The URL can be used to link to this page

Home My WebLink About0175 ASA MEIGS ROAD - Health A i5Asa Meig- Road - I&stons Mills P A = 030 072 I l I r• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ale, �- Property Address /► G � / Owner Owner's Name / LIVII information is _�/! !7� required for every � � page. City/Town State Zip Code .Date of Inspe 'on ' Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information 6/0 14164? , on the computer, use only the tab Tylark!!!� . Ac key to move your Name of Inspector cursor-do not , M l �- use the return Company Name 4key. Company Address City/Town State Zip Code f �'D� ego �o9� ) License Number Telephone mber B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenanc f on-site sewage disposal systems.After conducting this inspection I have determined that the s 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 0 1��41_- Inspecto 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. tSinsp.doc.rev.7/26/2018 ?itle 5 OfSdai'inspection=orn:subsur,'ace Sewage Disposal System•?age 1 of 18 i Commonwealth of Massachusetts IV. � a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments e � s Property Address / /V Owner Owner's Name information is required for every a rs O64S C page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System P es: I have not found any information which indicates that any or 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: 2) 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 ff 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): t5insp.doc•rev.7262018 ?me 5 0-5aai inspenon=orm:Suosurace Sewage Dispose;System•?age 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form .11 CF Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 7S S le .� Property Address k-1 X Owner Owner's Name information is required for every page. City/Town State Zip Code Date of nspelf C. Inspection Summary (cost.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 -tue 5 Official:nspecuon conr.:suosurface sewage Disposai System•Page 3 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 17S �49 , Property Address / Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Ins p ction C. Inspection Summary (cons.) ❑ 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 n. 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ,_, / B up of sewage into facility or system component due to overloaded or i LLL(((((��d"'' 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 -iba 5 Of5dai ins?ec6on POrm:Subsurface Sewage Disposal System•?age 6 of 18 5insp.tloc•rev.7252018 r Commonwealth of Massachusetts I r. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address, Owner Owner's Nam /rc 144 information is e required for every 14e �s page. City/Town State Zip Code Cate of IrApectionf C. Inspection Summary (cons.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 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'/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed Pi e 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 water supply well. LJ ��Any ny portion of a cesspool or privy is within 50 feet of a private water supply well. 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.] T system is a cesspool serving a facility with a design flow of 2000 gpd- 0,000 gpd. r 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. system 5) Large Systems: To be considered a large system the 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"no7 to each of the following, in addition to the questions in Section 0.4. Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feel 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 it of a public water supply well 5insp.tloc•rev.7262018 T.;9e 5 `Cac u^.ec�on=om:subsu`ace Sewage�soosal System•page 5 0`18 Commonwealth of Massachusetts Title 5 Official Inspection Form 191-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name �j- information is X required for every r page. CitylTown State Zip Code Date of Insp ction C. Inspection Summary (cost.) If you have answered"yes'to any question in Section 0.5 the system is considered a significant threat, or answered "yes"to any question in Section C.4 above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes ❑ raping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ as 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 NIA) 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)] -iJe 5 atoiat inspenon.cccn:suos.rfaoe sewage Disposal System•?age 6 of 18 t5insp.doc•rev.7/26/2018 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Namr inform N ame is � � required for every page. CitylTown State Zip Code Date of Ins ction D. System Information .1. Residential Flow Conditions: ` 2 Number of bedrooms (design): Number of bedrooms (actual). DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: /'• X-At 4 571 /lvt i* 1p 6,1 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes [=IGo If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 50 information in this report.) Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes to Water meter readings, if available (last 2 years usage (gpd)): Detail N Sump pump? Yes e�L4Ir/lew Last date of occupancy: Date Tide 5 `dal inspecaor=cmL Sucsujace sewege oisposai system•?age?of 18 t5insp.doc-rev.712612018 Commonwealth of Massachusetts F Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments z r s.s 1401 Property Address .01 Owner Owner's Name / information is required for every 4,s-4vA 6 9 page. CityfTown State Zip Code Date of Ins ection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available.- Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: �0 Source of information: Was system pumped as part of the inspection? ❑ Yes o If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.00c•rev.7126/2018 -ine 5 officiai insoexon For:Subsurface Sewage 0405ai System•?age B of 18 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is / N required for every. A# page. Cityrrown State Zip Code Date of Inspe on D. System Information (cont.) 4. Type of S tem: 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): O f� Approximate age of all components; date installed (if known) and source of in rmatio: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 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.): '.ale 5 specton"Form.5uosurface Sewage Disposal system•?age 9 of 18 t5insp•doc•rev.7/26/201 8 f Commonwealth of Massachusetts Title 5 Official Inspection Form i' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Q v Owner Owner's Name information is � required for every C/ page. City/Town State Zip Code Date of Inspe ion D. System Information (cons.) 6. Septic Tank (locate on site plan): iJ Depth below grade: ,eet Material o struction: concrete ❑ metal ❑ fiberglass ❑ polyethyiene ❑ 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle �f/��f � ,M Scum thickness Z V S CA P" 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? !e - Mr Comments (on pumping recommendations, inlet and outlet tee or baffle conditio , structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t5insp.doc•rev.7126/2018 7tire 5 Jt`aa nspecacn=o gin:suesurtace Sewage Disposai System•Page 10 of 18 r Commonwealth of Massachusetts Res p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Insp tion D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 Tile 5 cmaa'..:,pemon-on:suosu face sewage Disposal system•?age 1 t of 18 t5insp.doc-rev.712612018 L Commonwealth of Massachusetts Title 5 Official Inspection Form 51.1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Ao Owner Owner's Name /� information is art _ Q required for every own —� lx�__ page. CitylT State Zip Code Date of Inspec' n D. System Information (cons.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): ,�--- Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): O ?,Ue 5 0-,5cal!nspecuon Form—suosurface sewage Disposal system•?age 12 of 18 t8insp.doc•rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form WHO Rr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name information is N / ad v- required for every V b page. City/Town State Zip Code Date of lnspecqn D. System Information (cons.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): if SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ each ing galleries number: ` �( leaching trenches number; length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: Cl innovativeiaitemative system Type/name of"technology: --- ---- — •Page 13 of 18 t5insp.doc•rev.7/262018 -me 5 0f`cai lsxvor,=cr:suos,race sewage Disposai system Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is �� / required for every 1 page. City/Town State Zip Code Date of ins f ection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): me d..-C'7 �f 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.eoc•rev.726/2018 ine 5 OA9ed,rspecven=on:Sulu;a Sewage Disposa System•?age 14 0!18 r Commonwealth of Massachusetts i Title. 5 Official Inspection Form ", Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / Afcix Property Address .11 Owner Owners Name information is required for every page. City/Town State Zip Code Date of Insp ion D. System Information (cons.) 13. 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 Tice 5 otou Inspzcaon=om..swsur.,ace sewage Disposal System•?age is of 18 I' t5insp.doc-rev.7/262018 Commonwealth of Massachusetts z Title 5 Official Inspection Form eel Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �S q er s Property Address Owner Owner's Name information is Pnrequired for everypage. City/TovmState Zip Code Date of Inspe D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a w vie o ewage disposal system, including ties to at least two permanent reference landmarks or. enchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buildi . Check one of the boxes below: ❑ nd-sketch in the area below drawing attached separately i i i l l I l I i i i t6insp.Goc•rev.712612018 Title 5 Cfflcal inspenon=om:Subsu.rface Sewage Disposal System•Page 16 of 78 r fl I Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 175 Asa Meggs Road Property Address Owner Oram Dube owner's Name information is required for every Marstons Mills MA _page. City/Iown 02648 1/20/2014 D. system Information (cont.) State Zip Code Date of Inspection 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 (3A�k A 6 O 13 3 It eu 0 � 01 306 31� 3 33 33 -------------- ------------- t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 9,(0 ro %-- �o�o p� . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every �/!S / / page. CitylTown State Zip Code Date of Ins ection D. System Information (cunt.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells1 Estimated depth to high ground water: �C) 7' � 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 ❑ site (abutting property/observation hole within 150 feet of SAS) Checked with loca(a d of Health - explain. Ell Checkedwith iocal excavators; installers- (attach documentation) Ll Accessed USGS database-explain.- You must describ w you establis a the high ground water elev tion: L4 Lz dd e _ s t Before filing this Inspection Report, please see Report Completeness Checklist on next page. t6msp.6oc-rev.7/262018 `5e 5 cf5cai nspe=on Fom:Su7su'ace Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - of for Voluntary Assessments Property Address / � j Owner Owners Nam A1,11C / information is AI�C-L, required for every page. City/I own State Zip Code Date of insp ction E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. certification: Signed & Dated and 1, 2, 31 or 4 checked Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failur riteria)and 6 (Checklist)completed System Information: For 8:Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp.Goc•rev.7i26i20i8 7 Ue 5 of' :nspe=on Fo,-r,:suosurtace sewage omposai sys[en•?age 1s of 18 `0 TOWN OF BARNSTABLE LOCATION 176' iqS P M SEWAGE # VILLAGE i'61 O K6i®n M 111S ASSESSOR'S MAP& LOT D 30—a7. INSTALLER'S NAME&PHONE NO. 1 G P e SCP+t L, G n S f SEPTIC TANK CAPACITY 166!5 CIA L LEACHING FACILITY: (type) CA (size) lob x 7 NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: y" - 7 !ram COMPLIANCE DATE: �' �r'�b Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by — -e. 1 ® �i (NI �,9r Way. 7, ��y�� s D 30 No. — /Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migpogai *pgtem Congtruction permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. I Owner's Name,Address and Tel.No. a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No. of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow _ gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs o Alterations(Answer when applicable) S N ST OA- `-3— t t 2A_A Date last inspected: Agreement: --- The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod and not to place the system in operation until a Certifi- cate of Compliance has b B Signed Date Application Approved by --Application Disapproved for the fo owing reasons Permit No. //o- ,]/ Date Issued No. t5T Fee�(l - t THE COMMONWEALTH OF MASSACHUSETTS 1, PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 2pprication for Migpogal bpgtem Conoruction Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage.Disposal System at: Location Address or Lot No. + / Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures f Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date ` Title r Description of Soil Nature of Repairs o Alterations(Answer when applicable) _=N ST iA-< <)4y- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Cod and not to place the system in operation until a Certifi- cate of Compliance has b Bo d, Signed Date Application Approved by Application Disapproved for the fo owing reasons s , Permit No.� �/ Date Issued --------------------------------_--------- C THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS if Certificate of Compliance THIS IS TO,,C ythat the-0 - 'te Sewage Disposal System instal ( �o epaired/reQlaced( )on -(?4P by c5l , r v� � for - -- D c, -C S A � 6�. ' as `,- c R,�2_ J has been constructed in accordance with the provisions of Title 5 and the for Nsposal System Construction Permit No. /— ,, dated !V Use.of this system is conditioned on compliance with the provisions set forth b_low -A i i No. �Al �1' Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS { r1i6pogar *pgtem Congtruction Permit Permission is hereby granted to to construct( )repair( C�"On-site Sewage System located at E�s W e '�,� I�1il • Ilh� � S v i, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to 1 I! comply with Title 5 and the following local provisions or special conditions. p 1 i All construction must be completed within two years of the date below. 1 Date: Approved by E � 1 J I i u�. e CEItTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WURKS CONS'F UC1'ION 1'E1tM1j' (wri'IIUUT DESIGNED PLANS) hereby certify that the application for,disposal works construction permit signed by me dated `� —O� ��P . concerning the property located at 7 J V-4SA- V't <S meets all-of the following criteria: • There arc no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system The observed groundwater(able is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. . SIGNED DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I � ,�.,.. �a I�Lt i ��w�'' I