The URL can be used to link to this page

Home My WebLink About0109 WEST BAY ROAD - Health 109 West Ba! p-okb , �1'1�Ilv -=Y TOWN OF BARJ�NSTABLE LOCATION �d s� �ZX # S T -VILLAGE ® �P'J i�`Q ASSESSOR'S MAP&PARCEL NAME&PHONE NO. I 1 SEPTIC TANK CAPACITY I000 LEACHING FACILITY:(type) (size) PM NO.OF BEDROOMS OWNER U PERMIT DATE: C SATE:�I C.R 0 i Separation Distance Between the: 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 - J J r ! ! r f r r f J f f f 1 f f f r J•~f f r i ! i f J i ! J i f � ! f f l f f ! f f f r • 23 35 36 50 50 a West Bay Road 7 Commonwealth of Massachusetts w Title 5 Official Inspection- Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February17, 2012 every 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` A. General Information When filling out ! � forms on the computer,use 1. Inspector:- (� only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 'e/9n City/Town State Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r February 17, 2012 Job# 12-26 Zitctor'i Oignatur 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•11/10 Title 5 Official Inspect n Fo :Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February 17, 2012 every 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: Tank was not in need of pumping at time of inspection. Leaching pit was found empty. 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February 17, 2012 every page. City/Town 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 J ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts ?312 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February17, 2012 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_day flow t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is Osterville MA 02655 February 17, 2012 required for ry every page. CitylTown 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. 15ins•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 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Cisterville MA 02655 February 17, 2012 every 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): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February17, 2012 every 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 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied. 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 ,M 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February 17, 201-42 every 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: Tank pumped in 2002 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is Osterville MA 02655 February 17, 2012 required for ry 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: 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 61' Depth below grade: 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 0" t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February17, 2012 every page. Citylrown 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 Scum thickness 0" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank had liquid only, no solids. Tees were intact and clear and liquid level was found at bottom of outlet invert. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February 17, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No 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 l5ins•11110 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 wM 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osteryille MA 02655 February 17, 2012 every page. City(fown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box. etc.): No solids or high stains present. 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: l5ins•11110 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 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February 17, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields - number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Pit was found empty at time of inspection. Observed a faint stain line one foot from bottom of pit. 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 1.1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osteryille MA 02655 February 17, 2012 every 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.): i 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 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is Osterville MA 02655 February 17, 2012 required for ry every page. City/Town 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 23 "kk' 5 36 50 50 1 S; West Bay Hoad Commonwealth of Massachusetts W Title 5 Official Inspection Forma Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February17, 2012 every page. Cityfrown 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: 15+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater elevation map shows water below el.5 and topo map shows property at el. 40. 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 109 West Bay Road Property Address Peter Brooks Owner Owner's Name information is required for Osterville MA 02655 February 17, 2012 every page. CitylTown 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 COMMONWEALTH OY MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTEC i JUN 1 1 1 RNSTABLE O A F B ` TOWHEALTH DEPT. TITLE 5 , OFFICIAL INSPECTION FORM'—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name: . Owner's Address: /,t, ,ram leodll® A OD[o S,S Date of Inspection: Name of Inspector: (please print) J S r-401001-' Company Name. + , C Mailing Address: �0 y. Telephone Number: 09'. 7 7 i • � CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to ect►on 15340 of Title 5(310 CMR 15.000). The system: , Passes Conditionally Passes e s F rther Evaluation by the Local Approving Authority iIs Inspector's Signature: Date: 0 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and.Comments ****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. Title 5 Inspection Forme 6/15/2000 page.l ,' Page.2 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: d Inspection.Summary: Check.A,B,C,D or E./ALWAYS!complete all of Section D. A. ystem 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 thej"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND).in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years.old* or the' septic tank(whether metal or not) is structurally unsound;exhibits substantial infiltration or exfiltration or tank failure is imminent. System will.pass inspection.if the existing tank is replaced with.a.complying septic tank as'approved by the Board of Health. *A metal septic tank will pass inspection if it is structurallysound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with, approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution,box is.leveled or:replaced ND explain: The system required pumping more than*4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. ' broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of.1.1 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A a CERTIFICATION(continued) Property Address: w1a, &A0 wvi` dfj Owner Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. . 1. System will pass unless Board of Health determines in accordance with 310 CMR 1.5 303(1)(b)that the system is not functioning in a manner which.will protect public health,safety and'the environment: Cesspool or privy is within 50 feet of a surface water * Cesspool or privy is..within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(!and Public Water Supplier,if any)determines that the system is functioning in a manner that`protects the public health,safety and environtnent: _ 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 tankand SAS'anq the SAS is within a Zone 1 of a public water supply.. The system has a septic tank'and'SA.S the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS An the SAS is less than 100,feet but 50 feet or more from' private water supply well". Method used to d�ten-nine distance "This system passes if the well water analysis,,performed at DEP certified laboratory, for coliform bacteria and volatile organ i Ccompound s indicotes that the well is free from'pollution`from that"facility.and ' the presence of ammonia nitrogen-and nitrate r}itrogen 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: 3 i dr Page 4 of 1 I OFFICIAL.INSPECTION FORM—NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR' A CERTIFICATION(continued) j Property Address: Owner: Date of Inspection: Co S/D J D. System Failure Criteria applicable.to all systems: You must indicate"yes"or."no"to.each of the.following for all inspections: Yes. N Backup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool` Discharge or po.nd.ing 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 loutlet invert due to an overloaded or clogged SAS or cesspool i Liquid depth in cesspool is less than 6"below invert or available volume is.less than %day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped j 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 I of a public:well. Any portion of a cesspool or privy is within 50 feet ofa private water supply well. Any portion of cesspool or privy is less than 100 feet but greater than.50 feet from a private water supplywell with no acceptable water quality analysis. [This:system passes if the well water analysis; performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds I indicates that the well i.s..free from pollution om:that facility and the,.presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) f u (Yes/No)The system fails. I have determined that one or:more of the above failure criteria exist as described in 3.10 CMR 15.303,therefore the.system fails. The system owner should contact the Board of Health to determine what will be necessary to c�orrecf the failure. i 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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply _ _ the system is within 200 feet of a tributary to.a sui face drinking water supply _ — the system is located in a nitrogen sensitive area( nterim Wellhead Protection Area—IWPA)or a mapped Zone 11.of a public water supply well If you have answered"yes"to any question in Section E thel 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 1.1 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW AGI DISPQSAL SYSTEM INSPECTION`FORM 'PART B CII CKLIST- Property Address: 4 � ` Owner• Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes ;.0 N1 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?(1f they were not available note as N/A) Was the facility.or dwelling inspected for signs of sewage back up V-11" Was the site inspected for signs of break-ou;t? € , 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 9 it The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes quo ; o 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(3)(b)] R Page 6 bf l l OFFICIALINSPECTIONTORM=NOT FOR VOLUNTARY°ASSESSMENTS - SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPI'JCTION FORM PART C SYSTEM INFORMATION Property Address: G(/ Owner: Date of Inspection: g:e/S::&- RESIDENT IAL ✓ FLOW CONDITIONS Number of bedrooms(design): 3 . Number of bedrooms(actual): . DESIGN flow based on 310.CMR 15.203 (for example: 11.0- d x#of bedrooms):s Number of current residents: o� Does residence.'have.a garbage grinder(yes or no):�/fZCF Is laundry on a separate sewage system(yes or no)fZ� of yes separate inspection required) Laundry system inspected(yes or not" Seasonal use: (yes or no 4-- Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or nol--/ i Last date of occupancy:0"AA&I—Vt*lJ AV�eAd ✓W-e—� COMMERCIAL/INDUSTRIAIt/x,& Type of establishment,. Design flow.(based on 310 CMR.15.203): Igpd Basis of design.flow(§eats/persons/sgft,etc.): 1 „ Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):-_ , Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source:of information: PJ I A-M Q f W Was system pumped as part of the inspection.(yes or no):�)If yes,volume pumped: How was duanttty pumped. determined? ' Reason:Tor.pumping: ;7ie O SYSTEMtictank,distribution box,soil absorption system gle cesspool _Overflow cesspool Privy _Shared system.(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) —Tight tank _Attach a copy'of the DEP.approval _Other(describe): M A roximate age of a components,dafe In ailed if k own)and sour a of information. Were sewage odors-detected when arriving.at the site(yes!or no): 6 Page 7 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM P RT C SYSTEM INFORMATION(continued) Property Address: A Owner l� Date'ofInspection: BUILDING SEWER(locate on site plan) Depth below-grade: Materials of construction: cast iron 40 PVC other(explain): Distance from private water supply well or suction line] Comments(on condition of joints, venting,evidence oflleakage,etc.): t L . - SEPTIC TANK:—AX(ocate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is ace confirmed.by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Q I Dimensions: i - - Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 34 i Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: 1 1111,0 C pJI/� �Fyti Comments(on pumping recommenl9tions, inlet and outlet tee or baffle condition,structural integrity, liquid-levels related to outlet invert,e idence of leaka e,etc.): si GREASE TRAP locate owsite plan) Depth below grade:— - Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: I Scum thickness: Distance from top of scum to top of outlet tee or baffl9: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: N Comments(on pumping recommendations,inlet and oiutlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): j 7 Page 8 of 11 OFFICIAL.INSPECTION FORM-..NOT FOR VOLUNTARY:ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART-C SYSTEM..INFOkMATION(continued) Property Address: . /,e Owner:. Date of Inspection: TIGHT or HOLDING.TANK:A&-tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(expla.in): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):; Date of last pumping: Comments(condition of alarm and float switches, etc.); DISTRIBUTION BOX: L (if present must be opened)(locate,on site plan) Depth of liquid level above outlet invert: 4,2,4j Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of kage into or out of box et &tw ape I PUMP CHAMBE`R:112wocate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.) j� Page 9 of 11 OFFICIAL INSPECTION FORM—�OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address L(' Owner: Date of Inspection: /5-/p SOIL ABSORPTION SYSTEM (SAS): /(locate on site plan,excavation not required) -If SAS not located explain why: Type eaching pits,number: 1 leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: n innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, /i i/ 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 ofground.vater.inflow(yes or no): Comments(note condition of soil,signs of hydraulic•failure, level of pbiiding,cbndition 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.): Page 10.of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DDISPO ALI SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued.) Property Address: Owner:, Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. a p J O 10 Page 11 of l] - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) .Property Address: 0/ AIA Owner: Date of In pection: SITE EXAM Slope Surface water Check cellar Shallow wells y Estimated depth to ground water feet " Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Observed site(abutting property/observation holewithin 150 feet of SAS) Checked with local.Board of Health-explain: � Checked with local excavators, installers-(attach documentation) �/Accessed USGS database:-explain: You must describe how you established the high ground water elevation: i '4(" Y 11 YOU WISH TO OPEN A BUSINESS. For Your Information: Business certificates'[cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which You must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1 FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) K ax :r° r DATE: 7 /S� Fill in please: APPLICANT'S YOUR NAME/S: P_ r 0.,4S BUSINESS YOUR HOME ADDRESS: b9 6 z TELEPHONE # Home Telephone Number 3��- p L NAME OF CORPORATION: NAME OF NEW BUSINESS 56oir TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES ADDRESS OF BUSINESS L t^CJZ' U r U MAP/PARCEL NUMBER I( 6 D .I [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO Main Gt. (corner of Yarmouth. Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this,town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. - Authorized Signature* COMMENTS: 2. BOARD OF HEALTH This individual h s n infor f he T£re it ments that,pertain to this type of business. Authorized i nature COMMENTS: 3. CONSUMER AFFAIRS [LICENSING.AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: TOWN OF BARNSTABLE LOCATION �lJ� G� ��?/�° SEWAGE # �yale VILLAGE ASSESSOR'S MAP Cz LOT INSTALLER'S NAME PHONE'`NO.��r'��7/ �U �'�� SEPTIC TANK CAPACITY �ld�CJ LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL O UBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No l �. .' ' � r 0 ,� I y� i �y��ay �� <36 THE COMMONWEALTH OF MASSACHUSETTS /1FPR31................ .......— BOAR® OF HEALTH TOWN OF BARNSTABLE Applirttiion for M-4tiniial Workii Toust �= Application is hereby made for a Permit to Construct ( ) or Repair (/) an Individual Sewage Disposal System at: --.....Zd .-...... %... ...................... .......................................................... 1... Location-Addr ss ////� J� or /7. Nv! 5.1 . ............./--v-�......... "' .r D... Lot-No...(:d .... ••..... ....__. ......... /J� r a _� `� Owner 7/� dress ............................................................. C� _-./_ � Installer Address 4— Type of Building „� Size Lot�0_11 .,r.Sq. feet Dwelling—No. of Bedrooms________________ -..............___._..Expansion Attic ( ) Garbage Grinder ( ) `4da Other—Type of Building ............................ No. of Persons Showers ( ) — Cafeteria Other fixtures -------••--•......----•-•-- --------------------- ---._.._..----------------- -•-••---------- .(..._>. W Design Flow.............. -_.-•-----•---..gallons per person per day. Total daily flow------------- .................gallons. WSeptic Tank—Liquid capacity/M..gallons Length................ Width................ Diameter-.._-_--____-___ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...........,/----- Diameter-------1-4..... Depth below inlet......j6.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...........................................................••---•--••-•-• Date........................................ W Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water--____-------•--.---__-. a -•-------•-............ •........... --------------- -------------- ----------------------.----------....................... x . Description of Soil...................�...`------ _ f• o .... 5446-_- V ..............•••-...-••--•--•••-••-•------...._....-•-------•-•----------••----•---............---•--•----------------------------•-•-•---•---- W M. •-...................................................................................................................................................................................................... U Na ure of Repairs or Alteration ns—Answer w1 n appl' ble._l0U/Y��__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h ee issue g bo rd f altlz. -- Signed ------------- -- ---- .......- ................ --.. .. .e...-��. ApplicationApproved By ................. ... .. ---�..; /' .......-............................................ ---- Dace Application Disapproved for the following reasons- --------------------------------- ........--- ..................... . -------------- ---------- --................. ----------------- -- -- ------------------ ----------------------- - ----- -- ------------------- -------------- - ---------------------------------------------------------------------- ......................... -------- PermitNo. ............. Issued .-------- --------....................................Date............ Dare No.- - ..12✓ ' //� - G .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ap'liration for Disposal Works Tonstrarf-ion ' _3' Application is hereby made for a Permit to Construct ( ) or Repair (/Q an Individual Sewage Disposal System at: --•---•--•----•------------------------------------------•---.........._--•_.. - Location-Address or Lot No. �. '��.: _tiuf�•1.............•/GS chic cr --...••••-•••--- -....._ --------•• ---------------------------•---•--•----••••-•..__..._••-•-•- Owner� �� dress a /�G� 1 J�4- yQ`/ �� .l_... .. ••-_.. ........................................•-----•-• ----...--•-----......------•----•-----_.:... ................................... Installer Address Type of Building Size Lott?()_11_01')__:::..Sq. feet Dwelling—No. of Bedrooms.........................1-3 ................... Attic ( ) Garbage Grinder ( ) `LI Other—Type T e of Building No. of persons............................ Showers � YP g ---------------------------• P ( ) — Cafeteria ( ) d10 Other :fixtures -----------••-• --•--•-------•---•-•--••••---------------------------•••••..._..------. ............................................................ Design Flow...............:.-5-�_................gallons per person per day. Total daily flow............. . ? ................. WSeptic Tank—Liqu_d capacity//,Y_V.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........../..... Diameter......./ ..... Depth below inlet......z_......... 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.....................__. 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ P4 -•--------•------------------•--------•-----•-•------••--•-----.....-------......_----•---•--_••--•-......................................................... x . Description of Soil--------------------- ` ------ -...... l/C---/ ....`=• U -----------------•-----•------------•-----•..._..-------------•----------•----••-•----------...-•-------•-------------•---•-•--------••-----•-------•-----•-----•-•--•-•------------- ------------------ W U Nature of Repairs -Alter ations—Answer w�n aPP1f ble._ uYp__ � P ____.. ............................; --• N .__/ �i?x_h/S\f/"��✓�1� �=GSvSci?�- Ut S 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`ee issued by t'i board f health:— , G Signed ............... -_ ------------.. ----lJ ... �. are Application Approved By . � -- Date Application Disapproved for the following reasons- ---- -------------- ------------------------------------- -------------------------------=------------------------------------ .....................................................----`-----------------:........................................................---- -- --- -- -------.......--...---...................------. . - . �^�.. Dare PermitNo. ...--- ----(o.)-`.....�".......--- - --�.................. Issued .................---- --....................................... Da[e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ILle>r#tftrate of Contyliartce THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed ( ) or Repaired (�) s�_ by---------------- ------------------------- z ... � ................ rc�,J s ----------------------------------------------------------- ---------- ---------------------------- ------ at .......... �.............................................................y........---J---..................................-----`---------- ..-_--..... --L 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. .....5I.P.,n...y.�-...,1...---- dated ----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE-----------------------` .— = ._::............................ Inspector .......--------- t� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF E cRN TABLE No... ..T.. _a� FEE...�d........... 'T Disposal oaks on nrfion Permit Permission is hereby granted........................ �� Gt_U!�- ........(f_U^� " -- to Construct ( ) or Repair ( an Individual Sewage Disposal System at No. l r .....................................% 1 6ST� ----------------- •-- ----- -------••----•-• ---•---•-------...._..-••...... Street as shown on the application for Disposal Works Construction Permit No. =_Y�_�Dated.......................................... 2 g .................................... .....f..........................................................._ DATE. J A -------•_---- Board of Health FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS