HomeMy WebLinkAbout0156 CHUCKLES WAY - Health 156 Chuckles Way, Marstons Mills
I A= 101-123 Lot 2
1
COMMONWEAL M OF MASSACHUSETTS �� FO`yNOF 6 2000
EXECUTIVE OFFICE OF' EIh'vIRO.13MENTAL ,4FFAIP,S O*"*,'
DwARTKcNT OF El atoNMENTAL PROTECTION
ONE WINTER STREET, BOSTC>N MA 02108 (617)292-5500
TRIJ DY COXE
Beast&:)
AFAEO PAUL CELLUCCI I+I;VED 11.111MA RS
Cownaor SUBSURFACE SEWAGE DEAL SYSTM NSPICT10N FOW Co=iesionsr
PART A .
rr C61TfF1CArim ^� n
f�la�paetyf Ad*.: 15 6 C 4vaj•e-"� (Jew C_ Mama of Owear
Dsrfa of
Neese of Iaspaesar.!tea- �nq�,;. �� ut�.3hS ✓�s t'� �.
I are a ow a• pooreuN it is Seallm 15.340 of Title 6(310 CUR 15.000)
COMPOW owoea: o n SPa 4 Cc..1
IN I N 8 Ache": 5-
Tdapherfe No her Q �6aR
I Cerft that I have personalty Inspeot&d.the sewage disposal system at this address end that the information reported below Is
and complete as of the time of inspection. The Inspection was performed ba&ed on my training and experience in tho proper ivnroltonj er,d
maintenance of on-site sewage d epoaid systems. The system:
Pe""
_ Conditlenelly hssees
_ Needs further EvsluiMon By the Local Approving Autl" ty
_ Falls
IrraBa'ts°'r'sligrrnesro~ ..i!y{�� .---.. 174: C�
The System Inspector&hall submit a cc,py of this inapscdon report to the Approving Authority(Board of Health or DEpiwhhlrr tfiil't'r(310i dales of
cOn"9 sting this hupee1110n. If the systsr.I Is a shared system or has s design flow of 10,000 opd or orester,the inspector and nh,r system rrevner shall subnNt the report to the app►opftti,regional offlcs of the DaparVrAM of Environmental protection, The original shotdei bs a net to tl>!n
system owner and Copies sent to the buy ppr
buyer,If applleeMo, end the aovin g raithoraty.
N09'E2 AND C6INl111ENTS
L '
Ile
revised 9/2/98 f'r�,tieftl
0 P"M001 on Racyclod Paper /
1} 4,
• SUBSURFACE SMAaE DISPOSAL SYSTEM NISPECTION FOAM
PART A
C®tTM7C/1TIOM Ie�ertelrtered)
Marty Adlbeae: 15'rW C Lt►X:iI os
Oaenr: �-Q.�Gi A�Q
D■ao of MAPOOok :
SwwfillecTm rilllmARY: Cho* III, & C. or D:
A. ,$fSI PASM:
_ K i have not found any Information which Indicates that any of the failure conditions described In 310 CMA I S.303 sxiv.. Aony i0w-a
criteria not evaluated we Indicated below.
cclMllilelr>rlt: _ _ __-_
S. SYSTEM COMiDfP10MALlY PASSED:
One or more system coo, name as described in the'Conditional Pass'sacti cad to be replaced or repaired. ''iw.iv,stern, ►,pan
completion of the replacernew:or repair,as approved by Ow board =on
He will page.
Indkets yes, no,or not determined(Y,IV,or MM Describe basis of d ll instances. If "not determined",euplsiit v,by m.t.
The septic tank is metal,unless the owner or or Man provided the system inspector with a copy cif a 1110ifi,calo of
Compliance(attioched)indicating that the to as Installed within twenty(20)years prior to the data of ithli i! ;or
the septic tank,whether or not metal,i asked,structurally unsound, shows substantial infiltration at ouffiiratien, or umk
falkno is Imminent. The system will so Inspection if the existing septic tank is replaced with a complying ur ptic uInir its
appovad by the Sersrd of Monk
Sewage backup or eakout of high stale water level obasrved in the distribution boa is due to broken or pls,ip`uctad 11o4(s)
ZMe=lth).
, settled or uneven distribution box. The system will pass inspection if(with approval of tliwi 8oani of
broiken pipe(s) a►e replaced
is removeddistribution box is levelled or replacead Pumping more then four*vM a yaw due to broken or obstructed Opals). The system vriM pool,
brepeot)oe if(with lMovei of the Dowd of!hatch):
!broken pipa(a)are replaced
obstruction is remeved
revised 9/2/98 tia=ottt
SUBSURFACE SEWAGE DISPOSAL SYSTEM MSPECTWN FOAM
PART A
CERT1i1CAT10N lendra"
MpartY Addrraa: /S6 G�c.��(e 5 1l�� ]
Owen: �+
Derr 6f MssSraUM
C. FURTHER EVALUATION M REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further*valuation by the Board of Headth in order to datormine if the sy is failiing to proteol the
public health,safety and the"ronment•
t) SYSIM 1f LL PASS Uflllfili BOARD OF HEALTH D M N ACCORDANCE WITH CIi1A 15.303(1011 ivww'114E SMiTM
IS MOT MOCTIONMlA N A ISANNER WHFCH WALL PROTECT THE IMALIC HEALTH AND THE®II111AIpD1�1iviw.
Cesspool or privy Is within 60 feet of surfaes wow
Cesspool or privy is within 60 fest of a bordering vogetated wetlar► a salt manly.
,21 SYSTIWR WILL FAAL UNLESS /and
Of TH(AND PUBLIC WAM SUPPLIER.IF ANY)DETE UMN T1b4T 1:.ILIE 111rf{TtS4 IS
FUNCTI)NM�IN A M4NNMITS THE PUBLIC HEALTH AND SAFETY AND Tig ENvmO MMT:
The system has a soSON ebeoiption eyetem Iaw/S)and the SAS is within 100 feet of s surlaeIs v,41ter sup�y or
tributary to a surfacly.
„�, The system has a sod soil absorption system and the SAS is within a Zone I of a public wgMw uujjI y well.
The system has a sid colt absorption system aiMd the SAS is within 50 feet of a private wean trut!ply wsl9.
The system has a ad soli absorption system s,ad the SAS Is toss then 100 feet but 60 feet*1,rrro. a from e
private water su weN,unless a WON water analysis for+conform bacteria and volatile organic compowndn iir!tlierrtes 11%rt the
well is free I%tion from that facility and tine presence of ammonia nitrogen and nitrate nitrogen Is sow,tl to or M,se
than 5 ppm. d used to datwrnine distance jappreximadon not vegdl.
31) OTMfA
revised 9/2/99 Agt,of to ,
SPACE ISWAGE DMPDBAL SYSTEM og$PECTNM FORM
PART A
C�TIPfCATION tattttYa+edl
Mom► � � ���.(�es �
Dais of tr poweeft:
D. By"M PALL: ! r
You must Indicate either"Yes" of "Me" to each of the follow"!
I have dowrrAr ed that one o,i»ors of the following feilure conditions exist as described in 310 CMR 16.303, The Ins t fo,r thla
�a detorrrdnstion is identified be(ow. The Board of Health should ba contacted to determine what will be necessary•tc etw tot the 1sih,rs.
Yes No
_ Backup of sewage Into facility or system component due to an ovorloaded or god SAS or cesspool.
_ Discharge at ponding of effluent to the surface of the ground or surfs stars due to an overloaded or 6blille l JiAli•o
cesspool.
Static liquid level in the distribution box above outlet Inver a to an overloaded or clogged SAS or cesop)0.
Uquid depth M essi:pool is less then 6"below In r avonabie volume Is less than 1/2 day flow.
Required pumping stint Man 4 times in the Vast due to Clogged or obstructed pips(s).
Number,of times pumped_.
Any portion of the 11t41 Absorption stern, oessaool or privy is below the high groundwater elevation.
Any portion of a compool or vy is within 100 fact of a surface water supply of tributary to a surface *atom supply.
Any portion of a can or privy Is within a Zone I of a public wall.
Any portion of a npool or privy,is within 60 feet of a private water supply wen.
d Any potion o Cehupool ar privy is less•than 100 feet bwt greater then 60 feet from a private water supply liwdl with no
accept water quality analysis. If the well has been analyted to be acceptable. agaeh espy of well Hotter in,olyals iar
call bacteria, volstne organic Compounds,ammonie niilragen and nitrate nitrogen.
L 1 90E M'TEY FAL.S:
You trust indicate either"Yes"or 'No'' to each of the following;
Ohs farowing oritsda apply to rates systems in addition to tit crltsri ve:
The system serves a facility v4th a design flow of 10,000 or greet&{large System)and the system is a signiflc;ern. Arest tto pubic
Mahn and safety and the anvironmeM because cthe or •of the following conditions exist:
yes No
the system is within 400 feet o surface drinking wow supply
_ the system Is within$00 Of a tributary to o surface dri�Mting water supply
ON syatom Is loc In a nitrogen sonshiw area(Interim%4111ead NOW on Area='IVVPA)ors mapped;Lone 11 of a isulhae
water supply w
Ths owner or operator of an uch systirm shail upgrade the system In accordance with 310 CMR 16.304(2). Please consult the iocol rallltortai
office of the D"Wanent further infarmatlon.
Yam.
revised 9/2/98 Ppessftt
9XISSURFACE SEWAGE OISEOSAL ZVOW SIISIWTtON FOW
PART•
C HEC I(LIST'
► es j
-7Ivto1�
Choi*If tM Wowing have been dons:You must indicate either "Yes"or "No', as to each of the following.
No
!•carnpNhg infeerraaAlori bras provided by the owner,occupant,or board of Health.
_ None of the system oomponemts have boon pumped for at Ileast two weeks and the system has been mc*%Rrq;-rprmai dmv
rates during that podud. Large volumes of water have not been introduced into the system recently or ua pail•.,ff thiai
Y»poction.
_ As built plane have been obtained and examined. Neste If they are not available with NIA.
4rThe foollity or dw*Mnll was inspected for signs of sewage backup.
_ The system does mat rocaive non•sanitery or Induetrlal wants flow.
_ The of was Walleclef for sign of breakout.
_ AN system components,excluding the Sod Absorption tystsm,have boon located an the site.
_ The ssptie tank maniledes were uncovered,opened, and the.Interior of the septic tank was inspected for ea>iu!14 in-of ImIffi s
or tees.material of construction.dimensions,depth of kmid.depth of sludge, depth of scum.
The site and Moeller•of the top Absorption System an the site has been determined based on:
_ Existing Information. For exernple,plan at S.O.H.
Determined In the flele,III any of the failure criteria related t'o part C is at issue,approximation of distoncu is cans X"taht4lb1
116.302131tb11
dC _ The fecNlty owner iaiw!occupants,If difforarri from ownerWwora provided whh information on the
Subsurface Disposal!yetoms. proper nhcdn.a nsuice c d
revised 9/2/9$ hassotal
SUBSURFACE SEWAGE ON04MAL SYSTEM/IiSPECTtOM FORM
~ PART C
SYSTEM NPORMAY M
owrner: .�
Dora 40 A'Pes"dw 7 60
1 FLOW CONDrIX Qi
a o-71
s.o.d. .
Number of hurnber of bedrooms(actusi)a
Torah 1�ESMM frig
Musatbsr of cturaat nesments:
Goes"Srhnder(Yes or rro):
Laundry/separate systern) (yas or nall--b; if yes, separate Inspection rewilred
Lawrndry system inspected or ne)
on Saaal oat Oyes or no)
Water meter resdlegs,If available(Oast two year's usage(gpd):
Sunny Purr*(yas or no)
Last data of o cy-? �r
Type of seftblishment- _
Oea)gn low: and (SaNd on 1 S.
Basis of design low
Grasse vp pmeeM:(yea or no)— ---- -e----
lndiretrial Waste Nowno Tank : (yes or no)—
Nowisanitsry waste d1sehargo0ofe the 11ds E system:Oyes or no)"
water rnater r- d --Of
Lost dots of oc
OTldal:(OeseNbel _
'.set deft of y:_
a SM>a01MMAT10N
FtX~RECOROi and source of 1nh;rsnstion:
System pumped as part of W11-eation:Oyes or noIA25
It yea,Volume pumped: _____,Mona
(Reason far pumping: _
T OF SYst�M
Spdc tonkldistribut)en boxls,til absorption systorrs
Sk4e cesspool
OVerlew cesspool
NVY
Shared system(yes or no) Of loss,attsch previous lnapectlon records,if any)
VA Technology etas. Attach ca fey of up to data Operation end rrtahmnance contract
�.._ JI►u Tank Copy of UEP Approval
OtMr
APPROX11MATTt AGE of an componor=,slate insloed pf known)and source of mfonmdons,
SWIP odta'e detected when arriving st the site:(yes or no)
I
revised 9/2/9.8 pop baflt
iRMU1FACE UWAOE DOPOAL SIfSTEM MSPECTION FORS{
'ART C
SYSTM WFO11MAIMI 400►A►w4
o l �c�ve�(yes cc.��.7
Deft o*rt.r.�«+: 7 r fro
Whom fiEMld1:
(tones on oft phn)
Dp1h bsfow pods ZL
MmwW of construction: oast iron Id0 PVC s other(expktin)
Distance � ar we supply wool or suction fins
DkWVWW f/01�
Cann rwm:(condition of joints,vsntirgl,evidence of lookoge,eta.)
(oesto on eke Olen)
D"4h bebw graft: u
Molw w of construction:Iconerato--mew_"Wryloss _„Polyethylene_othorlexploin)
If trade Is nweal,Oat op,_ to op oordIrmod by CortMasts of Compliance (Yu/No)
awansions: / ��
kW"dpMy ` _
u
Dialance,from to of Skallp to bottom o!outlet too or bafflo:o!
scam thickness: 7*'
Distance from top of saum to Up of outiat we or baffle:
Distance from bottom of scum to bqnapri of outlet top or bell(*:
'lour dimensions were datermined ��
Comments:
Irecommendetlon for pumpft,con on of(Mot end outlet tees or befflss, oesth of i id 1 al i rof tlon to outie Inv* , stracturid intsipity,
Ovid a of Tooke" 1 _ c
--ba —.I0. rh[
WMAaE TRAP:
doante on eft plan)
0601h bdovr raft._�
MOWIM of conatniatlon:_concrete,Inetol,, 111berglsss _PoiyethytiM _othe►(O:ploini
Dinxddiia+s:_
sawn thickness:
Dfa MO frmn top of scum to top of OWN ae or beMe:
Dlsfnnce horn bottom of scum to bottom of outlet befM:
Date of lost pumping:
connntonts:
(reaammondodon for pumping. coed( of Inlet and outlet tees or baHlee,dpth of Nquld low in►Netlon a outlet
Ovkhave of lookpo,ote.) tweet,satiatug;q intg,".,
revised 9/2/98 PsOe7oftt `
r
AUSSURFACE SEWAGE DISPOSAL gTSTEM WSPECTtOM FORM
PART C
SYSTEM Of 01 NATION laordraradl
F4nrrtTAddr s-
Owrnsm
Dow*f` : -t l L 0z'
TMWT OR MOLDOM TANK: ITank must bt pumped prior to, or at irf, inspection)
(knata on aka Plan)
Depth bole grade:_
Mo adal of constnAcdon:_concrete-moral_Fibarelast Polyethylene- otheriaxplain)
Okrvrrwierra:
Copedty:
DasiEn Now: Nallonelday
Akwm present
Akwm W**: Alarm In we p ardor:ties_ No—
Dora of proviam purnoft:
commons:
leandtian of inlet toe. of alarm and float switches,ste.1
SOX-.—
(looeto an aft pion)
/ DMpt*of Ytp+id level above am"invert: e V f o'-
Cawmarns:
(note If level and dieIributioals equal, ividance of solids carryover,evide a of toakaQa Into or out of box,oft.)�
4 c► r
PURV CNAMWt;,,,_
(laoata an site plan)
Pwnps in wort ft order:(Yes or me)__"
Alarms in waAft ardor(Yee or No)„___
Comolnents:
(Wort condition of pump chamber,conaM•don reps and appummonenae a,oft.)
revised 9/2/98 >hr{rFoflt
SUM MACE SIElAfwGlf CWPOIIAL SYSTff:'oA MPECTfON FORM
PART C
SYSTM ON401AIATMOO laaMbenef
? tao [®o
SOIL as8oaAMIS SYSTM"W4.
flocato on oko plan.if possible;a:caved*n not roqul►od,location may be approximated by non-Intrusive n+athods)
if not located. bxploln.
Type: _
o pifs,rwrrlber:r
kleciong eRanbe/a, asnoba:.�
moo"some floe,rwmba:_
venehes,nunwba,koph:
Moo"Holes,rrrn*w,dhMniriens:
Ova iow oesepod,
Alfarnetive eyatarr+: —
Name of Todmdogy:
Can roonto:
'i (Hate condition of seY,a na of hydraulic failure,level of pondfn9,damp oii,condition of vevatet( etc.)
-Aar, _
CUs(r®fxs:
UociM an sleo plan)
"_.,:Nundter are aanflguretiori:,�,,,,____,�_
�ap�hroop of add eo a,lt hiwrc: _
Wth of aeuds lover: _
owth of*awn loym: _
wneonaloft of cesspool:,—_
MaairWe of oonaVucd@n:_„_
Indfaadon of gmiindwotw 14 1
inflow(cusped moat be mpled as pate (nspef odonl�_
CorrwRwnta:
fnote*end lon of a elgml of hydmag;fa#uro,level of pending, condition of vaoetation, etc.)
(+Merl:
flocei on a(»plon)
Motu ies of construction:
DW01 of adide:® D(menMons:
Cerrrnnerrte:
(note condition of signs of hydraulic i'Wua. level of pending. condiion of velpotellon,ate.)
revised 9/2/96 fs{e9oru
SUB WIfACE SEWAGE DWOSAL SYSTUA WJSPECTWN foul
PART c
SYSTM NO O1MATM(em"btuedl
A . eg U)O-,
oww..: 1.1ela+.cie
Data l�c� CO
SKIRM OF SEWAGE DISPOSAL SYSlMM--
kiciudo Iles to at least two purinensmt reference landmarks or bertchmarks
locate ad wens witR n 100' It.ocate where PIlc water supply comas hKo house)
i
It
5
1
3
610 .,
"
revised 9/2/98 pw30or11
f tMSt3RFACE SEWAGEOl paM SY'STMN MPECn M FOAIM
PART C
SYSTMN 16FOR24ATIOM lelln*w"
wep.rey
Owsr: k�
MRCS Report nerne _ —
SeN Type`
Tyo"depth to groundwater._
uSOS Does webeke vlalted
OQswvodon Welts checked
ammdwoter depth: Shspow_-._ Modersto __Deep
SM.EXAM Steps
Surhee caster
Chock COW
Dhelow waft
Ettfrmsted Depth to Oroundwstor Fein
Please Indloste&I the methods used to d+stenMno High aroundwetor Nevetlon:
09tslnod from Design Plane an record
Observed Sit'lAlk tine property, observation hole,basomem sump otc.)
Detwn*sd born local conditions
Checked with kcal Dowd of ho*hh
Checked FEMA M%m
Chocked pumping records
Checked tote excavators,inttaNa►s:
Us"uses Dada
OaseMft. h"you es Wehed the High Clmundwater B*vatfon. (OM be oornideted)
UVS Q'IWVJ V� Col -OC*�A .
S
revised 9/2/96 Feet it at it
TOWN OF BARNSTABLE �l
'%,oCATIO 1 i. _ G4ucAd e5 iLbm SEWAGE #
1!II;: A�vE 1 1 �S j ASSESSOR'S MAP & LOT
Il& R'S NAME&PHONE NO.
.V.5eeca N 3Up
SEPTIC TANK CAPACITY --/
LEACHING FACILITY: (type) C k A40-5S'®I's (size)
NO.OF BEDROOMS 13
BUILDER OR OWNER `t e-,Dkr ✓k'o F E lcn fry�2
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
t
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
-fo
b.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
jj Subsurface Sewage Disposal System Fo - of for Voluntary Assessments
�L
1 Property Address ti
/-
Gar
informationis Y"
Owner Owner's Name od c'Y�` /O g (/
w
r f '/
required for every J
page. Cityffown State Zip Code Date of Ins ectio
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. Inspector Irar,4_
ation
filling out forms
on the computer,use only the tab 1(
key to move your Name of Inspector
cursor-do not �O
use the return Company Name /
key. ,0_ ev
Company Address /_s� O�b
City/To G State Zip Code
f� ---- �..5xS
Teleph.L_ umbe License Number
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 maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that;the s
1. Passes
Z. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
/D
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 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.
Sinsp.doc•rev.7/26/2018 -i2e 5 of-,oai,-specuon=onn:Sebsurface Sewage Disposal System.?age t of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
f Scu C l/es C/'a
Property Address
Owner Owner's Name
information is Cj�/5Nf��l//required for every T Q
page. City/Town State Zip Code Date of I pecti n
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
l 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:
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 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):
t5insp clot•rev.7W2018 'me 5 o tioai mspecaon=orn:suosurace Sewage Disposes System•Page 2 of 18
Commonwealth of Massachusetts
I
-. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form C%WCJ�4.5'
-Not for Voluntary Assessments/16 (AA
cl
Property Address
p rty d ess /
o er
Owner Owner's Name J
information is
required for everyA/1
��4 11f
�/� Y /0 a /
Q/�
page. City/Town State Zip Code Date of[rApecti6n
C. Inspection Summary (cont.)
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.712612018 Title 5 Qfficizi:rsspectlon Form:Suosurface Sewage`risposai System-?age 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
arc cvG
Property Address j
Owner Owners Name `/� /j�J /O
information is
required for every
page. CitylTown State Zip Code Date of Aspe ion
C. Inspection Summary (cont.)
❑ 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
b. 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 DCP 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
❑ rt/ Backup of sewage into facility or system component due to overloaded or
I� clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
LJ due to an overloaded or clogged SAS or cesspool
Title 5 Offioai'nspectibn Porn:subsurface sewage Disposal System•Page 4 of 18
tsinsp.tloc•rev.7262018
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�vr( vtu� eles tv a
Property Address,
col Zee
Owner Owner's Name l information is �(d
required for every AXWS4"' A"A'— � (/ OA//'9
page. CitylTown State Zip Code Date of Inseectiorl
C. Inspection Summary (cont.)
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
iquid depth in cesspool is less than 6" below invert or available volume is less
ham'/2 day flow
U uired pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
Any portion of the SAS, cesspool or privy is below high ground water elevation.
Any portion'of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
,-- Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
I Any portion of a cesspool or privy is within 50 feet of a private water supply well.
LK 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 2000 gpd-
10,000 gpd.
r-; The system fails. [ 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.
5) 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 C.4.
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
I
Area—IW PA)or a mapped Zone II of a public water supply well
5irup.tlx ray.7262018O_C.G nspeuton Form:suosu`ece sewage Disoosal System•?age s of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owners Name /0
information is
required for every
page. City/Town State Zip Code Date of I pe on
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.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
❑ 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?
❑ s 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?
t� ❑ 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)]
Tive 5 Of`dai inso-lion rcrn:Subsurface Sewage Disposal system•Page 5 or/8
t5insp.doc•rev.7/252018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C40 C-Ua G✓G 51
Property Address
Owner Owner's Name
information is
required for every
page. Cd /Town State Zip Code Date of In ecti
D. System Information
.1. Residential Flow Conditions: 3
Number of bedrooms (design): Number of bedrooms (actual): 330
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms).
Description:
!� w/ a.w�✓
Number of current residents.-
Does residence have a garbage grinder? ❑ Yes Et No
Does residence have a water treatment unit? ❑ Yes L? No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes to _
information in this report.)
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
( No
Sump pump? Yes `''
(4
Last date of occupancy: Date
Tire 5 `dal:ospecnor=cr.- jucsuiace Sewage Dispesai System•?age 7 of 18
t5insp.Coc•rev.7126/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name n,
information is
required for every � S
page. City/Town State Zip Code Date of In pection
D. System Information (cont.)
2. Commerciallindustrial 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:
Source of information: -C~"f O W�'�-✓
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gaiions
How was quantity pumped determined?
Reason for pumping:
t5insp.Coc•rev.712612018 Tine 5 Offiaai Msoeaior=orm:suos,fface sewage asposai system•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1/Ps Goa
Property Address
C40
Owner Owner's Name (id /�!� (0ULF
information is rj Ja T required for every State Zip code Date of In
page CitylTown
D. System Information (cont.)
4. Type of Sy
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):
-Approximate age of all coGm�ponents, date installed (if known) and source f informs r
96 .- 916-C�V_T z W-M 1,-/-
Were sewage odors detected when arriving at the site?
❑ Yes
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑cast iron 0 PVC ❑ other(explain): r
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
-;fie 3 37`oal irsP on=or.5ucsurface Sewage Disposes 5ystem-?age 9 of t8
u5insP.doc•rev.7262018
Commonwealth of Massachusetts
mum
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is /� p
required for every A 14,/r ✓� �`�'� p ��
page. City/Town State Zip Code Date of I pec on
D. System Information (coot.)
6. Septic Tank (locate on site plan):
Depth below grade: feet
;te 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:
Sludge depth.-
Distance from top of sludge to bottom of outlet tee or baffle �-
u VV7
Scum th'.ickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle —
O Xe 415 /C
How were dimensions determined? CXI
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,, etc.):
Gi80*41 4tee_
t5insp.doc•mH.7r26/2018 4'r-
e vF`Qai Inspecnca=o-m:Suosuiace Sewage Disposai System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
G
Property Address
r,01
�
Owner Owner's Name
information is �9
required for every
page. Cityfrown State Zip Code Date of I pecti n
D. System Information (cost.)
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
-;rle 5' aa'+nspzcuon Fom:Subsurface Sewage disposal system•Page 11 of 18
t5insp.doc•rev.7/26/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
(� �K C11 441 C./-G
Property Address
Owner Owners Name
information is ��. Hf
required for every
page. City/Town State Zip Code Date of Inspec on
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 GL�
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.):
t
�tJe 6 Ducal nspeczon FOrM.S 'face Sewage Disposal system•?age 12 of 18
t5insp.doc•rev.7262018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6,
Property Address
Owner Owner's Name
information is a•-r -s s 8X ae
required for every �d
page. Cityffown State Zip Code Date of sp on
D. System Information (cont.)
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 rot located, explain why:
YP 15 .7
❑ leaching pits number
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
innovativeialtemative system
Type/name of technology: --- ----
'me 5 Off oai:nForm:soeadon= m:SUDSITaGe Sewage DISpOsai system•?age 13 of 18
t5insp.doc-rev.7/26/2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not/for VoluJnt4a/�Assessments
G
�r S�
l�.S W
Property Address
O
Owner Owners Name / A,4
information is s — (v
rpaguered for every City/Town State Zip Code Date of Insf zectto�::
D. System Information (cost.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
v) y PAvI QN�
G� h�
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.):
-ine nspecuon=om:sucsudace sewage otsposal system•Page 14 of 18
t5insp.tloo•rev.726/2018
Commonwealth of Massachusetts
P Title- 5 Official Inspection Form
Subsurface Sewage Disposal System Form • of for VoluntaryAssessments ssments
Property Address
Owner Owner's Name O
information is 0 /�
required for every
page. City/Town State Zip Code Date of Ins ectio
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.):
6insp.doc•rev.7/26/2018 True 5 v fiaai�nspecuon=orm.Swsarface Sewage Disposal System-?age 15 of t8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form//-Not for Voluntary Assessments St u crags �G
Property Address
O
Owner Owner's Name ,l �[ /
information is ar.� s y�C
required for every (/ v
page. Cityrrown State Zip Code Date of Insp ctio
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a vjpw of the sewage disposal system, including ties to at least two permanent reference
lae
or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
th . Check one of the boxes below:
ketch in the area below
❑ drawing attached separately
i
1
I
i
i
Nj
! i
I
i /fI
/
!
A
i
i
I I
t5insp.doc-rev.712612018 Title 5 ottc:21 Irspecoon Fom1:Subsc-tace Sewage Disposal system-page 16 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -/Not for Voluntary Assessments
J :b C4j bt G 4/ we
Property Address —19
Owner Owners Name Qz��- .
information is e3� ors / /V-
�� /Wrequired for everyC/ to S/N
page. City/Town State Zip Code Date of In ectio
D. System Information (cont.)
15. Site Exam:
L1 Check Slope
❑ Surface water
❑ Check ceilar
❑ Shalow wells
/g
Estimated depth to high ground water: 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
❑ served site(abutting property/observation hole within 150 feet of SAS)
Checked withAl ' oard of Nealt(�xplain:
Checked with local excavators; installers - (attach documentation)
❑ Accessed USGS database-explain:
You must descr e ow you esta fished t' e high ground water elevation:
AV
Qt✓ .
C7 s-;k Ile A71c&I I
4.
14(,1
Before ding this inspection Report, please see Report Completeness Checklist on next page.
5insp.doc•rev.7262018 `tle 5 075aal Mspe=,'=o-:Suosur"ace Sewage Disposai system•Page 17 of t8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ASubsurface Sewage Disposal System Form -Not for Voluntary Assessments
t4 C a_r
vv,.-
Property Address
Owner Owner's Name
inforrnation is A/44rf ^f ' �•required for every �v
page. Cii Town State Zip Code Date of In4ectiorf
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
B. Certification: Signed & Dated and 1, 2, 3, or checked
C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
Z(Eilure Criteria)and 6 (Checklist)completed
stem Information:
For 8:Tight/Holding Tank—Pumping contract attached
For '4: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
':ne 5 Qifioai:nspecuon Po.—:Suosurtace Sewage D*posai System.?age 18 of 18
t5insp.doc.rev.7126=18
O B iSTABLE
L( A'fION' t0t'a2 6-hy &1e,5 SEWAGE # "Z4/3
A LAGE 1V¢f5 f0&5 S ASSESSOR'S MAP & LOT O/�
INSTALLER'S NAME&PHONE NO. ��
SEPTIC TANK CAPACITY ,-OO Vl
LEACHING FACILITY: (type) 4 —I 0 (size) 410 —7/ 17"y Uv
NO.OF BEDROOMS 3 �j
BUILDER OR OWNER
PERMITDATE: ��� COMPLIANCE DATE: '' '` .
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water SupplyrWell 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 leq,4ng facility) Feet
.Furnished by
)' � � h
i i
n � . � ` � �� �� �
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® a �
r
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101 - IJ-3
' c
No. Fee I
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Mioonl bpgtem Construction 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.
(07 /tJ iiG C'CucCles l.ra� y�.�sd :fP /7�0,@,(•rs qi �c
i
14JrVtrlS �.7/f -7-71-0663 I
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�'arEa16t(% C' 1( '�7/- 439E
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '3 6 gallons per day. Calculated daily flow L 4 /' gallons.
Plan Date Number of sheets Revision Date
Title
i
Description of Soil scc 2Ckae4.a4/a.•
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 issu this B d of lth ,
Signed � �' o Date
Application Approved by 1AY
`-
Application Disapproved for the following reasons
Permit No. Date Issued
No. .�' /C;13 Fee
-THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOW@PRARY571461_Es MASSACHUSETTS
_01-pprication for Mi!5poga1 �Abpgtem Cougtruction Permit
Y
I'.
Applicationds..hereby made for a Permit to Construct( x )or Repair( )an On-site Sewage Disposal System a
Location Address or Lot No. Owner's Name,Address and Tel.No.
-Ia,cEe�c , ils � 77/�.�,vo3
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
77/- g3Yf
� t
di
Type of Building:
Dwelling No. of Bedrooms Garbage Grinder( )
Other, Type of Building No. of Persons Showers( ) Cafeteria( ) 1
Other Fixftkes 1
Design Flow ;d gallons per day. Calculated daily flow G gallons.
Plan Date Number of sheets- Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: 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 issue` b this B d of ' alth f
Signed G} - GG"� ,tZ� j Date
Application Approved by
Application Disapproved for the following reasons
l
Permit No. Date Issued qL—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal,System in alled( )or r aired/replaced( )on
by �yrtul6t� ; �r,r �4. for <<b.f S
A tot C �c k!-f (,�,� JH. /Lf.! s s constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated c •- (_, — f
Use of this system is conditioned on compliance with the provisions sA4orth be w:
-- --=f—`r=------------------------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
i
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migoar bpetem Con6tructiou Permit
Permission is hereby granted to 9 v V b p I D 44 (' 6-,,.,t,.C-i a'�^
to constructS� )repair( )an On-site Sewage System located at t it C ko G k le s Gv>�/
14. M •tls
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.
Date: 7Z 6—9 11 Approved by
Ll
Ir
d
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