HomeMy WebLinkAbout0015 CAMERON LANE - Health 1S tAME] L;AN,l MARST.MILLS
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COMMONWEALTH OF MASACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS ,.
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET BOSTON MA 02108(617)292-3500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L38r4
Name of Owner DONALD PIRES
Address of Owner: 15 CAMERON LANE MARSTONS MILLS,MA 02648
Date of Inspection: 9/25/00
Name of Inspector: JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
1
CERTIFICATION STATEMENT
I certify that I have personally inspected the-sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection.The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.The system:
X.Passes
_.,4nditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: Date:9/26/00
The System Inspector shall s mit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If he 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 Department of Environmental Protection.The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS .
'The inspection is based on criteria defined in Title V,code 310 CMR 15.303.My findings are of how the system is performing at the time of inspection.M.
inspection does not imply any warranty or guarantee of the longevity of the septic system and any of its component's useful life."
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEN PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL
LIFE.RECOMMEND MOVING SPRINKLER LINE NEAR COVER OF SEPTIC TANK.
revised 9098 Pape 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9/25/00
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not
evaluated are indicated below.
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 o
the replacement or repair,as approved by the Board of Health,will pass.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances. If"not determined",explain why not.
n1a 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 complying septic tank as approved
by the Board of Health.
n/a Sewage backup oribreakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)o
due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health).
_broken pipe(s)are replaced
_obstruction is removed
distribution box is levelled or replaced
nla The system required pumping more than four times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
_obstruction is removed
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revised 9/2/98 Paqe 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9/25/00
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 the public health,
safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM I:
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,upless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollutionlfrom that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm,Method used to determine distance nla (approximation not valid).
3) OTHER
n/a
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revised 9/2/98 Page 3 of 11
„ ;SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9125/00
D. SYSTEM FAILS:
You must indicate either"Yes”or"No"to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water
quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health
and safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone 11 of a public water supply
well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of
the Department for further information.
revised 9/2/98 Pa f ae 4 o 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner: DONALD PIRES
Date of Inspection: 9/25/00
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X _ None 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 introduced into the system recently or as part of this inspection.
X As built plans have been obtained and examined.Note if they are not available with N/A.
X _ The facility or dwelling was inspected for signs of sewage back-up.
X - The system does not receive non-sanitary or industrial waste flow.
X _ The site was inspected for signs of breakout.
X _ All system components,excluding the Soil Absorption System,have been located on the site.
X _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material
of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site
has been determined based on:
X - Existing information,For example, Plan at B4O,H,
X _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)1 5.302(3)(b)]
X _ The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal
Systems.
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revised 9/2/98 Paae 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9125/00
FLOW CONDITIONS
RESIDENTIAL
Design flow: 110 g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual): n/a
Total DESIGN flow: 330 gpd
Number of current residents:3
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no): NO
Seasonal use(yes or no): NO
Water meter readings,if available(last two year's usage): n/a gpd
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment:. n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow:n/a
Grease trap present:(yes or no): NO
Industrial Waste Holding Tank present: (yes or no): NO
Non-sanitary waste discharged to the Title 5 system:(yes or no):NO
Water meter readings.if available: n/a
Last date of occupancy:nla its .
OTHER: (Describe)
n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n/a
System pumped as part of inspection:(yes or no):NO
If yes,volume pumped n/a gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_ I/A Technology etc.Attach copy of up to date operation and maintenance contract
_ Tight Tank Copy of DEP Approval
I�f�
Other:n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1996
Sewage odors detected when errlving at the alto, (yes or no): NO
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
revised 9/2/98 Pape 6 of 11
I .
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PART C
SYSTEM INFORMATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9/25/00
BUILDING SEWER:X
(Locate on site plan)
Depth below grade: 30"
Material of construction: _ cast iron _ 40 Pvc X other(explain)
Distance from private water supply well or suction line: n/a
Diameter: n/a
Comments: (condition of joints,venting,evidence of leakage,etc.)
TOWN WATER
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 24"
Material of construction: X concrete_ metal_ Fiberglass_ Polyethylene_ other
explain: n/a
If tank is metal, list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Age: n/a
Dimensions: 160OG L 10'6"H 5'6"W 5'8""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.) i
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade: n/a
Material of construction: _concrete_ metal_ Fiberglass _ Polyethylene_other
Explain: n/a
Dimensions:n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle n/a
Date of last pumping: n/a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of
leakage,etc.)
n/a
revised 9/2/98 Paae 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9/25/00
TIGHT OR HOLDING TANK: _ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan) _
Depth below grade: nla
Material of construction: _concrete_ metal_Fiberglass _Polyethylene _other
Explain: n/a
Dimensions: n/a
Capacity: nla gallons
Design flow: n/a gallons/day
Alarm present: NO
Alarm level: N/A Alarm in working order:NO
Date of previous pumping: n/a
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
UNABLE TO LOCATE DISTRIBUTION BOX-NO AS BUILT ON FILE WITH THE BOARD OF HEALTH
PUMP CHAMBER: _
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order(Yes or No): NO
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
n/a
-:w
revised 9/2/98 Paoe 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L384
Name of Owner DONALD PIRES
Date of Inspection: 9/25/00
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
n/a
Type:
leaching pits,number:(n/a)n/a
leaching chambers,number: (n/a)n/a
leaching galleries,number: (n/a)n/a
leaching trenches,number,length: (1)60
leaching fields,number,dimensions: (n/a)n/a
overflow cesspool,number: (n/a)n/a
Alternative system: n/a
Name of Technology: n/a
Comments:
(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH TRENCH APPEARS TO BE FUNCTIONING PROPERLY.THE SYSTEM SHOWS NO SIGNS OF FAILURE.SOIL PROBED DRY IN
LEACH AREA.
CESSPOOLS: _
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer. n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection)NO
Comments: ;1,
(note condition of soil,signs of hydraulic.failure, level of ponding,condition of vegetation,etc.)
n/a „
PRIVY:
(locate on site plan)
Materials of construction: n/a Dimensions: n/a
Depth of solids: n/a .�
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n/a
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revised 9/2/98 Paoe 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9/25100
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
PC 4
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revised 9/2/98 Paae 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 15 CAMERON LANE MARSTONS MILLS, MA 02648 M064 P007 L3&4
Name of Owner DONALD PIRES
Date of Inspection: 9/25/00
NRCS Report name: n/a
Soil Type: n/a
Typical depth to groundwater: n/a
USGS Date website visited: n/a
Observation Wells checked: NO
Groundwater depth: Shallow_ Moderate_ Deep_
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet+
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
UGSS MAPS AND CHARTS-10+FEET
revised 9/2/98 Paoe 11 of 11
TOWN OF BARNSTABLE
LOCATION ) {Gl �� SEWAGE #
VILLAGE \ 1� `� �.I�S ASSESSOR'S MAP & LOT'0(0y'M7" 7
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NG: OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
03
n
TOWN OF BARNSTABLE
LOCATION lei s- ( Ah� SEWAGE # ~ 12 J
F VILLAGE I`�l��S`�?�t�1C If`-ft I�S ASSESSOR'S MAP & LOT640'4
INSTALLER'S NAME&PHONE NO. C �
{ SEPTIC TANK CAPACITY ' CS-
�'L I
f; x ) i T S e�vt
' LEACHING FACILITY: (type)�, L(� � )
N��
t.
i :OF BEDROOMS
BUILDER OR OWNER QICS
PERMITDATE: y9 LO COMPLIANCE DATE: 3
' Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE TIFY,that thA On-site Sewage Disposal System installed( qr repaired/replaced( Y )on'by—for
as es,
sbeen constrult in ccordance
with the provisions of Title 5 and the for Dosal System Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions set forth be w:
— ———————————————————— ----.--------r / �
No. v s /Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppliCotion for ;Dioo5all *Potem Cow6trurtton 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.
1.5"&,Amwwi4 La -DM Plats �
Mt4ns'ia lutr� 4qz se-UN a44ar
o u,r.-
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
}� C $(2. NiAlt4 -'T'
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 AAAQ, 2,a 14q(o Num er of sheets 7�_ Revision Date
Title 6w�r11<icgn� ?Lcr Illlilll TO 15' h4i 1�=�� Ire-i/�—`1���) P12Z5
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No.T�/a Date Issued �OK (2
No. / fi_ .:� ��� --j,,, 4- . az Fee le
THE.COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE., MASSACHUSETTS
0100ication for Miopaal *p5tem Conztructton 3permtt x
Application is hereby made for a Permit to Construct( )or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. 3 4 k Owner's Name,Address and Tel.No.
4AyV1l ws4 Lb. QZ S�UNK../drs�"
/YlA�2S'rp� 44IL S G1_N e32v1
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
73Al TGIZ -� ►J /a Igo,
{ 812 MA1n1 'ill"
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Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 5S /a?t1)rzS&J gallons per day. Calculated daily flow V)�b gallons.
Plan Date AA AIL 2.0. IGG G Num er of sheets ?i Revision Date
Title, 6&-Er11=1� ?t-OZ' �LA#4 . 1(Am/ 1014S 441" , JIL 4o' (v14,-DoN Pjaz
Description of Soil
M[-;DIVv�n. ArJC�
l
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
i*� t
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 Certifi-
cate of Compliance has been issued by this,Board of Health.
Signed x Date
Application Approved by
Application Disapproved for the following reasons
Permit No. =/.� �� Date IssuedC�
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS
Certificate of Compliance -
THIS IS TO C)3jZT1FY,that the On-site Sewage Disposal System installed( or repaired/replaced( 1 )on tr_Y_Z�"
by /Ra ,u fy {`t' cii. for
as 1 1 44&.,,AV- ---F41s been constru,at�ed in accordance
with the provisions of Title 5 and t e for disposal System Construction Permit No. �- dated 4 b�.
Use of this system is conditioned on compliance with the provisions set forth be w:
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No. n Fee 42 en
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
'wi5po,5ar *pgtem Con$truction Permit
Permission is hereby granted to
to construct(X repair( )an On-site Sewage Sysfem located at
:7: :2) a 131,aA4 - L -A 1,41 > 4e,
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.
All construction must be completed within two years of the date below. t
Date: Approved by .
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