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HomeMy WebLinkAbout0034 EMERALD LANE - Health 34 Emerald-Lane , Marstons Mills P A = 046 048 1 I COMMONWEALTH OF MASSACHUSETTS FIZE EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS COPY � Y DEPARTMENT OF ENVIRONME - MAP P/,RCEL ,� 1b JUL 2 7 2004 r�Y TOWN OF BARNSTABLE HEALTH DEPT.. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection:05/06/04 Name.of Inspector:(please print) ��� Company Name: Windriver Environmental Mailing Address: 577 Main Street Hudson,MA 01749 Telephone Number:800499-1682 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 the inspection.The inspection was performed based on my training and experiefice in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signatur ate: 05/06/04 The system inspector shallisit a copy oft s inspection report to the Approving Authority(Board of Health or DEP)within 30 days of comg 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. Notes and Comments: 1 —Recommend yearly service of tank;2—recommend filter be installed on outlet to protect leaching;recommend building up tank covers to within state code ""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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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: see front page 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. Answer yes,no or not determined(Y,N,ND)in the_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. ND explain: _ 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 obstruction is removed _distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Tito r,Tnc—f;^n Rnr All ciInnn 2 r Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection:05106iO4 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: T;rl... G rnonc+rfinn Tlnr All 4q/7nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address:Same Date of Inspection:05/06/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to 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 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_. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] X (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• 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) yes no _ the system is within 400 feet of a surface drinking water supply _the system is within 200 feet of a tributary to a surface drinking water supply _the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Tala ';T" .,f;n P­411 vInnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 Check if the following have been done.You must indicate"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 Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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: Yes No 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(3)(b)) Title G T—.,f;^n P^r Oil;i)nnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO_ [if yes separate inspection required] Laundry•system inspected(yes or no): Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 106361 gals reading last year 146 gals per day_ Sump pump(yes or no): NO Last date of occupancy:. w',fE'—r" 1?EN7A c COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER.(describe): GENERAL INFORMATION Pumping Records Source of information: Home owner 2 years ago Was system pumped as part of the inspection(yes or no): YES_ If yes,volume pumped:_gallons--How was quantity pumped determined? Measured Reason for pumping: to check the integrity of the tank TYPE OF SYSTEM YES Septic tank,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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 10 years per certificate of compliance Were sewage odors detected when arriving at the site(yes or no): NO q 6 T;+l. C Tncnortinn P^r All f/100O 'P li Page 7 of 11 OFFICIA L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address:Same Date of Inspection:05/06/04 BUILDING SEWER(locate on site plan) Depth below grade: 225" Materials of construction: _cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line:_ Comments(on condition of joints, venting,evidence of leakage,etc.): No evidence of leaks e SEPTIC TANK: X (locate on site plan) Depth below grade: 13" Material of construction: -X concrete_metal—fiberglass Polyethylene other(explain) _polyeth If tank is metal list age:— Is age confirmed by a Certificate of Com liace —copy P (yes or no):_(attach a copy of Dimensions: 8'L X 4V X 21)1i uid level 48" Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle:22" Scum thickness: 3" — Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How were dimensions determined: measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels inn inlet and related to outlet invert,evidence of leakage,etc.):_tank in good condition no leakage itact outlet baffles are GREASE Tom: (locate on site plan) ------------- Depth below grade: Mate rial of construction:_concrete_metal_fiberglass Dimensions: __polyethylene_other(explain): 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte as related to outlet invert,evidence of leakage,etc.): 1'nty,liquid levels Tiflo C Tnoncnfinn T+nrm(,�1 v�nnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address:Same Date of Inspection: 05/06/04 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/day Alarm present(yes or no): Alarm level:_Alarm in working order(yes or no): Date of last pumping: Comments(condition_of alarm and float switches,etc.): DISTRIBUTION BOX: X box is 17"L X 9"W X 15"D 30"BG (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:0- 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.):no leakage into or out of box box out level installed speed level to even out flow to both leach pits PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms.in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. S T--t4n"Fn—(11,;i,)nnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection:05/06/04 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type le_ leaching pits,number: 2 6'diameter X 6.5' depth leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): opened pit E 36"of liquid 36"of available space as inlet enters pit through center cover build up 54" above current liquid level,I did not open pit F 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 sludge layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): 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.): T41. G Tnc—fi—T7—4/1 C/')(NNl 9 r Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane Marston'Mills MA Owner's Name: Lawrence Fernald Owner's Address:Same Date of Inspection:05/06/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the benchmarks.Locate all wells within 100 feet Locate where public lwater supply east two nterstthe building.reference landmarks or 'b*a rive garage AC-26'BC-25'AD-31' E BD-33'6" AE-26' BE-42' 'D AF-46' BF-55" rF T41. inenArfinn Fnr»� 10 w Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 SITE EXAM Slope: X Surface water: Check cellar: Shallow wells: Estimated depth to ground water�Ui*eet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how.you established the high ground water elevation: Title G Tncnr+rtinn Fnrm 6/1 MAMA 11 T- ZI COMMONWEALTH OF MASSACHUSETTS z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 109 � _ d DEPARTMENT OF ENVIRONMENTAL PROTECTION Jp fVAP t PARCEL TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:34 Emerald Lane,Marstons Mills MA a Owner's Name: Lawrence Fernald t IK- Owner's Address: Same c3 C::: Z Date of Inspection: 05/06/04 w Name of Inspector: (please print) [`i�9E "v Company Name: Windriver Environmental c.9 Mailing Address: 577 Main Street Hudson,MA 01749 c Telephone Number: 800-499-1682 rrt 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's SignaturI r ate: 05/06/04 The system inspector shall s nut a copy of7thsspection report to the Approving Authority(Board of Health or DEP)within 30 days of co pleting 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. Notes and Comments: 1 —Recommend yearly service of tank;2—recommend filter be installed on outlet to protect leaching;recommend building up tank covers to within state code ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X_ 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: see front page 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. Answer yes,no or not determined(Y,N,ND)in the_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 exfTltration 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. ND explain: _ 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 _obstruction is removed _distribution box is leveled or replaced ND explain: _ 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 obstruction is removed ND explain: T;tIP S Tnor, fi—T7 -,,,An v1000 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: T;tla G T»anon+;--T7-All';i')nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to 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'h 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_. X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] X (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• 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) yes no _ the system is within 400 feet of a surface drinking water supply _the system is within 200 feet of a tributary to a surface drinking water supply _the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. T41. 1;T--,.*;--17,,,-,,,All ;/1000 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 Check if the following have been done.You must indicate"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 Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period X Have large volumes of water been introduced to the system recently or as part of this inspection? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? X 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: Yes No 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(3)(b)] T;+l. �,r„-mFi-F,,, All 5 f Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no):NO_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 106361 gals reading last year 146 gals per day_ Sump pump(yes or no): NO Last date of occupancy: APAft Aeff—r"7✓ — �1?EN7A t C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203):_gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Home owner 2 years ago Was system pumped as part of the inspection(yes or no): YES_ If yes,volume pumped:_gallons--How was quantity pumped determined? Measured Reason for pumping: to check the integrity of the tank TYPE OF SYSTEM YES Septic tank,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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: 10 years per certificate of compliance Were sewage odors detected when arriving at the site(yes or no): NO T41A G Tnor, ti—W,,,-,,,An,;MMO 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 BUILDING SEWER(locate on site plan) Depth below grade: 25" Materials of construction:_cast iron X 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of leakage SEPTIC TANK: X (locate on site plan) Depth below grade: 13"_ Material of construction: X concrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 8' L X 4'W X 5'D liquid level 48" Sludge depth: 8" Distance from top of sludge to bottom of outlet tee or baffle: 22"_ Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 12" 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.):_tank in good condition no leakage inlet and outlet baffles are intact GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 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/day Alarm present(yes or no): Alarm level:_Alarm in working order(yes or no): Date of last pumping: Comments(condition_of alarm and float switches, etc.): DISTRIBUTION BOX: X box is 17"L X 9"W X 15"D 30"BG (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 0 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.):no leakage into or out of box box out level installed speed level to even out flow to both leach pits PUMP CHAMBER:_(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): T41. c r--f;—W--,,,An 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _ le leaching pits,number:_2 6' diameter X 6.5' depth leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): opened pit E 36"of liquid 36"of available space as inlet enters pit through center cover build up 54" above current liquid level;I did not open pit F 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 sludge layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06/04 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. back rive garage deck AC-26' B BC-25' AD-31' E BD-33'6" AE-26' D BE-42' AF-46' BF-55' F T;tla G Tncr,crt;nn Rnrm�ii�nnnn 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:34 Emerald Lane,Marstons Mills MA Owner's Name: Lawrence Fernald Owner's Address: Same Date of Inspection: 05/06,104 SITE EXAM Slope: X Surface water: Check cellar:_a Shallow wells: Estimated depth to ground wate feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain:/ggo24,z�yw yp/lov�Ae Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: T41. G T„�„arfinn T�inrm ui�i�nnn 11 TOWN OF BARNSTABLE L.CjC ATION 14��elzgld 4n SEWAGE # %f 711 VILLAGE M �Lo�1s Mt --s ASSESSOR'S MAP & L T�'���' � I INSTALLER'S NAME & PHONE NO.,,l /�Vy�Aw©*11 iZ SEPTIC TANK CAPACITY l 000 LEACHING FACILITY:(type) (size) 1©o0 NO. OF BEDROOMS . PUBLIC WATER BUILDER OR OWNER ,,o4 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No `�� -----LF I I � , i l�LD No..•l-Li ci.2`1 Fim ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliraftan fur Di-ripuittl Wurk,i Tomitrnr#iun 11amit Application is hereby made for a Permit to Construct ( ) or Repait}{jg)j an Individual Sewage Disposal System at: ............34...EMe .s lcl...Lane...MarStonS Mi1lspMass� Location-Address or Lot No. Michael Pereira ......................_.......................................................................... -•----•-------------•••---••••-••--••••---•--•••-•--------...••-•-...........------....--------••- Owner Address a JePeMacomber Jr. Installer Address Q Type of Building Size Lot................ q. feet Dwellingx—No. of Bedroefiis------------3-_-----__--------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building --------------------------- No. of persons-_____-__--_--_.__--:------- Showers ( ) — Cafeteria ( ) a' Other fixtures --------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter.-.-............ Depth.............. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.-__--_--_-_-__--___--. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_....................... -------------------------------------------------.......................................................................................................... Descriptionof Soil......................................................................................................................................................................... v .-------------------------------------•-•--...Sand.--_& Grav21 ............... W UNature of Repairs or Alterations—Answer when applicable----Add_in-g of_.-a--1.00()0 crallon___leagh•--... pit t , ;an existing- tank & oit. -•--•--•••••.... _....---•--------•••-•-•--•--. ••••• -------- -•-•---- •----•--•••-•....----•--•••-----•-----•.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ued- y the board of alt . Signed ------ -- --- = ' . ...... ...1.2./_5_.9_4...._:------ // re Application Approved By .:............. .`....... . - ��-- - - -- - ` -' - -- ---- to /Application Disapproved for the ollowin easons- ------------------------------------------------------------------------------------------------------------------------------------- --------------------------- ------------------------------------------------- �* / Date Permit No. /.....�' 74/....... .. Issued Date No..�T.`.-1:...711 Fx$... .... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AVV tratiun for Bivjipuittl Works To- tuarnrtiun rrrmtt Application is hereby made for a Permit to Construct ( ) or Repair,Kl(Xy.) an Individual Sewage Disposal System at: --� ,,,_,_,,,,,34__.Fmeral_d _Lane Marstons Mills,Mass. -•------------------------------------•---....--------•-----•-----------....................-•---- Location-Address or Lot No. Michael Pereira Owner Address W J.P.Macomber Jr. Installer Address UType of Building Size Lot............................Sq. feet Dwellings No. of Bedroamis............3------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -:-------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ----------------------------------------•------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-_-_----__-gallons Length---------------- Width-------..-_----- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width--------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-_------------------ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) W Percolation Test Results Performed by--------------------- ---------------------------------------------------- Date........................................ Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ GT., Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a --------------------------------------------------------------------------------•-•---------•--..........----------------•-------------. 0 Description of Soil....................................................................................................................................................................... x Sand & Gravel v ---------------------------------------------------------------------------•----------------•--------------------------------------------------------...--------------------------•----------•--------- W -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•-----........ U Nature of Repairs or Alterations—Answer when applicable----Addina of a 1 fl0.0-0.. stall-on__ leach_..... pit to an existing tank & pit. ------------------------- - .... --•-----------------------•---------------------------------------------- • •--•---•-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliancerhas been issued by the board of ealt ' Signed ! Date Application Approved B - PP PP Y ........._... ................... .. -- ---------------------------------- Date Application Disapproved for the ollowingireasons- ---------------------------------------------------------------------------------------------------------------------------------------- ........._.... .. --.............................................................. -- . . ....................._.......... -- -- .. ........................................ �.Lf./ te Permit No. .........../-. - -7//----------------------- Issued ............................................................Da........ Date 1 - . Y .,THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of C�ompltttlnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ()(XX) J P Macomber .fir............. _- ----------------------------------------------------------------------............--------------------------- by ...........,............................. ........ hstauet 34 Emerald Lane Marstons Mills,Mass . at -------- - --------------------------------......--------._....-------------------------------------------------.._..........--------------------------------------------------------------------------------------------._----- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ......./c 4 - 1.�/...------ dated .._............................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / 5 DATE......... .- Cam..... 1 .:T----------------_ Inspectors . -------- ----------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE $ 30 00 No....11.....-.. /.. FEE...........'........... �t��u�tt1 urk� �un.�tr�rttun �rrnttt Permission is hereby granted J.P.I�IaComber..Jr.-------------------------------------------------------------------------------•........ v to Construct ( ) or Re airX-( X) an Individual Sewage Disposal System at No._s4---:E.nerald ane---. arstons---A1i1.1s.tMass..---------------------------------------------------------------------------•---....... Street C�j as shown on the application for Disposal Works Construction Permit No_V�__�.�__-- Dated___. ----...-•---•----•---•-----------------— ----------------------------------------- DATE............. AXISHERS ----------•------------ FORM 36508 HOBBS&WARREN-INC.,PUB 7, 0,C A ION fir(' SEWAGE PERMIT NO. "t [�1n !f/s ;� 7 VILLAGE i INSTA LLER'S NAME & ADDRESS B U I'L D E R OR OWNER DATE PERMIT ISSUE DATE COMPLIANCE ISSUED e I THE COMMONWEALTH OF MASSACHUSETTS ...........OF....... rl�...... .................. App4ation -for Mapaiial Ourkii Tojustrurtion Vrrmft Application *,� hereby'made for a Permit to Construct r Repair an Individual Sewagf Di osal is System at: ow Installer Address Type o ilding feet ........ . Jilding .PA� Z Other Distribution box Dosing tank /VC 1.4 '------------'--'--'-------'—'—''----------'---------------------'-- Agrecmroc: The undersigned agrees to install th foredescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanita 'o — T u r igne rther agrees not to place tl syste in operation until a Certificate of Compliance has s e t b ard ealth. 'Apy�cut�x� Approved Uy.—. .��..����..��.��'Date ^�-�—.- � w^ ~~` Application Disapproved for the following/reasons:-----_------_.---.--.----.----__—_---------' � —'------------'—'------'-----'-----'''-----------------------'----------'-- Date | Permit Issued........................................................ � Date L_—''---__---------------------------------'--'—'—'----' '----' -- —'—'---'—' '' '.— No._ f............ Fa a.. ....... a.........._ THE COMMONWEALTH OF MASSACHU ETTS BOARD QV HEAL g� ...- .OF...... ...:... T" , pphrttfiun -fur R.4puiittl Workii >ar t rnrfiutt rrntif Application hereby'made for a Permit to Construct ( r R air ( ) an Indiv' ual Sewage Di osal System at k ell --------..._•.._•. --' -- '-'__ ---• -- --_.:. .'-+..........................:. .. .--_--' •.. ............-------••-• '"--•------'--- ........ .............. L�cati .......o -A ress No. ------------ • -•----------------- Ow ............... . ........................Aqe.......................... .................. ...........................---------------------- - - --------- Installer Address IU Type o ilding Size Lot.... .......................Sq. feet -� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 1 per, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) s wg Othe.�res ----------------�(----...... ----P----------P---....- --------------------_----------------- -7-- -___..____-.___._.g�......-.. � 1 q gallon Length--- _.... Width.-- .._.. Dizmeter________________ Depth.---------- - W Dest n Flow............... Mons per et-son e day. Total d- flow..._ . gallons. Septic Tanit—Liquid ca�aci xDisposal Trench—N �•y-�-----.---... 7Vota - tl -- ..•• T 1 ing area sq. ft. Seepage Pit No..___. i i Pl Jth o i e _. . otal eaching area-�.�--`al. ft. g tank Other Distribution box Dosing ` C` Z ( ) ( ) aPercolation Test Results Performed by ................................. Date---------------------------------------- Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water-----------------.------ �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__._:-_--___--�--__- ,cyst / r�r �' / D Descri do f Soil-.--_ 4" " _#?_.. •S_ �, !- - x ----------- -- --------- ---------------------------------------Zya.,;n"_ --------------------------------------------------------- --------------------------------------------------------------- i U Nature of Repairs or Alterations—Answer when applicable..-------------------- `^ --------------------------------------------------------------------------------------------------------------------------------------------------------- t---------------------------------------- Agreement: s '' The undersigned agrees to install the afor descr'bed Individ 1 Sewa e Disposal System in accordance with the provisions of Article XI of the State Sanitar Co — T u er igne further agrees not to place tl syste in operation until a Certificate of Compliance has ee issued 't ` boards `health. g ----------------+ems �s r----------- - Application Approved BY- . .......... - -C���' --------------- Date Application Disapproved for the following reasons------------------------------------------------------------------ e I �. I Date PermitNo......................................................... Issued--------------------- ................................. Date THE COMMONWEALTH OF MASSACHUSETTS } BOARD HEA, ..OF...' r (Irrfifirafr of f"uutplinnrr THIS IS TO CERTI Y, at th, divi ual Sewage Disposal System constructed ( or Repaired by------------------- ---- -- -------- -------- rF ler at -------•-•-_. ... --- has been installed in accordance with the provisions of t XI of The State Sanitary ode s deyy*bed in the application for Disposal Works Construction Permit N .. ....... ....................... dated'J "- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT,THE SYSTEM WILL FUNCTION SATISFACTORY. DATE �-- .. `- ----------------------- Inspector.. rt -------------------•-••- HE.COMMONWEALT OF MASSACHUSETTS BOARD F HE el No......... ......................... / FEE....................... `p np rurtiun Vamif Permission, is, riby granted-- ---- ----------------......... •---•----•--••• to Construct (") or e a r"') dividual e spos l Sys atNo................. -------- ---• •. -- . ---- --- ------- ----------------------------------=------------------- Street 7 7 as shown on the application for Disposal Works Construction mit Dated.......................................... 1..4-r...- .................................... Board of Hea 3 DATE............................................ ................................... i' FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - � 7) . ppjtl�' lii � A-, 1 Ab d' q A '41 �y r 0>1 V I%r. V iA bp Co 10 30 0 f 9 �� ��, ° � � � p',fry✓a '�#a r. , p s r(J r i " � r r v� / �i �tt✓, t �4 i " �� ft FC G'F�. 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