owner Owner's Name information is Osterville MA 02655 January 10, 2012 rev 1/18/12 required for every ry page. Cityrrown 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I - p � f ;To".. OF BARNSTABLE 11 9,Z�9- /J ,�r�.f"h S SEWAGE# LGC'ATION li7-AeO-PC/ YT,LAGB S.�t er--.1 e ;ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. s SEPMC TANK CAPACITY } r " , 1.EACIUNG FACILITY: (type) T T r.r1 t y-/ (size) 6 Q 149EF BEDROOMS t E ER OR OWNER DATE: 3-a-? -915- COMPLIANCE DATE: -4pon Distance Between the: Maximum Adjusted Groundwater Table and Bosom 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 fact of leaching facility) Feet Furnished by -3 ; 3.0 pin r Health Complaints 05-Feb-02 Time: 9:00:00 AM Date: 1/29/02 Complaint Number: 3258 Referred To: LEE MCCONNELL Taken By: BARBARA SULLIVAN Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE Article X Detail: Business Name: Number: 15 Street: South St. Village: OSTERVILLE Assessors Map-Parcel: Complaint Description: STACEY CALLED THE HEALTH OFFICE CONCERNED ABOUT POSIIBLE LEAD PAINT IN HER APARTMENT RENTAL. THE BATHROOM PAINT HAS BEEN CHIPPING AND PEELING FOR YEARS. SHE ASKED LANDLORD, SUE KINGMAN ( , TO FIX THE PAINT OR HAVE IT TESTED AND NOTHING WAS EVER.DONE. SHE IS CONCERNED FOR HER YOUNG CHILDRENS SAFETY. Actions Taken/Results: LM SPOKE WITH THE TENANT STACEY AND EXPLAINED HER RIGHTS. LM ALSO EXPLAINED THAT SHE WOULD NEED TO CALL A CERTIFIED LEAD INSPECTOR TO TEST THE PAINT. STACEY SAID SHE DID NOT WANT TO GET THE LANDLORD IN TROUBLE BUT THAT SHE WANTED THE INCIDENT REPORTED. Investigation Date: 1/29/02 Investigation Time: .3:00:00 PM 1 00 No..-- �-*-� Fas..... 0�.. r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE ApplirFatiou for Bi-nVniiFal Worlai Towitrnrttnn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at 1 Location- -\ddress Lot No. �?rlC 'f UZL TL ... .......................... z7� O++ner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms------------ ----------------------------Expansion Attic Garbage Grinder (K) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtur ..... W Design Flow.............. ................:.......gallons per person per day. Total daily flow----------- v..................... WSeptic Tank—Liquid capacitv/f(gallons Length---------------- Width---------------- Diameter_------------- Depth................ x Disposal Trench—No. .................... Width....-�...--..----.. Total Length...-----....�...... Total leaching area....................sq. ft. 3 Seepage Pit Not. ----- Diameter----.`0.--...-- Depth below inlet----&........... Total leaching area....... ..........sq. ft. Z Other Distribution box ( ) Dosing tank ( ) A—7; ,.., W Percolation Test Results Performed by-------------------------------------------------------.................. Date..--- ................................. Test Pit No. I----------------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------------------------ x - -------------------------------------- ----------... .... .. -----------------------....._._... --------- 0 Description of Soil......__/ ®Y.............. ..--._ U -•-•--------------------•-------•-••---......•-------------------------•-----------------.....•---------------......---••••----------•----------••-•-----•-••----------•----------......-•--------•---•- W ------------- -------------------------------------------...-----------------------------------------------------------------------------.............---------- ---------- U Natu/rJeo�f Re airs or Alterations— nswer when applicable.--�.. jli G. �V...«D�� �-x ...... Agreement: pt bl.G ok The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia e has been issu y t bo of health. I Signed .... t et--- -- --- --------------- z�.�.......... .. ...._.......� Date Application.Approved BY - ------ .... .-- Zr Date Application Disapproved for the following reasons- ---------------------------------------------------------------------------------.....----.....--------------------------------- -------------------------------------------------------------------------...--------------_............----.-......------------------------------- --------------------------------------- ....... Date ... S Permit No. ......... �...... - - Issued ............... Date -�� d oo ...� .v . .Fint..... .. .-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divi-Vitittl Workg Tonitrnrtion 1hrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ...............................................................��c= - c�z6 s s /3�,�;�5' / 70/ 0- �-------------------------------- ..._ ---- I _' Location-Address or Lot No. 1/}�lt T Z� r. �'_..: 7isi? s• - ---- _ Owner Address ,.a - -- -.......................... Installer Address d Type of Building / Size Lot................ Sq. feet ,., Dwelling—No. of Bedrooms............:{____-_-..__.----_-.--_---_-Expansion Attic Garbage Grinder (M) 04 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 0.1 Other fixture------------------------------------------------------- w Design Flow................ _________________________gallons per person per day. Total daily flow-.--------�!��---.................gallons. WSeptic Tank—Liquid capacity Z� gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. 3 Seepage Pit No�_�E-----. Diameter......6?.------- Depth below inlet.... ........... Total leaching area_.__......._..._...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) I' 7 5 47/ a Percolation Test Results Performed by-------- -------------•-•-•---•---•----.......-----------•--------•------- Date----------- -----------------------•--- a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No..2................minutes per inch Depth of Test Pit.-------_--__--__-. Depth to ground water........................ �+ ---------- --- ---------------. D Description of Soil.....................' '!- u L i v f1✓e/f xd--- W ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----•-••-------- ----------------------------------------------------------------------- --------------------------------------------•-------------•----------•-------------•- ---.............. 0 Napre of Re airs or Alterations— swer when applicable-'._ ✓Sl L--le ----/ OG..................................... ... -CX!5 is�G. ssr�D��....../!� f/✓Si d � _ � -r ...................= /�i "". Agreement. � '. o,< The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with 'the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss�y the board'of health. Signed / ...y s v ........................... -- --- ---------- Daze Application.Approved By ......... � F-e.�.{ - --------�._------.----- �.-3P, . p-.....Date Application Disapproved for the following reasons- ------------------------------ ------------------------------------------------------------------------------------------- ------ f ---------------------------------------------------- -----------------------.....----------------------------------------------- --------------- .................�� are..---------------- 7 Permit No. ........ -- �o-9.�� - Issued ...............�12.�/ f Dace —.—---_.._ --.—_—.--.--_— -- ————— __-- ----o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r TOWN OF BARNSTABLE Tertifira e of Cgomylia tre _ T_HI IS TO CERTIFY Th t the I�nydividual Sewage Disposal System constructed ( or aired �L T' -L= -e_ - 1..:'.�.. ............... .. .. - S .�. by ...... / - s�.nr at ...1_3��.. .�Y��._ .JET.... �'`�. �2tJ�LC.L----. d---- --1/. ®. '11 ---�---.... .. ---- - --- . --- --- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in r the application for Disposal Works Construction Permit No. _-----------------__---.... -------------- dated ..._._....----------------._....._.._.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE ................�-� - -- �hC6 --. Inspectot(-'...... .►���/. - - --------------------------------,_.___------_.------------- _,--__------- -� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 60-- S,� o No. .................. FEE __............. Disposal� Tunitrudion rrntit Permission is hereby granted TY``-v-(........... r---------------------------------------------------------------------••-----••---....-- to Construct ( ) or Repair (Y)' an Individual Sewage Disposal System at No...�3M'..So-" �- _�/ = r �UICCC_� « / // '7 //(6) "/ . ---- . ---------------------------------------I...........r................. Street n as shown on the application for Disposal Works Construction Permit Not�_-------� Dated_. z�---:-..�/&......... ,G,� DATE....... . 1 .................................................. _.. � Board of Health .................................� FORM 36508 HOBBS R WARREN.INC..PUBLISHERS 4 t �vonc T,✓.� — /moo G�h. - . /t✓�c�,t �i�- - L-�• 1000 t�� .SrnN�= /t�E�✓-.�/¢�5')z = >.S�r/O � ?BGo� . QED -ass v�� Zoo w5r�nrG- r',21 Ccsoaxs �G till Z � _ �g.rZ l ® �Iseos4. �oG � - New/900 6A-L. 440 y4-9 0 lL p sc_arto 13 -5401 f s L�3CI5/�l l�G � 'L�IS7y NG„ t /N OF BARNSTABLE MAS SA C HUS ET T S ASSESSORS MAPS e 1(00 •(66AC J ee q9 ate. e2JE •+ le-+a rl-'A- ', ae Al ,.SDD�' p n•pe' w•I y J 5 r oe)gP1 2AP� cAN6 6• ua q8 ty �Ger°°S a7 eo so 90 OrM 90 VCC' y� oy r � 70 0M _c.,o�- .dy 'Q 70 'n 2A A4 16.0-1 a,b A 19y Zb ec pp a O .0 i, � iE���6 I4• �.0 73 ao < s T.I gkc A6 el �a Al A 5� a.I P- yF\I� ye 2 1 313AL vly O \,oQ� e �M j1'5 PE' 0.3 4 2g �q Q \gZ• o°c _ '1 .0 alat. Pc 0 4 W1 10 r.wt 1 N 8 Ac `Z O 0ep4 Oqc //ems/ !i t. r .2 Q® \lb .�mo� 9 y y' /ao=z O 44 G d A 0 -PC- 60 .29 1 16JN qp4 O\ �, 'J1 OJ; y4 `qV � ? - VI 11"a SQU LIZG towooeelwlu"s 6\ 0 / 42 : .el At. 62' •Ajq► �/ � l I /6� Q 36 A0- A g •a. b�AG• 23 pG• 34 b ® I 1 0.29A4 - 35I15 37 .08Pc aw 12y' ♦►� ©�-.'IIvPy' 1 1131AG Itl1►C• 1SP�-• .190k6. 38 .fib.P` r �` IlA -•1 SUN VOL AIAC QA 4 l 9 ea 33 a ® � 9 31 .9A4 e . I59 , 75-1 / 39Ac. y! lei e�I� 1 oSAC• / O 6� 142 so t 2.1 e 100 .50AC /OJ boa r w OI ele. /g4� O�`f e /y2 T o .tea ► 81 1 144 l vt_w se7 /a / cw 30AC s .1 j4g_.. 1.ee At. • lD /at /(!B AC 104. //s t 66 56 67 2A .60K •'194C. e 4c p�O3 / 0 0? � /6/ C 4C. � 8 .114C 1 -:134C 52,. �,• as Igo H ® K12 « laaa TOwp 99 y 0 9i .%big Lq� N I p4 R aC ry b del foe I x,N� . ..46". � z .- ® 1qS .206C 7•b P-63' .3.3A< 112 n3 114 115 - +4�� 109 MPf 32Ac• ,IIAC. 11AC. .09AC. �c ' 131 .23AO-8 110 %. c 1,38 e- - �\ ye AG. 136 w es 11 4uM'��1 a 12p4 ? o � .31AC•8 n 63 .r 90 124 e i AL i •24"4 \ f .31AC. 121 \2�. jo 135 r a 129 135 W . <� A o ac•' � .t a /., AsBuil� ; Page 1 of 1 TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE.t �1 �-=—'' ASSESSOR'S MAP & LOT//7-/?l--cbe INSTALLER'S NAME & PHONE NO,a,__S I � 3 -77!�1r1 SEPTIC TANK CAPACITYL n06 LEACHING FACILITY:(type) size) lQ/ 1 r-4 NO. OF BEDROOMS PRIVATE WELL R PUBLIC WA' ER BUILDER OR OWNERS F L U_rts E L DATE PERMIT ISSUED.: DATE COMPLIANCE ISSUED: VARIANCE`GRANTEDr Yes No•)y zo� c . Obi re it http://issgl2/intranet/propdata/prebuilt.aspx?mappar=l 17180001&seq=1 3/29/2012 ;_ s 11 rlo..ya.P. � f/� - /�-.. 0 o/ �e Fiz$............._............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OE HEALTH TOWN OF BARNSTABLE Appliration for Uiipusal Works Tonstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (v an Individual Sewage Disposal System at: -�*j jr ......... ... ...................••-------._...._....... -••-----------••-•-•----..........._........•---------........--•-----..........-•----__........-- L cat Address or Lot No. '�'tJ�=--....... ����.L.......----•-----...•...._�--�1/Ic.STI�l. _lQiQ.!.✓S AV.- ?LhS---------...�..�..........-- a Own�� /COS WIZ � dress �v[ cJ --- ..._.. ---------------'...........--•--•-•-•----_.... ---. ..................------......-j------------------........1... �!---1...------... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ............................................. ------------------------------------------------- ------------ •-------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water......................... a -----------•--------------------------------------••--...................................................................................................... ODescription of Soil----------------------------------------------------..........................•.............................----....................................................... x V ................•-----------•-------.....------------•--•-------...-•-•--------------------------------------------------------------. •--•-------------•--------------------••----•--•-----.....•--..--- W x ------------------------------------------------ ........................................................- ----- ------ --- -------- V Nature of Repairs or Alterations—Answer when applicable-------- ....c !,J -f c.cs Z �i.l..._� J................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha e sued b t oard h alth. Signed --------------- .------......... ----------------- ........ ' • Dare Application Approved BY ... `,• --------------- ------------ .................. ..----------- ...... ..--..a'�...��..�. Date Application Disapproved for the following reasons- - ------------------ ---- --- ....----------...------------------.-- .............------------------------. ---------------------- ---- -------------------- --------------------- ------ --- ----- --------------- -- ------------------------ ------- -------.................................... --- ................------------------------ e� Date Permit No. ....../ a. .�6 y..-... Issued ----- ----------------------------- ------ -------------- -- Dare 4'-.> :' No._...-...---3. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE pplira#ion for Dhipaoa1 Works Tons rn.rtion 1[ rmi# Application is hereby made for a Permit to Construct ( ) or Repair (S</,) an Individual Sewage Disposal ~ System at: ;1411 or Lot No. Locati n-Address �� w /- /�/-�_ L ...................._ --- / ( OwnerG..O•�J 7G A dress a ........................................ ........................................................... �2/� ........................ . c S Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a " Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------••--•-•---------------------------•-•-----.-----•-----------••----•-----------•----•••-------------------------------•-----------.....---- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit....:............... Depth to ground water........................ Li, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ Pd •-------------------------------------------------------•.......---------..........---•--•---•••---......................................................... 0 Description of Soil............................................................................---•---------------•--••-----------------•---------------•-•-------------------------•----. x U ...............................•---•••----•-----......---....---._.....•----•-•-------------...----•--------------•-•--------•••---------------•-------------.....--------------••----------•--•-------- w x -------------------------------------------••-••---••--•-•---------••-•--••---••----.._..........•-------••--. - V Nature of Repairs or Alterations—Answer when applicable______-_ �- �� ____ 5 ..C.-a% •-S.____ ?t� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until_a Certificate of Compliance has,,b?e'eissued b thei-board, health. Signed -- ----------- `-.. �!l--. ... ...------ - ,� � Application Approved By .... J .....�t.....Date Application Disapproved for the following reasons- ------------------------ -- -- ----------------------------------------..............................................------- - ---------------- -------- ........................................ Permit No. ...... = �`��O Issued ---------------------------- ----------Date Date THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH TOWN OF BARNSTABLE Cfe>r#tftea#e of C111-IImpliattre THIS IS TO CERTIFY, That the 19dividual Sewage Disposal System constructed ( ) or Repaired ( �) by .............................. ....... LG%�1 - ..........................................................s� . Installer at -------------------------------------------- - --....-----._...-----------�� 4U ... --�7-i����.. --------- ........................... has been installed in accordance with the provisions of TITLE 5 pf The State Environmental Code as described in the application for Disposal Works Construction Permit No. .......l..o�......... .4'........ dated ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............................... f ...I---� "( Inspector .----- --....----.......-THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No- --a--.3�� FEE...3G.......................... Permission is hereby granted........................................U � ------------------------•- .............. to Construct ( ) or Repair (�)an Individual Sewage Disposal System at No.............................•------............ •_.3�e� 7 a`��' --------------------------•••----•----•••----_.... Street 9a- 36� as shown on the application for Disposal Works Construction Permit No............. ...... Dated.......................................... . . ------ 7 F Q' _ r� Board of Health DATE -----•---•--......-••--•.....0.. •--------•------•--- FORM 36508 HOBBS✓!t WARREN.INC..PUBLISHERS r TOWN OF BARNSTABLE LOCATION' dA8, SEWAGE # ;?0 VII_LAGE~ 65 o VU ASSESSOR'S MAP & LOT IN`STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY[ LEACHING FACILITY: (type) �\size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: �t I COMPLIANCE DATE: Separation Distance Between the: f Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist, on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A 4 a = ,fir 6 TOWN OF BARNSTABLE L:CCCATION SEWAGE # cE: VILLAGE ASSESSOR'S MAP & LOT//� INSTALLER'S NAME & PHONE NO.tea97DC61;7 6-a 'A&7 .104A -23EW SEPTIC TANK CAPACITY LEACHING FACILITY:(type) /�d� l�L" (size) NO. OF BEDROOMS_ PRIVATE WELL O UBLIC WATE BUILDER OR OWNER � G GAG DATE PERMIT ISSUED: jp�aal� DATE COZIPLIANCE ISSUED: VARIANCE GRANTED: Yes No � �� .._ � i� � � � � � o �� �� , . o �� � � , . . �7 _f . � P77- . TO OF BARNSTABLE V -LOCATION & SEWAGE # �3 V`?.LAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /��®��/ ff /Joilt C LEACHING FACILITY: (type) r, "t (size) 6 X 10 NO.OF BEDROOMS 9 1 BUILDER OR OWNER �i \ LA e PERMTTDATE: ��_ S9 COMPLIANCE DATE: 9"a6 '5 Separation Distance Between the: f 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 '36' -� Uc f rn t TOWN OF BARNSTABLE LOCATION IJ & .11 L .5�' SEWAGE # 01' VI-LLAGE iosmf-¢�`/I L-L-� ASSESSOR'S MAP & LOT//7-/0--�Z/ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY t&r--n LEACHING FACILITY:(type) (, fig- ��-L_ (size) t6r� &Oft,_ NO. OF BEDROOMS PRIVATE WELL =PUBLIC ER BUILDER OR OWNER .q DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Il— 4 1' �N 1 U 1 ...Sv �.3 �` a i v No..... � THE�COM^OONWEALT�F�HEALTH TS O//''99R® O TOWN OF BARNSTABLE Allp iration for Bispoiial Works Tutus rnrtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (,N;�) an Individual Sewage Disposal System at: /. --........ ..._....... � ,�.`�'��-�..�............. ---------------....-----.. ..-----•. Loca on- d s or Lo o. caner Addres ..... Installer Address U Type of Building Size Lo D - .Sq. feet Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ----- ----------------------------------------------------------------------------------------------------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter.-----.-..-.-.-- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-.------------.----- Depth to ground water-.-.-.----.-----_--...- ti, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------------------------------------------------------•-------------•-------......--•-••........................................................ 0 Description of Soil.............................................................................................................................................................---------- x U -----------------•--------------------------------------------...------------------.....•••••------------------------------•------------•-----•----------------------••---•-----....._..........._...... W -------------------------------------------------------------------------------------------------- VNature of Repairs or Alter tions—Answer when appli le -- ------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant as been issued /byy he board of health. �C �QIgned -�-- - --- - ------- -- -- ----- / ate Application Approved By ------------ ----- - -------------- -- --------------......................................................................... c�a... Application Disapproved for the following reasons- ---------------------------------------------------------------------------........................................................... -------- ---------------------------------------------------- --------------------------------------.................--------------: .................. ......................................... Dace Permit No. 14�-""---/ .............................. Issued /Z �� ... e II _J THECOMMONWEALTH F USETTS BOARD OF ,,HEALTH - I TOWN OF BARNSTABLE Applirttfion for Disposal Works Tottstrmftott Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (k) an Individual Sewage Disposal System at: .. .. ----- .... Locati n- ddress� Address --------------- Installer Address UType of Building Size Lot�4.�J.--------...Sq. feet �-r Dwelling—No. of Bedrooms................�..__...._....___..__..Expansion Attic ( ) Garbage Grinder ( ) Other—T e.of Building persons a yp g �_?��_�'_�-..._.._ No. of ___________________________ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------------------------------------------ W Design Flow............................................gallons per person per day. Total daily flow-----------_................................gallons. WSeptic Tank—Liquid capacity-------------gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •--------------------------------------------------------------•----------•••-............------•---......................................................... 0 Description of Soil....................................................................---------- x V .---------------•-------...•-----------------------...........--•-----•-•----------------.....-•---------...---------------------------------------------------------•----....._..-•---------•-•--------- Z -----------------------------------------------------------------------------------------•--•----------------- -"--- -----------....................................................... U Nature of Repairs or Alterations—Answer when applica ?_-.,.— P °- —�`�1 :e !I ?____..... Agreement: - The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued by the board of health. igned .... J % r�e --------�- ---------------- -/a.. 9r------ Application Approved BY �.-z���Q!`�•} = 'r "./............ ------------------------------------------------- -__... -- Q� Application Disapproved for the following reasons- ---------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------ �� / Dare Permit No. ........... -------------•-- b---------------------------- Issued -------- '�6 �� ------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , TOWN OF BARNSTABLE (ger#ifi ak of To14t plianu THIS IS TO CERTIFY, That e Individual Sewage Disposal ystem constructed ( ) or Repaired (X by------------- ---------- --------...J0 `--------� ... .. . ------------------------------------------------------------------....----...------- Installer at �1------------- ---- ------- ..--. �................ .........—...-'----'-- .----'--------------'------'--- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -BEE�CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL/FUNCTION SATISFACTORY. DATE...... t ..'.. `^ Inspector •/ ----------------------------------- THE ✓! = r COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH TOWN OF BARNSTABLE No._ 2.-. ...................... Disposal orko onofrurfion Vvrr 'f Permission is hereby granted...........14 --------------••--- ...... ......... -...r........................................ to Construct ( ) or Repair ( ) an I dividu Seyvag Dispos System _ Zv Street as shown on the application for Disposal Works Construction Permit No. 0_7 y Dated.._....__ � ?......... /Boar`d of 1FIealtli' DATE r-7....9'�-------------------•----------------------------- �i FORM 36508 HOBBS&WARREN.INC..PUBLISHERS