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HomeMy WebLinkAbout0177 CAMELBACK ROAD - Health 177 Ca melba ck Road Centerville —___ A=047 157 - — - - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/11' page. Cityrrown State Zip Code Date of inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computes, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections ay Company Name P.O.Box 896 Company Address East Dennis MA 02641 City/town state Zip Code 508-385 7608 SI 3742 Telephone Number license Number (� %O rrn M B. Certification c I certify that I have personally inspected the sewage disposal system at this address and that the U_ 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 D: - ' sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of CD i Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑' Fails ❑ Needs Further Evaluation by the Local Approving Authority 01/03/12 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. 1 � 1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface ge Disposal System•Page 1 of 17 Il- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton. Owner Owner's Name information is required for every Maestons Mills MA 02M 1M6l11 page. City/Town state Zip Code Date of Inspection B. Certification (cons.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not determined."(Y,N:, ND)for the following statements.If"not determined,"please explain. The septic tank is metal and over 20 yearn 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 r Commonwealth of Massachusetts Title 5 official Inspection Form "; Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is Maestons Mills MA 02648 1226/1'1- required for every page. Cityfrown 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' ❑i ND(Explain below): C) Further Evaluation is Required by the Board of Health:. ❑ Conditions exist which require further evaluation by 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 mannerwhich 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 Mas-f Wo Me 5 Official Inspection Form:Subsurface Sevage Disposal System-Page 3 of 17 `_ Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/1 I 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1M6/11 page. Citylrown state Zip Code Date of inspection B. Certification (cunt.) 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. E] ® 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 east as described in 310 CMR 1,5.303,.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`fifes'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 shalt upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/11 page. City(rown 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)P10 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 15203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title Official inspection Form:Subsurfacer Sewage Disposal.System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Roe Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226Y1.1' 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?[f 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 occu anc : current P Y Date Commerciallindustriaal 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 f Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 12/26/11 page. City[Town state Zip Code Date of Inspection. D. System Information (cunt.) 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) (f yes,attach previous inspection records,if any) ❑ Innovative/Altemative 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 VA 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 Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/11' page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed(if known)and source of information: 09l30/08 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: .3 fe Material of construction: ❑ cast iron E 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): Depth below grade: 1.7 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: 1000 gal Sludge depth: 3-1 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 L Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 12/26/11 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 27" Scum thickness 2" Distance from top of scum to top of outlettee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): The tank was sound and tight with tees in place and liquid at outlet invert Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal ❑fiberglass El polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth, of Massachusetts. Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1 M6/1't page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,r 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(condtion of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysbem•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form s, Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/11 page. Cityrrown state Zip Code Date of filspection D. System Information (cont) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No Alarms in working order: 0 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page Q of 17 f Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is Maestons Mills MA 02648 1226/11 required for every Citylrown page state Zip Code Date of.I'rlspection D. System Information (font.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): This system has three 500 gallon drywells in a 30'x10'field of stone.The drywell had 1'of liquid in i them with no stain line above. Cesspools(cesspool must be pumped as part of inspection) (locate on.site plan): Number and configuration Depth—top of liquid to inlet invert. Depth of solids layer Depth of scum layer _ Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/11 page. Cityfrown 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-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is Maestons Mills MA 02648 1226/11 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 I, lV I' t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is Maestons Mills MA 02648 1226E1.1 required for 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: 20.0 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 properly/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with focal excavators,installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Fomi: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 r 177 Camelback Road Property Address Frederick J Denton Owner Owner's Name information is required for every Maestons Mills MA 02648 1226/11 page. City(rown 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 ' J t5ins 11110 Trde 5 Official inspection Form:Subsurrace Sewage Disposal.System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION 177 SEWAGE # �3 V/IT_LAGE 1J►'4rS-�MS N�1615 ASSESSOR'S MAP & LOTO R �y INSTALLER'S NAME&PHONE NO. I�[l�S ��/J}g� Cak,� SEPTIC TANK CAPACITY /600 LEACHING FACILITY: (type) ,3,�ca GL..C�i�sr,/�te s (size) l Q X NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: % L�� COMPLIANCE DATE: 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 Wedand and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by r �66v-aj O / v � �-- 2 A 2 � � 133 �- <a -3 13 y No. Fee. HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS YeS ftpfication for Misposal Opstetu Construction i3ermit Application for a Permit to Construct( ) Repair( ) Upgrade(X) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3fo S� )6AS c_�, Owner's Name,Address,and Tel. No. Assessor's Map/Parcel All 41 1 c�,7 JA'94-1®'l�:- Installer's Name,Address,and Tel.No. 6&, aS- Designer's Name,Address,and Tel.No. Type of Building: DwellingNo.of Bedrooms G Lot Size �Ln�-+tt �. Garbage Grinder(�� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3LD gpd Design flow provided (oIv ti gpd Plan Date 01101 06 Number of sheets I Revision Date R���� Title S t- (�.?a-,.� - -3 crT.t A&a t�1J�© � '��h _ U b 4'? Size of Septic Tank IOOD G1� ( Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in o er io ft �Cje to of ,pqCompliance has been issued by this Board of Heal `�/ s `- 1 /�J ,�" Signed ate Z !� Application Approved byC; ate Application Disapproved by Date for the following reasons Permit No. Date Issued l ------------- - --- -- -- - -- - � - No. AN ; M Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: N PUBLIC HEALTH'DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS �, Yes f lAration for Nsposal Opstent (Construction i3ertttit Application for a Permit to Construct( ) Repair( ) Upgrade 04) Abandon( ) ❑ stem complete Sy stem y El Individual Components Location Address or Lot No. e 1'j? G-° ,1w1/t�!3A-�w Owner's Name,Address,and Tel.No. / Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. �I�is / r6�- Designer's Name,Address,and Tel.No. �-- ta, �y(, c...-t e, - �,,,, c - "04: ram., Type of Building: Dwelling No.of Bedrooms Lot Size tto Xe..t- cp-ft. Garbage Grinder(PV N G Other Type of Building Yl//M No.of Persons Showers( Cafeteria( ) Other Fixtures' „x.• _D. esignF Flo(min.required) '?c7 gpd Design flow provided 410 b d gP Plan Date', !!1 l 1 y I OP) Number of sheets 1 Revision Date q hq /&A F r } Title 1 P.Pd- ',S an,044w%� (4)i T 5 —7 ?r Size of Septic Tank /OC7t7 Gi,o, Type of S.A.S. Description of Soil :a ' a t Nature of Repairs or Alterations(Answer when applicable) (�:4� Date last inspected: Agreement: e The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in - accordance with the provisions of Title 5 of the Environmental Code and not to place the syssteemm in o peration unt' �Cjertiftate of Compliance has been issued by this Board of Hea h. - `Signed 7 / !.t—�� Date Z L2 Application Approved by Date Application Disapproved by Date for the following reasons U. Permit No. �� r ) �. , Date Issued . - - - - - - - - - - - - - - - - -- - ----------------------------------I THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Cotnplianre THIS IS TO CERTIFY,that the On-site Sg✓age Disposal system Construct J ed t� ) Repaired( ) Upgraded ) Abandoned( )by / V J V at has been constructed in accordance with the prov�So` �d the for Disposal Sys, ,m Consts ction Permit No"dated /��) Installer[. ; L��a!''� 4 JY�7 Designer ; tv/U�� /!Y #bedrooms Approved design flow i� gpd� The issuance of this permit shall not be construed as a guarantee that the system wilt' )o nassdesignnedDate l %Jf�() Inspector C./ f - - •- - - ---- - - -- - --- --- - - --- - -- --- Fee---�— � r r No. � J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS misposaY Opstrut (Construction 3pPrmit , Permission is hereby grant/�d o ' . tru t( ) Repair( ) Upgrade ) Abandon System located at / �C and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction in 'St be co i4eted within three years of the date of this permit. Date Approved by r 4 Doc= 1s098s371 09-23-2008 1 : 10 BARNSTABLIE LAND RT REGISTRY Deed Restriction WHEREAS, James H. Bowman and Jocelyn Bowman as Trustees of the Tahquamenon Marital Realty Trust u/d/t June 7, 1999, see Land Court Doc #768566 of PO Box 386, Harwich, MA, are owners of 177 Camelback Road, - Marstons Mills, MA; Land Court Plan Number Lot 40 LCP 37712-B (Sheets 3-6). WHEREAS, James H. Bowman and Jocelyn Bowman, Trustees of the Tahquamenon Marital Realty Trust u/d/t June 7, 1999 owner of said lot, have agreed with the Town of Barnstable Board of Health to a restriction on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15,000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage. WHEREAS,the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15,200 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement to the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW,.THEREFORE, James H. Bowman and Jocelyn Bowman as Trustees do hereby place the following restriction on the above-referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 177 Camelback Road, Marstons Mills, MA may have constructed upon the lot a house containing no more than 3 bedrooms. James H. Bowman and Jocelyn Bowman, Trustees agree that this shall be a permanent deed restriction affecting Locus located in Marstons Mills, MA, and being shown on the plan recorded on Land Court Plan Lot 40 LCP 37712-B (Sheets 3-6), or Land Court Certificate of Title Number 153466. Executed as a sealed instrument on the day of a , 2008. Owner's Signature: Owner's Signature: l �, 1 COMMONWEALTH OF MASSACHUSETTS SS 12008 Then personally appeared the above named James H. Bowman and Jocelyn Bowman, Trustees of the Tahquamenon Marital Realty Trust u/d/t June 7, 1999, known to me to be the persons s who executed the foregoing instrument and acknowledged the same to be hls $I�Qil free act and deed, before me, r (Notary Public) My commission expires: ,Zoi _ (Date) ELIZABETH M. KLINK NOTARY PUBLIC Commonwealth of Massachusetts My Commission Expires May 19, 2011 r l f 0 Town of Barnstable taw Regulatory Services ti Thomas F. Geiler,Director { Y BAMM MAS& Public Health Division 1639. Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Date: Sewage Permit# 200E-399 Assessor's Map/Parcel 41 �57 Installer&Designer Certification Form Designer: "T1t%%QT y S.BS " W Installer: ELLIS Uzr* S Coralsr. eu,r c.Am e�1G,�aee¢iN�,t tic- Address: ?,a.ao c,tSZS Address: 23 EMyr_?R%% 6An O Rt,C-Ar4S MA QU95S YARtnw t f oer MA On Eu.%s BStaTftn , Co.A cr. was issued a permit to install a (date) (installer) septic system at 1-11 CAMELPSKV.h 62&1W M11,� based on a design drawn by (address) ��r�oc►�Y S.5gL-01 PC dated Oq 11 200 6 (designer) X I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout(if required) was inspected and the soils were found satisfactory._ OF ature o`' J. (Installer'si� ) � TIMOTHY J. N BRADY CIVIL No.39769 (Desi er's Signature) (Affix e Her ZONAL E� PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH D N. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoffice forms\designercertification form.doc Town of Barnstable �pF ZME 1p� Regulatory Services BAgpSrABLE, : Thomas F. Geiler,Director 9 MASS. g �'iOTE039. Public Health Division Thomas McKean, Director 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 a licensed Disposal Works Installer in the Town of arnstable, authorize 4 � ks AD S �& C-.�' _ to act as my agent to obtain sewage permits certificates of compliance which have signed for and to request sewage inspections. Telephone # Signature. Date: v Witnessed: Date: Agent.doc No. Fee HE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 3 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for lhgpo$al �bp$tem Construction Vermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. /1�0 � C ` Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 1'u I( -O f n C- - Z Installer's Name,Address,and Tel.No. � 2-3 Designer's Na Address and Tel.No. ?`� Type of Building: �. Dwelling No.of Bedrooms Lot Size O' RC/�. ft. Garbage Grinder K149 Other Type of Building 7�-✓` No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3 0 gpd Design flow provided gpd Plan Date tL?V Number of sheets /� Revision Date I Lg f Title /3 Size of Septic Tank IraX-7 Type of S.A.S. Description of Soil c' r S �� e Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo rd of Health. Signed Date Application Approved by Date Application.Disapproved by: Date .for the-following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded (� ) Abandoned( )by 25--Z, Z at f-77 AWtZ, 4_4t , has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer g2W_!( AOX�-� : Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. Fee E COMMONWEALTH OF MASSACHUSETTS PUBLIC H AI,TH DIVISION—BARNSTABLE, MASSACHUSETTS Mi5po5at �bpg;tem Con5truction Permit Permission is hereby granted to Construct ( ) Repair ( ) Upgrade( ) Abandon ( ) System located at /Z�� e4,Wk �Z X04 1&W_nA1Kr AVY/6 hK -�—ir/-s' � �i� " ��� �a✓.� Rio and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construe 'on yfiust be cAin leted within three years of the date of this p i Date Approved by `4._ � •r. .'9 i No:-< Fee j ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes'. 01pphratiou for ;Bi5po5a1 *pgte, Cou5truction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components )r� Location Address or Lot No. to � '1�17b ( M'M r !J Owner's Name,Address,and Tel.No. 177 ���^ C �d5�? �� taw ►�-�,►� /'o A,-x 3&-& Assessor's Map/Parcel Mai 5' 5� 3G� _G1L Installer's Name,Address,and Tel.No. Designer's Namjddress and Tel.No. C-N A Ai Type of Building. Dwelling No.of Bedrooms Lot Size �� �r :ft. Garbage Grinder g (d; Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) ' 491P gpd gpd Design flow provided G 6 01 Y r Plan Date 6'2­7 Number of sheets Revision Date q I q Title Size of Septic Tank ,it. -2 f�/S7T c%t Type of S.A.S. r7 % P _ SGl7 9,a1? 0 4&Ws Description of Soil `7�r�er� C 5 c�� ,_ �,f�•?T•!(/ / Nature of Repairs or Alterations(Answer when applicable) O_ //�/,�/ .a /��� tee / 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in i accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by.this `Board of Health. Gj Signed Date < —..�� :::�n y Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,�wthat the On-site>Sewage Disposal System Cyo�nstructed./( ) Repaired ( ) Upgraded ( ) Abandoned( )byF/LL_.S at �� �G c7/,IL/� /cam! %1. has'been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No r —(dated Installer � Designer #bedrooms Approved design flow �_ gpd The issuance of this;permit shall not be construed as a guarantee that the system will function as designed. Date Inspector - 1 r• -' f - . ————————————==————————————————— ———— No. � �V � Fee100 ------ T/�E COMMONWEALTH OF MASSACHUSETTS i1PUBL�C 'Y LTH I3I,`v isi �N�1' BARNS TABLE, MASSACHUSETTS ; Digo5af *p,5tem Cou5tructiou Permit Permission is hereby granted to.Construct ( ) LR�epair ( ) Upgrade ( ) Abandon ( /,,)_ �A,,,, System located at� Y/77 �/,? t! c�G/C 1a;0� �iI/Z1�/1''C `f r/d� /!'1V . s and as described in the above Application for Disposal,System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. u Provided: Construction yhust be completed within three years of the date of this pe it. /Date Approved by r yy ' ,W. t �, � fit �• , oF� Town of Barnstable P# Department of Regulatory Services DAM6rABMr Public Health Division Date t63A �� 200 Main Street,Hyannis MA 02601 ,a Date Scheduled fR►oAK strrpTev+p 5,2--0 5 Time O Fee Pd: Soil Suitability Assessment for`'Sewage Disposal Performed By: CWPUS WtCNkj,0ja- Oki (APE l t�JE, , Witnessed By: LOCATION& GENERAL INFORMATION Location Address %1-7 Owner's Name ►"Vb'_sTb vniws. Address QA,$Zok (o, � wtcK Mri Assessor's Map/Parcel: ^Z `5 7 Engineer's Name EST CAeC(Z.4 NEW CONSTRUCTION. ._ REPAIR " Telephone# Sot3-ZS,9-_7 0,_ n 4 Land Use tc:�►Drr7vTh`. Slopes(%) Sy,a Surface Stones - Distances from: Open Water Body 7 t10o ft Possible Wet Area t vo ft Drinking Water Well ft Drainage Way 7 25 ft Property Line t ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) �TN,eZ 1+T1A A Y t� � cJ► O y� Z 1" CAtvt,�,lbAGt� QoAp Parent material(geologic) Tlw' s•K Depth to Bedrock too Depth to Groundwater. Standing Water in Hole: 1*j C Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to sca mottles: Depth to weeping from side of obs.bole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well lever A41.factor, Adj,Groundwater level, PERCOLATION TEST Date-17TVATxlnte �o� Observation Hole# ( Time at 9" M Depth of Perc 'ToP a 42 Time at 6" eo Start Pre-soak Time @ _ 'lime(9".6") _ End Pre-soak Z. Rate MinJlnch e'Zr't'a•ImCA :1V i r Site Suitability Assessment: Site Passed_ C Site Failed: Additional Testing Needed(Y/N) N Original: Pubic Health Division Observation Hole Data To Be Completed on Back----------- �**If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:4S_EPTICIPERC_FORM.DOC _ DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. consistency.%Grvel 5rr.t. VAg.5A,JO5 l8=25 Lok"5Aa b w1G Q sl ?Sh 13.Z G rvt�wrrSa►w� 1Q`!Q7�4 �IoNE s..00�,C>P�1YEL DEEP OBSERVATION HOLE LOG Hole# 7- Depth from Soil Horizon Soil Texture Soil Color Soil Other -� Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. - ons' ten %Gravel) 0":t,&P" Fu, Vae.Sates i(mt' 13 Z" mite M SA.+D t b�IZ ll) 6 5'-���. Cti1?AV91, DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil - - Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsi ten Flood Insurance Rate Map: _ Above 500 year flood boundary No— Yes Within 500.yeauboundary No L Yes, , r Within 100 year flood boundary No?f Yes I .. Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious mmaterial exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification I certify that on c.194g (date)I have passed the soil evaluator'examination approved by the �, Department of Environmental Protection and that the above analysis_was performed by me consistent with the required training, pertise and experience described in 310 CMR 15.017. r ISIoB Signature Date Q:\S,EPTICVERCFORM.DOC SOMOWN OFrBA NSTABLE LOCATION O 0 e l,4c SEWAGE # ® -23 � A PVILLAGE �,�/ AV ASSESSOR'S MAP & LOT 0 INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY 1060 LEACHING FACILITY:(type) j` (size) NO. OF BEDROOMS_ PRIVATE WELL OR PUBLIC WATE ;) BUILDER OR OWNER 6)EAya/c5 Syw,- eN5/, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No /v� vv� �� �` rt V"1 tj 1 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Otr1. 5---------------OF....... / iZ1T73 ApplirFa#iun for Eliupuual Works Toustrnrtion Famit Application is hereby made for a Permit to Construct or Repair an Individual Sewage ( ,/r P ( ) Disposal System-at �"� 77 G l,,� � Lod- ��zac ion-Addr�yS (,/� or Lot - ...... t N N.r�.....:.,I..1.A.�.... ..... � : °- -�� 1 - o N ... (1 N, w Owner Address a --•--•--. -------- = .... Installer Address UType of Building Size Lot..2E?1 5._.----...Sq. feet �-, Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) ` Other—T e of Buildin a4 yp g ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures -----•------------------------- w Design Flow............. ........................gallons per person per day. Total daily flow.........�.30......................gallons. WSeptic Tank—Liquid capacity��..gallons Lengthb.71".. Width.JW:"_Q'-' Diameter................ Depth`.-3'... x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I............ Diameter... Depth below inlet_61..::.a`.... Total leaching area.4!7......sqf�rc7pD Z Other Distribution box (/f Dosing tank ( ) a Percolation Test Result Performed b .. ............10...... .................... W....1-�...!.W Date...-___.---,.. -. -_-------...--.... Test Pit No. 1......�_......minutes per inch Depth of Test Pit.....`` Depth to ground water..N® !�l __. L=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R' ---•--... o o - 1 ; -------------------------- Description of Soil_d..'_��..__..._©.�..��...��P?� - - . �., 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 the provisions of iITIL4 5 of the State Sanitary Code—The undersigned further agrees not.fo place the system in operation until a Certificate of Compliance has bee issued y the board of hea r ... D�atf Application Approved BY = --............. ..................... ------. .... Z. . Da Application Disapproved for the following reasons:----•----------------------••---•----------------------•------------•-••------••-----_..._ ...---••------- / Date Permit No... . .................... �b •-- ' Issued ---------•-•-•- ..... 4.e--------- Date L r . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .........r--�..... .......................OF....... A..... Jv............................................ Appliratinn for Disposal Works Tomil.rnr#inn Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: /7 LLooc{ration Addr _ r _ or L_ot.N[ tS ............................. Owner Address W Installer Address Type of Building Size Lot__G�.`.{'.:3 .......Sq. feet U Dwelling—No. of Bedrooms___________ _____________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of BuildingNo. of persons____________________________ Showers — Cafeteria Other fixtures ____________________________ _ W Design Flow............ `2________________________gallons per person per day. Total daily flow......... Q_______.._.__._____.._gallons. WSeptic Tank—Liquid capacity�:��__gallons Length-_:�.___. Width_`_"_P-_ Diameter________________ Depth_U_: ___.. x Disposal Trench—No..................... Width.................... Total Length._____._.___.__.____ Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter._._.__:. ...I__._. Depth below inlet-�?_....�_..._. Total leaching area____:_ ?._.___sq (61 Z Other Distribution box ( Dosing tank ( ) ~" Percolation Test Results Performed by________________________________ _E__....?-.......tr'.'.. - 1' a - - ---==--------•-- Date----.:....__..... _ Test Pit No. 1._._r _______minutes per inch Depth of Test Pit_____ _________ Depth to ground water........................ L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil- �3..............� � , ?�3 s �s s - - ...... ............ .. ••••••- x -•----••---------•-----zfe'•......"� •-•� .r�' --' `t e3- -° ��- -_ .✓,L d�1 ti-3 t✓t e 1 1�.. 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 the provisions of iITI1i� 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in P Y g g P Y operation until a Certificate of Compliance has bees} issued by theb and of healtli. 7 ; ^ . lr ,r Application Approved BY 1-----------= = ... 21 ................. ---;:-......... ---------w 1 D! 70 at Application Disapproved for the following reasons:.............................................................................................................. ----•--•----------------•--....._.....__......_.......--•---....--------.....•---•-•----....-••._........I. Permit No.... _Y, - Date _ ;� } _..� -"-�---�-. Issued....•�"� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1 OF................................ .....:............................................. �rr�ifirtt�p of �nut��i�nr�e THIS IS TO CERTIFY, That the Individual Sewage,Disposal System constructed (j/) or Repaired ( ) .." . •-_.�..1. -............................. Installer at........:......!............. == =° s ! , C i I- );i has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code,as des ribed in the application for Disposal Works Construction Permit No.___ dated.....�_ � ._.Y .. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NY BE CONSTRUED AS A GUARANT THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �;V 7 ��� DATE.....:...................•---.....-•---.........--•••---............--•...------ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ar .... { N ._...._ 2 FEE........................ Disposal Works TOnstrurtion rrutii Permission is hereby granted................__...^' ? to Construct ( _ ) or Repair ( ) an Individual Sewage Disposal System I Street as shown on the application for Disposal Works Construction Permit No:=" n1 PP P ,/•/��Dat d�... o�Z y�� -•--- { .................... ......... �.. -rl. �Y ........................... —� Board of Health DATE.......... ....... •---._.... ......................... •----- FO 255 HOBBS & WARREN. INC.. PUBLISHERS u ;1 , ` ... .:.. ..a ...:: _.-n a .x. a-u'sv;:.ssr, e.-s. ..,:ca.+,+«.•n...r:..r_._.._.. 1, ` I T EN T�=' ' 441_ EkEt1AT10N,5 I-10MV ARE D A '--._-., �-=<, � ,2. P1T"CH ,4 4/NF'0 A M1N1,4ffC/rYd OF /8 /FT. 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SEPTIC TANK RE•RC4<C.o47"fGN R,.4rE - 2 M��..:.� / �G+� �J.�f,E!'1G'AN f'�'E'C,�ST; GR E'QUA•L 7 UN1,ESS DTHERWIS'E NDTEv.4�.�. SYSTE.�I IV07- TO S'Cr4.4,E CaoPONENT.5� 611,44, ,66 I /S7,-44LEF IN 0166�nh'Y,47'/0NS BY; JAr-tG,5 coti L.od NJTE• 7,41Vh'S RE-/NFORQE"L' T11ROUGH04/7- AC'G`DWRWICE YYITIV T/TkE _Y OF- 71-IE'ST..4T F 60AfR OF HE,41_TH W17 H -l-e0TRIC IYzc_'4 Mh - &ITH Z4,- %Z" 5,4NI URY CODE ANP,QNY k0C,4L RU ,65 E'NGIN,4"R, .4gIfOW ENG//NEEh'/NG 11VC, Erl�'BEf'l'EI� STEEl, Rc'PS IN TOP ! 607-r0M. PY91CH W,,4Y APl"kY r47E: -II O�rz, I ND7`,E`• ,4GC,E55 MANH01-E5 TU .SE,oTIG TAN,e I AND l,EACH/N6 PI T.5 TD B4 8U1,C_T lJP TD el,,CY4 ItO 'z'' f3� hl F/NISEI G. ,QAD,E. " FINISH GRAPE --FINISH GRAPE OYE'R TANK F/N! X ty ',4PE F"!NSH/ G,t2AD 2 OVE, ' E.f,EV- � o E4 Et✓= 5to 4YE>�"1.�•• QX 4 �� .E4E'Y. = J.,EAGN//VG G/T �a+� yz "oF "Zb - /4 RFA5TONE 0 0 a o 2 t 3 a 1 OF ' //VY= I o�ca 1N .-42t { O C) Q} ao o / -IN -0 c r r0 OF Z E•KE� n 0 O O O a � � � CaW5H,'_ O 57ONE C d v 'rrPE?'E @ O O O (1) %SCRrIC TANK /NV=4Z-i`Z n BOTTOM f�F = l7` m (TO ,84" LeYZZ ST,4B�Cf} J/ 1t w 4F J L FJ ti /,�,E'ACH//11G F' T a c % r r mac EA r J { = TYPICAL, S,EWAGF 5V5TEM P42o)c'/ .E zt NDT TO SCALE y 1 -cJri ____._ sEc ri /v FARCE, f ZONING PIS 7-RiCr )r1,00P 9,4Z,4RP PEf�N fr PROPOMP LOCATION Of OVELLING �V'tll fBER 0,X 5E�Pi4"00 4f _.T '._ EXISr C�11YERIA T�11�' S WMA6E PX5P06444 t YSTEI'i'1 P NT©11R PE��aN� PER ��PROO,� ...�_ ___ ,�RO EP�,� �� / R y (:;AA L A.4NS /7ER PERSON PER PAY EX ST, S �T E�E A TI QN 6 rc 3 PROP SEP sR07'E.t.EVAT/UN 8 to f RC01_ATIQN E TEST Rl . 0e SERE�AT1 N P17 ENGINEER N4 G'1SPL1 S,�4�, � O ,4 R PY NG/JV E" I R NG R C7 ,44wov ' f � t0 A NPLIc'11 lot,! � � -a -30 _t j _.. ,? - - oc , is ! 86 TCJ TA l.., �. �._ � �a r {..o , { cyroAlelp 46Y. APPP e Y. 4N NO. Q�� 5 G.�.k__E- 1" ri"u