Loading...
HomeMy WebLinkAbout0219 WEST WIND CIRCLE - Health 219 West Wind Circle, Osterville i J h t . I � o a i a t , z a a r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 every page. CityRown 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 I ,}-� L�'7 C computer, use 1. Inspector: only the tab key to move your David D. Coughanowr LL cursor-do not use the return Name of Inspector key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 'e"D1 City/Town State Zip Code 508 364 0894 1328 Telephone Number License Number B. Certification -ter I certify that I have personally inspected the sewage disposal system at this addtess anf fiat the information reported below is true, accurate and complete as of the time of the `spectionl The inspection was performed based on my training and experience in the proper function an taintenAfte of2on site sewage disposal systems. I am a DEP approved system inspector pursuan Section 15.340 of Title 5 (310 CMR 15.000). The system: ; ® Passes ❑ Conditionally Passes ❑ Fa Is c ❑ Needs Further Evaluation by the Local Approving Authority �S December 4, 2008 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. �ZJ5 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 every page. City/Town 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: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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•09/08 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 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 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 ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 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 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-09/08 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 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4 2008 every 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. t ❑ ® 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 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 gpd t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 —_ I Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owners Name information is required for Osterville MA 02655 December 4, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 d 107 gpd ( Y 9 (gpd)): Detail: 2006-2007 Sump pump? ❑ Yes ® No Last date of occupancy: undetermined 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 219 West Wind Circle i M Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 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: 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•09/06 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 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is Osterville MA 02655 December 4 2008 required for , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 23+ years. Certificate of compliance issued 11/22/85 (Board of Health permit#84-789) Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 3 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.): Sewer is behind finished wall and not accessible for inspection. No evidence of leakage or backup into dwelling was observed. Septic Tank (locate on site plan): Depth below grade: 1 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 ft x 6 ft x 5 ft(1000 gallon) Sludge depth: 4 in t5ins-09/08 Title 5 Official 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 i GSM 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 ' every 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 in Scum thickness 2 in Distance from top of scum to top of outlet tee or baffle 9 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Design Plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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-09/08 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 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4 2008 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears level with no evidence of leakage in or out. Some solids in sump. 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: t5ins•09/08 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 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4 2008 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: ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Pit was uncovered and found to be dry. A distinct stain line was noted 2.5 feet from the bottom. 1 . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration t Q _ 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 219 West Wind Circle Property Address P Y Manuel and Maria Dobem Owner Owner's Name information is Osterville MA 0265 required for 5 December 4 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 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 �M 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is Osterville MA 02655 December 2008 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•09/08 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 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is required for Osterville MA 02655 December 4, 2008 every 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: Permit issued 9/5/89 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: Approved design plan on file with the Board of Health shows no groundwater was encountered to a depth of 12 feet in a witnessed test pit on 6/2/1984. Town of Barnstable GIS Department records indicate that the property is over 25 feet above groundwater table. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 219 West Wind Circle Property Address Manuel and Maria Dobem Owner Owner's Name information is Osterville MA 02655 December 4, 2008 required for every 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I u TA �x m� Lof � y w 41 �\ ComMONV-EALTH OF MASSACHUSETTS ' ^� EXECUTIVE OFFICE OF ENVIRONMENTAL AFF �R �1�I i:1I ` DEPARTMENT OF ENVIRONMENTAL PR ® E`CTIO.• r� ONE WINTER STREET. BOSTON. NIA 0_106 617-29_-51(L" �CE�f1�'" �! ,. NOV 0 Tow 5 199T %%'ILLIAk'F.WELD - H�EPTAB[F TRL'p)'CO\1 Goyernc v tp Se:Tcan ARGEO PALL CELLt'CCI hs. .r J D!�'ID B.STRtI-E Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A .... CERTIFICATION JI Property Address; IA%c\ wy, Ttn„Wo t C�Z 6SC'�\LQ%li� Address of Owner:� vtS. 5 � t (If different)Date of Inspection: tW.0f E Name of Inspector: HIC�o 1 am a DEP approved system inspector pursuant to Section 13.340 of Title S (310 CMR 15.000) Company Name:,.4}//g vi--,'c En Y'r'rr-1 h #" P r. Mailing Address: R Q OS nx e_32?! JY1,97 &Xe-0— H -19-© 2Sl,�C/ Telephone Number: rSG 'J G� �— !Lic Zy - CERTIFICATION STATEMENT - cenjj that 1 have personally inspected the sewage disposal s'stern ai this address and tha: the information reported below is true, accurate and cornolete as of the time of rnspecttoo The inspection was performed base- on my training.and experience in the proper function and maintenance o;on-sae sewage disposa: systems. The system: - Passes _ Concitionaily Passes _ Neeos Further Evaluation By the Local Approving Authority Fags dl;Inspector's Signature: Date: T;,e Svste^ Insrocto• shal' submit a cope of this inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system o� has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the repo- to the appropriate regional office of the Department of Environmenta' Protection. The orig!na! should be sent to the system owner and copies .-nt to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or' D:i A] SYSTEM PASSES: s XI have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. 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. Indicate yes, no. or not determined (Y, N, or ND'i. Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rev-wiled 04/2s!97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _- - 7 ..'4 , T PART A 'CERTIFICATION (continued) w -- Property Addr4ss: Owner: Date of Inspection: 1 81 SYSTEM CONDITIONALLY PASSES (continued Sewage backup or breakout or high static water level observed in the distributioj box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will ass inspection if(with approval of the Board of Health).. Describe observations: . broken pipe(s) are replaced . obstruction is removed ; distribution box is levelled or replaced T _ The system required pumping more than four times a year due to broke or obstructed pipets).,The system will pass inspection if (with approval of the Board of Health): broken pipets; are replaces obstruction is removed Z.1t CJ FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH Conditions exist which require further evaluation by the Board of He th in order to determine if the system is failing to protect the public health, safety and the environment. W'r 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY ND THE ENVIRONMENT: _ Cesspool or priv-, is within 50 feet of a surface wat Cesspool or prig, is within 50 feet of a bordering egetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH ND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE.SYSTEM IS FUNCTIONING IN A MANNER THAT ROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil abs Lion system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil a sorption system and the SAS is within a Zone I of a public water supply well. _ The system has a septic tank and soil bsorption system and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and so' absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a ell water analysis for coliform bacteria and volatile organic compounds indiates tha the well is free from pollution fro that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used determine distance (approximation not valid). 3) OTHER (revised 04/2519") Page 2 of 10 :. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addrpss: Owner. Date of Inspection: DJ SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: . I have determined that the system violates one or more of the following failure criteria defined in 310 CMR 15.303 Tne cars for this determination is identified below. The Board of Health should be contactedtto etermine what will be necessary to correct the failure. r , Yes Nd Backup of sewage into facility or system component due to an overload or clogged SAS-or'cesspool. _ Discharge or ponding of effluent to the surface of the ground or surfa waters due to an overloaded or clogge? SAS or cesspool. Static baud levei in the distributor, bo).above outlet invert due t an overloaded' or clogged SAS or cesspoo;. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flov, Reeuired pumping more than 4 times in the last year NOT du to clogged or obstructed pipes.. Number o'times pumped_ Anv portion o'the Soil Absorption System, cesspool or priv is below-the high groundwater eievation Am por,:on of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.' Any portion of a cesspoo: or pri%ti, is Aithin a Zone I o a public well Ar+\, portion• o-. a cesspool or pri,61• is within 50 feet f a private water supply we!! 4' Am por,,on O'a cesspool or privy is less than 10 feet but greater than 50 feet from a�private water supple we!i with no acceptable water quality analysis. If the well ha been analyzed to be acceptable, arach cope of well water aria ysis for coliform bacteria. volatile organic compounds, mmonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "'�o" as to each of the follm ing: The folioN:rg criteria appiv to large systems in addition to the criteria above: The system serves a facility with a design flow gr'10,000 gpd or greater (Large System, and the system is a significant threat to public hea!th and safety and the environment cause one or more of the following conditions exist: Yes No the system is within 400 feet of surface drinking water supply the system is within 200 feet o a tributary to a surface drinking water supply - the system is located in a nitr en sensitive area (Interim Wellhead Protection Area, IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system sh 11 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. PI)ease consult the local regional office of the Departmen: for further information. (revised 04"25/97) Page 3 of 10 SLISSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIOti FORM .PART B "CHECKLIST " w Property Address: �.kct G`L Owner: GV\a L.,3 Date of Inspection: ou must indicate either"Yes" or 'No as to each of the following: Check if the following have been done Y Yes ti0 _ Pumping information was provided by the owner, occupant, or Board of Health. _ hone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been in into the system recently or as part of this inspection.e� s As built plans have been obtained and examined. Note if they are not available with N/A. The fac!li:� or d�+ellin is inspected for signs o`sewage back-up. - The s%-stem does not receive non-sanitary or industrial waste flow. - — The site %%as inspected for signs of breakout.= X _ All sv iem"components, .excluding the So!! Absorption System, have been located on the site. The septic tank manholes were uncovered. opened. and the interior of the septic tank was inspected for condition of baffies or tees. materia' o'construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location 0;the Soil Absorption System on the site has been determined based on: maintenance of — The factirt-, o%•ne• iano occupants. if dif7erent trorrt owners were provided with information on the proper Sub-Surface Disposal Svsterr.. p Existing information. Ex. Plan at B.O.H. - 3 _ Determmed m the field td an, of the failure criteria related to Part C is at issue, approximation of distance is unaccea:abie 115.302t3t,,b`? Page 4 of 10 (revised 04/25/57) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNt -PART C ` -' SYSTEM INFORMATION '. Propert,. Address: 01 15 W"T 101'at..j Owner: S1f\Wa) Date of Ihspection. I I 1`'1 FLOW CONDITIONS RESIDENTIAL: Design flo% 3t>U g.p.d1bedroom for S.A.S Number of bedrooms f Number o'current residents Garbage g%:der (yes or m:�1 Laundry cor.'^ected to system (yes or no). ,S p Seasonal use ryes or no!: NQ Water meter readings, if available (last two Q: vear usagettgpdi:' NC'� Sump Pump Ives or no): N -. _ ..,;_. _ ww.: . ..._,...... _. . ..:.., _. Lai: da;e o-occupancy COMMERCiAI_9NDUSTRIAL: a Type of establishment. Design fiov- ga!ions/da% Crease trap present. Ives or no_ P Industna! Taste Holding Tani; present. Ives or no :on-sanitan waste discharged to the Tale 5 wstern. tves or no \dater meter readings. if availabie Las:pa;e o; o .,-p2nc% _ OTHER. Deicribe _ Las Gate of occuoanc, CENU AL INFORMATION PUMPI%G RECORDS and source or information .,. .. , System pumped as par, of inspection: (ves or no.Qr,) If yes, volume pumped ¢allons ) Reason for pumping TYPE OF SYSTEM r x, Septic tank,rdistribunon boVsoil absorption system, Single cesspool Overflow cesspool Shared system (yes or no) Of yes, attach previous inspection records, if any) t ' VA Technologv etc. Copy of up to date contract? Other . APPROXIMATE AGE of all components, `date installed (if known)`and'source of informaiion: Sewage odors detected when arriving at the site. (yes or no) -.�J$.._-.____.____._..___._.__....__.,�____..__.-_.._.. -• - - frwiaad 0�/2S/9�) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SY57E�t (!-FORMATION (continued) Property Address: a1 9 . w6vw Owner: �Qyt►.). Date of Inspection: BUILDING SEWER: n �� (locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction Ire - : Diameter _. Comments: (condition of joints, venting, evidence of leakage, etc.) - _ - 1 g _. SEPTIC TANK: .__-___ (locate on site plan Depth below grade 9,0'i Material of construl -Lconcrete _me:a _Fioerg!as. _Polvethviene _othertexpiam' If tank is metal, Its: age _ Is age conf,rmec b\ Ce•t:fica:e of Compilance _(YesNo Dimensions I U00�1f�' Sludge depth 1 t Distance from top o: sludge to bot•.o^i"of ouue: tee o•bz=a_ Scum thickness " Distance from top of scum to top of outle: tee or ba=ie k _ Distance from bottom of scum to boom oT out)e: tee e• bz-,e_� T How dimensions were determined Comments. trecommendation for.pumping. condition of role: and outlet tees or baffles. depth of liquid leve! in relation to outlet invert, structura integrity, evidence of leakage. e:c.) Mo I�D QV%N 4 t17 GREASE TRAP: (locate on site plan; Depth below grade: Material of construction: _concrete _metal Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from.bottom*of scum to botiom'of outlet tee or baffie: Date of last pumping: _.'-._„-:_.... --_._.._----�-__ Commenu: �• (recommendation for pumping, condition of islet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25:9-,) Page 6 o! 10 s SUBSURFACE S'EWA_GE DISPOSAL SYSTEM INSPECTION FOR.'A, PART C SYSTEM INFORMATION (continued) , Propert% Address: ONners�� Date of Inspection: _ TIGHT OR HOLDING TANK:. 'Tank must be pumped prior to, or at time, of inspections (locate on site plan, Depth below grade. _.. Material of construction. _concrete _metal_Fibergiass._Polyethylene —other(explain) Dimensions _._ _.. Capacm: gallons o i. Design floe gahons,*da. Alarm leve! Alarm in working order_ Yes _ No - •-- — '__ :'� ` Date of previous pu~nping Comments (condition of inlet tee. condition o'a!arm and float switches. etc.)' ' DISTRIBUTION BOX: Ve,S - (locate on site p°a^ Depth of liquid leve! above outie: ime ctGQ L"31 Ov�'��iV•1�21 � Comments _ tnote :f leve! and disrr -juor is eaua' evidence of solids carryover, evidence of leakage into or out of box, etc.) v t o. PUMP CHAMBER: (locate 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.) _ .. _- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEyt INFORMATION (continued) - Property Addr-ss:a\ Owner:-%U". Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on sitepian, n possible; exca�at�on not required, but may be approximated by non-intrusive methods; If not determined to be present, explain: Type: leaching pits, number. leaching chambe�s,'number: leaching galleries, number." leaching trenches, humber,iength: leaching fields, number, dimensions overflow cesspool, number _ Ahernatwe s%,stem Name of Technologv: Comments, inote con rtion o`soii, signs orkd aulic failure, eve: of ponding, ndition o�v tation, etc.) I( O CESSPOOLS. _i—b (locate on site play. Numbe, and cor:figara:.or Depth-top of liquid to inlet inven Depth of solids lave Depth of scum layer. - Dimensions of cesspool- Materials of construaior. Indication of groundwater inflow tcesspool must tie pumpeC as par, of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: - _ Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04;25/97) page a of 10 e . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued. { Property Address: W c N Owner: Date of In,pection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least r.,vo permanent reierences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house' : r.. a .. :.. .... h. - ..` • ,.-. , ` 2 1D y. 3 SS F (rev;ee�- OAlZt/471 ,r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address• p?.1q 4. $ wir+Ja C lez' " Owner: ���� ` Date of Inspecuon:`l t t Depth to Groundwater k�s Fee: Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record ,. Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Cnec'k with loca! Board o7 nea!t Chec� FE.titA maps Check pumping record: Check loca! excavators. installers Use LSC5 Da:a r• Describe in vou,.o�%n %%oras no%% �o:: established the Groundwater Elevation. (Must be completed- Vs, AZ 5kL& 3! y � (zav:sed ;4.'25'9'. pegs 10 of 10 Date: 7E '� YU TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: ain- nGInc. BUSINESS LOCATION: 1 Ss :MA)I h 7�b nh S fir. S . 17rc yi- MAILINGADDRESS: 'So-me C.S cx..l�ooviL Mail To: Board of Health TELEPHONE NUMBER: 991 —1 L4( OfZ Town of Barnstable CONTACTPERSON: yy1_nud 1)e)ac rn P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: , e I L 4-I Hyannis, MA 02601 TYPEOFBUSINESS: Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES ✓ NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: Z I «0( C,�&& , OS41-­VII& ADDRESS: SC n-, in FandS I>✓. S . 1borr 49 TELEPHONE: 9�9-7 -1 L14 1 LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers 9 Q Paints, varnishes, stains, dyes PCB's j Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners de, Floor& furniture strippers (including chloroform, formaldehyde, Metal polishes hydrochloric acid, other acids) Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Town of Barnstable �pilto j' ,Building Department Complaint4nquiry Report Date• - Rec'd by: ` Assessor's No.: Complaint Name: - Location Address: o� / vy G✓T _ �� W-� �i�, l / Tt L Complaint Description: V Inquiry 0 Description: _ For OlTicc Use Only Inspector's p Q Action/Comments Date: _ 3 s/ O Inspector. 2e�-- Follow-up Action Additional Info.Att died -------- Cop %W&--Depamrrent File Yellow-Inspector ink-Inspector Rerun to Office Manager) f i pl- LOCATION SEWAGE PE MIT . NO. Lod` 'Li L W 54�t�� C���� �' �i" `7 q VILLAGE os-�fiv v I & INSTALLER'SAME ,8� ADDRESS pew r ®�f BUILDER 0! OWNER DATE PERMIT ISSUED O DAT E COMPLIANCE ISSUED Pule `al i 1 1� Lo �- l � No...a..1....;!7 4.-,_ _ Fus....5 ...................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALT t21 ...... 74..O F................. ..... - H f Zi I Apptiratiun for Toustrnrtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: r - rf 4 Location- ddrej�j or�Loottt�NBo. 1•-. ......3..`CJ._.N .C... C IY.Y..I........ .................. .. E'1f' (I7J...`� -..---.................-- Ownerddress . 4 Installer Address Type d Type of Building Size Lot.,//.-&_r...Sq. feet Dwelling—No. of Bedrooms___..._..... ..........................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building P IAIQ 64ti t No. of persons......... Showers — Cafeteria Otherfixtures ...................... - a:........................ -•--------------------- W Design Flow......... �... . ................gallons per person per/day,, Total dail Aow...............3•_,�--_ :......._..._gallons.r � Septic Tank—Liquid'capacity.1._ allons Length___—&.6... Width..... ......... Diameter________________ Depth....G... . :. _ 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 ( I) ' Dosing nk ) Percolation Test Results Performed by._. .......S.--.Z_-'42"" aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ f% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ ODescription of Soil................... --------- -------------------------------------------------------------------------- x W -•--------••-- ........................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable---------------------------------------____________`_.........................._............. Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with y the provisions of TIT E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i ued by the board of h h. gned ..... s t ` _-----------------•--------- Date Application Approved B`.......`........................... .-•.......••-••-•-•---------•-•-••-•------•--••----------• ........................................ Date Application Disapproved f t following reasons---------------------------------•---•-------•-----------------------------------•---•-••--------........--•----- •-----•---•----------•-•---•--•••-•.................•--------...•--........---•-••----•---•--••-•--•---•--•••••••-••-.••--•----••••------••----•-••--•---•---•---•-•--••----•---------•----•••......... Date PermitNo......................................................... Issued....................................................... Date No................. -- 7 „ • FEs.._�.`..r_.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE LTK Appliraation for Uhip Baal Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ") or Repair ( ) an Individual Sewage Disposal System at --------------- ---- Location-Add ,.or ° ... Iw No. y�.................................... ! Owner 4 Installer Address �i UType of Building Size Lottr.i__�. �. ....Sq. feet I—. Dwelling—No. of Bedrooms........... ......................Expansion Attic ( ) Garbage Grinder ( ) `A Other—Type of Buildin PA yp g:�_feV .f No. of persons........ ................. Showers ) — Cafeteria ( ) Otherfixtures:.....----•-•---------- ----------------------------------------------------------------------------r. W Design Flow................��.................gallons per person erfdgy. Total dailyeflow................ .._ ._._....._._�lonsr' WSeptic Tank—Liquid capacityl..0.l0gallons Length..10_6..._ Width__......._ Diameter................ Depth..:??_.. .. x Disposal Trench—No. .................... Width..... ............. Total Length..............r---- Total leaching area....................sq. ft. Seepage Pit No--------I----------- Diameter------- ---------- Depth below inlet......d----------- Total leaching areup_$_7'_...sq. ft Z Other Distribution box (f ) Dosing ank ) 6 ;;:v,/ Percolation Test Results Performed by... _ _ ' _._.. ✓ !` ate......_ ._« ........... .` . Test Pit No. 1................minutes per inch Depth of Test-Pit.................... Depth to ground water........................ PLI Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil-------------•---__ l .f...� 1 L!-- - -1.__.....� �i �............................----------•--•------......---------------------- xP r!----i-------------------------------------------•-------•......-----.....-----•---•- w x •---••-•-•-•-•-------------••--•-••--•--------•-•--•-••••---------••••--•-••--••-•-•-••------•••--•----•-----•--•--•---•---------•---••--•••--••-••------•-•-----•---•-••••••...-••--•-•-----•--•-..... U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------_..................................... .......-•----•---------------------------------------------------------•------•-•--•--••-------............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITI.% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ne ...' 7 Date Application Approved B ...... .................. = Date Application Disapproved r Ie following reasons-................... -------•----•--------------------------------------------------•-•••-•-•-•---•--••----•••-- :.------•-•----------•----------------------•---------------•-------------•-----••------...--..-------------•-----------------------------••---------------------------•--------------------------•--- Date PermitNo......................................................... Issued--------•----------•--................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... Trrtif iraatr of f ompfiatnrr THIS S/�TO CERTI`FFY�/That the Individual r ewage Disposal System constructed (-� or Repaired ( ) by ...._. �1 J tf:;r' L:bcL r In ..•_.• -------•--••---....._.� .._..._._... taller at et = .�' � ' Sc4pkd------------ has been installed in accordance with the provisions of TITTR 5 of The State Sanitary Co'df'�as Sl in the application for Disposal Works Construction Permit No.. �f::... 1 ............. dated %_.%� .. :_. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTIOt4 SATISFACTORY. DATE.......................... J...ZZ/5------------------- Inspector...........FM............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH j i f ......... 71...O F...... No.::.........'............ FEE....:................... Dis#osaal Workii Tnndr i.on rrani Permission s hereby granted--------I t •1-:. .......:. 'lI � _= f to Construct (- ) r\Repair ( ) an Individual Sewage Disposal S stem 11.4 . )... Street as shown on the application.for Disposal Works Construction Permit No................. Dated........................................... ............. a _--•.... ------------------------------------•-•-•....•--_...._ - •-- Board of Health DATE/ ------------------------------------------ FORM 1255 A. M. SULKIN, INC.. BOSTON --- - —_ B.a.se ra crot." 9I71--64 ALL L.tQES A MtAItMUt� of t/t,../V`*-rT ALA- P1 Hoc SY STD 1 S r+P.l l c l _ _ \ 1 r -_ _- �sE C,A S7 i 2�U � SL.ra�D U•...E AO P�/� — Zd— .� ►ni _ / / r O ,� _ ALL. SEPTIC TAI.IKS, p15TF-v5kJrIo �►J �>`, A -1() O 0 LEI�Ew-its lE7 PR SHALL �,E 17ES1U..tECJ T .� -. WHEN fNSTALLEDUNDER PAVING . `. ��'�` � --- - �'_ �-;-- - - --- -.-� • �-- 2Er�no✓E Au_ ut.1S�JIT-A3�.E MATE�IAI_ L�E+ lF�•Tl-i J-T I � ,n 00 � �� 0 - THE Irlt�/Eet- ELJ✓�/Arlo,1S of LEPc�+t. PrrS i --- r = C co') GF ;J AJ0 goer-Pi- wITl1 CLs�y F??G1� �I ' � — a O 1 nT nk y O , �E r�CSTtF ED Wt4E�J Tµ� �`ISTEM 1S NF_A� --LL I I I n COft1P T f L-EIbt 1 o P20� TD t�ac_tLFl�itu6t O 0TV4eP-\- SE P�oTEU, A''i_. :!;15T-t-1 T.A 1C. ' ((�jj�� rr' �J ---TEc '/ i Z�N' O l5� O C) C�t�P4)I+�E1�1T�S '.S4#AL� �E It.l�T'A`�cC� t►J �L©�DL�--1C_�. �n/t'Tl-t TtTLE c•i= -T�1� �TL�TE TYi'icct,L _ DiSTV-«uT-►ate —Pc,x _ O co O c) ' 1 (�Q �` O `?C...`I IT�.E' ( COUE Sti1D At Jy �C�dLi>t_ES �f '4,JN(cr+ ►.1 ay acne/. PJC: :o::t� . .. ►_1 O-fi" Tf8 'jt A l_E �- _ � _ _w.,r a T ►. � ���TetavT.�..i �x r.�a I lu`-'U <-y�_ T`/P►c�*tj.i jL3G �.�ra� _ (/J t VA710AJ O/7-5 pwECtC..►. J PCCC-r.5r NorT4 sc,44t-E Gf� �QVAL 1.R�-: T�+3 K S �i<i1,j FCaCC.E G T�•Gtt..lC ld p,)T `- -_^---_ _ ..-- twJtTl-i E`t.ECT�1L VJEL(yELS WtQE y,/tTF1 . . St-l"A ?DED SeaL eac>s �+J .�.- . � AFtT) 1.6ArMt►j(� P O83E.PY.4T/oit 6 6y. �c �''�'ALrNh<5� fT SEorlc Tr..sc PR+�ti.t `+'RE. Bo,4 LO ,4 L TH TaR 60Tt oM- CoR►C. Is 4000 Pam_ TE*T ' TO VW- [3VI�T VP TO tLt�1<t4ES TOP F*w4 DAT� bE lGK! f r t,t I S N 6 6i s r - "`-� A7L EL �^ i►.r.►►5µ 6[�►0� F tw►►Sr► 6�r-.t7iE F t�.11'S►t 6� o� Gv��L O cJJ/.1� Z; i t ev.� ;r� O" Cli►TrE• - ealsC TwAtK+ 52 5 tXrE2 1�I'�C1e ��e.I►CN�►1G ? ii �ACYFaLL ell cF 0 A O O 4 (D 0 0 d . �sT*or�1 9rr --- '!'Q kSE LGVV-L STAO,L4 S E WA-ClE 54s --I �"T't t_I� K16 r To S< L � �'- ,' �..Eara•t � �` -- ,,,�, • I �i,.E II. 7� � E t:N INCH p fIT " . i 2i Ott• t� 1+ � � , t. - ?� I L� MAP SECT/ON PARCE4, GOT ADDRESS gal � -44 Io& n� , . 4� . y r PROPOSED OWE LING LOCATION DES/G�J C,e/TEC/ i� o cav7PJiitC s'"N i r ,`�• �� wJ PROPOSEG1 SENAGE PISPOSAI, SYSTEM �t/v M B ESP of 6Eo.2 are M x -'- :�� Exi7t mar A�v � RO$,-RT _, _ P�tao• �Et bti• �: �- G I- `�`4 Yv j �/ � `` - t 6AlLGWS f'�L i�C�aN PE>Q'Dr4 Y PL�eCGICi!!hK/ to RA�PIO _� ND t_ . QEQLA/lEl� ";✓ :.•k�� Oa3�L.�CvGfT/tYt� P/T. Nc.? 83 ,. �'. i-ti? v '�� P120POSED LMACHIMO- PITA�.PPr..iG.�.IJTf rw.tcr,,uc tt: r f` THP-0!Ci�� rt't ;.Y f; C!J: AeeCW E4GlNEEeiwG INC. ` J 100 % ExPAtj51oP1 S>• sr. � ��� �K�r t O DR. (oO � FaL C1-i HiGNruA.�l . Sf-wsfa UE5 G►r lROBE' < �t� ROB �� J• r-1 _�,�>_�i. ! j� % t 1�t ,. E. RAYMOND, -+ AS N4 TED U N" C I S 9{ > OF 1 Tst ?4' 5S �l ,d ,�I ..ICA�.'Tl 01�.� � J ( ORAvy++ BY; "KID BY: AV" ter: PLAN NO.WI�49