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HomeMy WebLinkAbout0554 FLINT STREET - Health 554 Flint Street t A 102—056 �- - - - - - - - - - - —t Marstons Mills i i i I II Tepe �5-0914 3 55y ��.� LSsu� u-r�-Gi dQN I Jun 1715,09:31 p p.18 I�1 f DAP Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �. 554 Flint Street i a Property Address 11 Terece Horton Owner Owner's Name information is Marston MiNs y� MA 02648 6-17-15 required for every page. Cityrrown State Zip Code Date of Inspection 1`t5 Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information `��``allltnlllU�iq on the computer, ® 5� ``gf� kA OF t,14 i z&,' use only the tab 1. Inspector: key to move your c o; '•.S� cursor-do not James D.Sears JAMIES :m use the return Name of Inspector key. a *•, —'_ Capewide Enterprises,LLC = ' Company Name rIF��.���` — _153_C_ommercial Street �4i�����5'rrNSPE"�����` Company Address —Mash-R _ _. MA 02649 City/Town State Zip Code 508-477-8877 S1623 _ Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported betow 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 dispcsal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: 0 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I 6-17-15 nspector•s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 1� Y j 15ins•3M 3 Title 5 01ficiat Inspection Form:Subsurface Sewage Oispasel System-Page 1 of 17 Jun 17 15 09:31 p p.19 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 554 Flint Street Property Address Terece Horton Owner Owner's Name information is Marston Mills MA 02648 6-17-15 required for every page. CityrTown state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: The system is a 1500 Gal.Tank D Box and pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for`yes", "no"or"not determined" (Y. N, ND)for the following statements. If'not determined,"please explain. The septic tank is metal and over 20 years old" or the septic tank (whether metal or not) is structurally t 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): !Sins•3i13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 ct 17 Jun 1715,09:32p p.20 Commonwealth of Massachusetts Title 5 Official Inspection Form 5 - Assessments Subsurface Sewage Disposal System Form Not for Voluntary Asse ents r( 554 Flint Street Property Address Terece Horton Owner Owners Name information is required for every (Marston Mills MA 02648 6-17-15 paw Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpsialarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NC (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): 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 t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 17 Jun 1715,09:32p p.21 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i - if 554 Flint Street Property Address Terece Horton Owner Owner's Name information is required for every Marston Mills MA 02648 6-17-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: `*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ M Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in eslespgW is less than 6" below invert or available volume is less than day flow Pl7— 15ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 4 of 17 IJup 1715.09:32p p,22 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments :J 554 Flint Street Property Address Terece Horton Owner Owner's Name information is Marston Mills MA 02648 6-17-15 required for every _ _— —.- page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form_] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15-303, therefo,-T--,the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. C) tlAryc 3yatcn�a: Tv be wnaidarct!a larc�c a�alcrrr flit aralcnr nruaL acrvc a faa:ilill villr 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 fallowing, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "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. 151ns•3M Title 5 Official Inspection Farm.Subsurfau,Sowage Disposal System•Page 5 of W Jun 1715-09:33p p.23 Commonwealth of Massachusetts >~ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton _ Owner Owner's Name information required for every Marston Mills MA 02648 6-17-15 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System.(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3---- Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x*of bedrooms): 330 t5ins-M3 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 6 of 17 Jun 1715-09:34p p.24 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owner's Name information is required for every Marston Mills MA 02648 6-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.tank D. Box and pit. Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes 1Z No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes EK No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2013-15,000Gais 2014-11,000Gal's Detail: Sump pump? ❑ Yes No Last date of occupancy: Present Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(opd) Basis of design flow(seats/persons/sq.ft.,etc.).- Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Jun 1715.09:34p p.25 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owner's Name M information is Marston Mills MA 02648 6-17-15 required for every page. Cityrrown State Zip Code Date of,Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2009-2014 Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: - -- gallons How was quantity pumped determined? Reason for pumping: - — Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ InnovativelAlternative 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): t5ins•3113 Title 5 Official Inspection Forth:Subsurfw-a Sewage Disposal System•Page 8 of 17 r Jun 1715.09:34p p.26 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owner's Name equir atcfo is Marston Mills MA 02648 6-17-15 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1978 Permit 78-502. 6-2015 New D Box and lines Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 21 feet Material of construction: ❑cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 15" feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: .1500 Gal. Precast H-10 Sludge depth: 2" t5ins-31113 Tille 5 tidal Inspeclon Form:Subsurface Sewage Disposal System-Page 9 of 17 Jun 17 1 S09:35p p.27 Commonwealth of Massachusetts qj­ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owners Name information required for every Marston Mills MA 02648 6-17-15 page. Cityrrown State Zip Code Dale of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17 How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and covers at 15" below grade. Inlet tee,oubet tee. No sign of leakage or overloading. 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 t5in3-3M3 Title 5 Of val Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Jun 171509:35p p.28 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owner's Name information required for every Marston Mills MA 02648 6-17-15 page, City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins-3H 3 Tine 5 Official Inspection Form:Subsurface Sawage Disposal System•Page 1 I of 17 Jun 1715.09:35p p.29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 554 Flint Street Property Address Terece Horton Owner Owner's Name information required for every Marston Mills MA 02648 6-17-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(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.): D Box is W'x16"-25" below grade w/one line out. Box is new 6-2015 w/cover at 6". 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. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins 243 Title 5 Official Inspection Form:Subsurface Scwap Nupcsal System•Page 12 of 17 Jun 1715.09:36p p.30 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Properly Address Terece Horton Owner Owner's Name information required for every Marston Mills MA 02648 6-17-15 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ 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.): Leaching is a 1000 Gal. Precast pit w12' stone. Pit and cover at T below grade. 6"water in pit wlstain line at 18 Wall are clean,no high stain line. 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 t5lns•3113 TAW 5 Official Inspeclion Forme Subsurface Sewage Disposal System•Pape 13 of 17 Jun 171509:36p p.31 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owner's Name information required for every Marston Mills MA 02648 6-17-15 page_ Cityfrown State Zip Code Date of Inspection D. System Information (cost.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ` Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 6 Official Insperlion Fotm:Subsurface Sewage Disposa!System-Page 14 of 17 Jun 171509:36p p.32 Commonwealth of Massachuseft - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton -- _ Owner Owner's Name — — —-- -- reformation is Marston Mills MA 02648 6-17-15 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cons.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below dr-awing attached se nrnimly _—_ i j `I IC 3 3 - r 14 3a 00 v. 15ms•W13 Title 5 omcia kwpecvon Foarr.ScbsWaoa Sewage Dv"sd System•Page 15 of 17 Jun 1715 09:37p p.33 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street_ Property Address Terece Horton Owner Owner's Name informationairedfor is Marston Mills MA 02648 6-17-'15 required for every page. CityrTown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells i Estimated depth to igh ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: on file ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must:describe how you established the high ground water elevation: T.H.on file at BOH 1978 no G,W. at 12'+. Bottom of pit at 9' below grade. Bottom of pit at Y above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.3113 Title 5 official Inspection Form.Subsurface Sewage Disposal System•Page 16 or 17 Jean.171 5 09:37p p.34 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Flint Street Property Address Terece Horton Owner Owners Name requiredifo is Marston Mills MA 02648 6-17-15 required for every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information —Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file l 15ins•3113 Tile 5 Official inspection Forth_Subsurface Sewage Disposal System•Page 17 of 17 r � Z ti+ Affidavit u I, Terece M. Horton, formerly known as Terece M. Twitchell, of 554 Flint Street, A. Marstons Mills, Massachusetts, on oath depose and state the following: 1. I have personal knowledge of the statements made in this Affidavit. 2. I purchase the real estate at 554 Flint Street, Marstons Mills, Massachusetts (the "Premises") from Banner Home Corporation pursuant to a deed dated November 14, 1978, and recorded in the Barnstable County Registry of Deeds in Book 2819, Page 226. A copy.of my deed is attached.hereto as Exhibit.'1. 3. I have resided at the premises continuously since.1978. 4. At the time I purchased the premises, the dwelling on the Premises contained two bedrooms, a bathroom, a kitchen and.a living room on the first floor. The second floor was unfinished. 5. 1 understood from the builder,that the septic system which was installed in 1978 was capable of supporting two additional bedrooms. 6. In 1986, I applied for a building permit to finish the upstairs by adding two bedrooms and a full bathroom. A copy of the building permit application which I filled out and signed, is attached as Exhibit 2. 7. Since 1986, the dwelling on Premises has contained four (4) bedrooms. 8. In June of 2015, Capewide Enterprises replaced the line from the house to the septic tank, the distribution box and the line from the distribution box to the leach pit. A copy of the Application and Certificate of Compliance for the work is attached as Exhibit 3. 9. On June 17, 2015, James D. Sears, of Capewide Enterprises inspected the septic system. A copy of the inspection report is attached as Exhibit 4. At that time, I questioned the size of the septic tank (listed as 1500 gallons) and the number of bedrooms that the septic system was designed for as I have understood since the house was constructed in 1978 that the septic was designed for four(4) bedrooms. F � 10. The septic system was recently uncovered and inspected by Robert Paolini. Mr. Paolini's report indicates that there is a 1,000 gallon septic tank and a leach pit that is lined with a minimum of 2 feet and in some places 3 feet of stone. A copy of Mr. Paolini's report is attached hereto as Exhibit 5. [THE REMAINDER OF THIS PAGE HAS BEEN INTENTIONALLY LEFT BLANK] EXECUTED as a sealed instrument this ` day of June, 2016. /7 , 74V, TERECE M. HORTON, Vk/a TERECE M. TWITCHELL COMMONWEALTH OF MASSACHUSETTS Barnstable, ss On this day of June, 2016,before me, the undersigned notary public, personally appeared TERECE M. HORTON, as aforesaid,who roved to me through satisfactory evidence of identification,which was M&' 0 0 4 U C.• to be the person whose name is signed on the preceding or attached document,and acknowledged to me that he/she signed it voluntarily for its stated purpose and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of his/her knowledge and belief. 'Notary Public My Commission Expires: �% OO�OrARY pJO:�•Z`g�: 2 McKean, Thomas From: McKean, Thomas Sent: Tuesday, May 31,.2016 2:30 PM To: 'Michael Schulz' Subject: RE: 554 Flint Street Thank you for the attached document which does not provide bedroom information.This document does not satisfy the requirements for approval of four bedrooms. If someone does not understand the difference between a "room" and a "bedroom," it does not provide the Health Division with just cause to approve additional bedrooms above the permitted number. The permitted number was "two" with capacity for three. From: Michael Schulz [ma i Ito:mschulz(Pschulzlawoffices.com] Sent: Tuesday, May 31, 2016 2:16 PM To: McKean, Thomas Cc: Michael Schulz Subject: 554 Flint Street Tom: Attached is the 1986 building permit, which was to add a dormer to the roof and finish the upstairs. The seller has owned the property since 1978 and she applied for the permit in 1986 she believing that "number of rooms" meant "number of bedrooms" as 4—which makes sense because the house certainly had more than 4 rooms. In the past, we have done affidavits where the owner use and system capacity predate either the WP or Salt Water Estuary. Please let me know if the seller can prepare an affidavit to confirm the 4 bedroom use. Thank you very much. Michael Michael F. Schulz, Esq. Schulz Law Offices, LLC 7 Parker Road OsterviVle, Massachusetts 02655 Telephone: (508)428-0950 Facsimile: (508)420-1536 Cell: (508) 364-6364 www.schulziawoffices.com This email and any files transmitted with it contain PRIVILEGED and CONFIDENTIAL INFORMATION and are intended only for the person(s)to whom this e-mail message is addressed. As such, they are subject to attorney-client privilege and/or attorney work product and you;are hereby notified that any dissemination or copying of this email is strictly prohibited. If you have received this e-mail message in error, please notify the sendor immediately by telephone or e- mail and destroy the original message without making a copy. Thank you. 1 Assessor's office (1st floor), ff Assessor's map and loi.number ...✓....��, Board of Health (3rd floor); Sewage;Permit number raQM c� � rnt .•.• ... }i BA 3STALL i Engineering Department Ord floor): + AA6IL a Housenumber ........................................................................ APPLICATIONS PROCESSED 8:30.9:30 A.M. and 1:00.2:00 P.M. only - TOWN OF BARNSTABLE BUILDING ' INSPECTOR APPLICATION FOR PERMIT TO 9ddt'tiff .f'.... o.af..�n.�....:i:+�.:,...�i:....i�.� �a...��...................... TYPE of c4NsrRucrfoN .....f U'QGI .....:F .m. ...........:.................. 19.16 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby}}appliees for a permit according to the following information: y / Location ..65.`�:......l:.a .J,.......5+i.............�1.{�.(,S.Aons......M-1.�.1-s.....i...t.!1.p.......0 x..61.9....... Proposed Use ........(ll.j::!.!, .mv.fd!.I.n. ........................................................... —/ Zoning District .......................................................................Fire District �.(( 1�. ...........7Fi V Il� Name of Owner .. .(n .�L.�J.....r �J. ...................Address .... t'. jjo r..... �� .(� G!() !•r�:�il 1. .........Address f....F. .!...:5.{.[............. Name of Builder .a........... ........ f� 1414 .me of Architect ..jI.Address .....................f,. .�.� ... ..................... ..................... Number of Rooms` r .I............^..J.................�...,..�.�........./.........Foundation ......I.^.Nil ....1...............�.,..n...........Io Exterior ... kl� .�3Q 'l..fi(.....: ....7<(J.. I�(.........Roofing .....,. .la.i.(lC�..1. .,.S�n`....IJOU�ole..couel-0 Lc ... ............ Floors .....iCa(p.&d..(:J� :.............................::......................Interior! 5(J(1 �lFrt./1,.. va1 L -. . ....... ................. Heating ,.�.. J 4.:�� FtJa� 1.�.I...Z..............t............C..�.t.....4................:Plumbing ......i.i. ....1.,..................�.'�.r..!!:..........Gf, J flr.� Fireplace ...Approximate Cost fE... C)if) " Definitive Plan Approved 6y Planning Board -t 9__, Area Diagram of .Lot and Builcing with Dimensions J s� Fee ...../.Q!.............................. SUBJECT TO APPROVAL OF BOARD OF HEALTH I OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction, 1 Name �: ... /�i..f!..., ..... ..... i Construction Supervisor's License No Z9.425...... Permit for BuJad...darmer..on... ......V.149;LP.JAMax...dwelling......................... Location $M..................................... ............. ................................. Owner ...:Kerece Horton ........................................................... Type of Construction .........frame ................................. .............I.................I.............................I................ Plot ............................ Lot ................................ Permit Granted .............Iday..30.............i986 Date of Inspection .....................................19 DateCompleted ......................................19 No.......J......- _ t Fps... ......... 5�I �^ THE COMMONWEALTH OF MASSACHUSETTS ��VJJ W BOAR® OF HEALTH Appliration for Uhi nsa1 Works Tomitrurtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal S�stem at, _ ocation-Addres or Lot No. - T Al Installe Address QType of Building Size Lot_.jQA_.'Z_�_)____..Sq. feet Dwelling—No. of Bedrooms.......................................................Expansion Attic ( Garbage Grinder ( ) Other—T e of Building ..... No. of persons............................ Showers — Cafeteria a Other fixtures --------•--••---•......---•-----• --- d wDesign Flow.............................:..............gallons per person per day. Total daily flow.._..:� ...................gallbns. WSeptic Tank—Liquid*capacity O gallons Length__- Width._/-1_......_ Diameter________________ Depth................ x Disposal Trench—No. .................... WidthTotal Length.................... Total leaching area-______._____-______sq. ft. 3 Seepage Pit No......I............. Diameter. . .......-..... Depth below inlet....6........... Total leaching area..1--i!—�,-C6..sq; ft. Z Other Distribution box 0<j Dosing tank ( ) Percolation Test Results. Performed by.-.- . ...t>k t�c'. ..: ? 1. ................... Date.....`_. __:' ....... Test Pit No. 1.....�_.-_-.....minutes per inch - Depth of Test Pit----- Depth to ground water.... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ix _.................................. - - --------------------__-______-----___--_----------------------________-------- ------ ----- ---------- O Description of Soil 5 :::.:3--•--•- ------. ��--•-•- � � -:So.i�L..................................... ---•---•---------••---••--.......... "�? 1 _ _�� ------------------------------------------------------------------------------------------ w ----••---------------------------------•-•--•-------•----•------------•-•---------•-----------------------------•----------------...-------------------•----•--------•--•••••. ......................... V Naturejp)f Repairs o[r'Alterations —Answer when appp�licable............................. _-•__----------- -.+.---•_---- -__-•-__-_----_-----. -------_-_-i'4 ._1-AP-r?.P--L---�r Ti�'d----------a--~--------"'r'--- -- ---?--$....------. -#--.-......... -1,:.---�&..-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITTE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be -ss d by thn boar �iealth. Sied_ .................. ----- -----------------------•- ---I.-2- ......1� f. Date Application Approved By.....r 7 - Date Application Disapproved for the following reasons---------------------- == D .._......_.:.._ ......................•------•--.....--------------------------------------------------------------••-•-•------....---•-------•------......-•-----•---••---•-------•--------•-------------------•------ 7� ---------Date PermitNo......................................................... Issued_.....?? 1-??--`- -.... Date / r Fps, ^�--t��.r�rJ NO........ .............. _............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...�. 3..............OF.......... ' ` a lc.... -••-.........•••- Applirtttion for Uiipnsttl 19orko Tomitrnrtion rrmit Application is hereby made for a Permit to Construct K or Repair ( ) an Individual Sewage Disposal S stem at: 1 a �. -'i '$ _ �L 1 9 �/ � lS}G' 9 �,n'� \> s C J. A..................... ..... ........ .-...... ...t............ ,J .............._........ �- `....`..--........................................................i ocation Addres ` or Lot No. s 4 i� "._. a�t?!a '� .T I 1.'. SS / as. �........ti .._.�__�5.. �. . ............S. � Install Address l'9 d Type of Building Size Lot...��_.. 1...._ .....Sq. feet U Dwelling—No. of Bedrooms......-.2.:...............................Expansion Attic ( Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria al Other fixtures ................................... Design Flow............................................gallons per person per f day. Total daily flow----- ' ' ..:................gallons. WSeptic Tank—Liquid capacity)Lb0gallons Length_•-iR........ Width._"`I........ Diameter________________ Depth................ x Disposal Trench—No..................... Width.._._...._._..._.._. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......L............. Diameter. °._---...... Depth below inlet.....6.___._._._. Total leaching area.,.42e .(.;�,..sq. ft. Z Other Distribution box ( DosinZ tank ( ) t `� Percolation Test Results Performed by.__ _ ... )e A................... Date..... ..o� ,aa Test Pit No. L..:. ....minutes per inch Depth of Test Pit..... Depth to ground water.... O— .. , Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---..................... ................................. ................... .................................................................................................... O Description of Soil----- > 6......... ` "'s ..---" C a ' �1 L`----•---------•---------•---•---.....-•-----------•-------------------•----- t- - W ••-•••---------'••••---------•-•-•••••••--•--••---•-•---------••••--••-•••------•-•-•-•-••••-•••-------••---------------•-------...••----•----••----------•-••••--•-----•--•-......••---.....------•---- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ..----------•-------------------------------------------•--•---------------------------•----------•-----•---------------------------•--•-------------------------••••-•••--------•---•-•-.........--•••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT:E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' s . d by thoardealth. SW� f ,rw Date Application Approved By. .- -,------------------- Date Application Disapproved for the following reasons:........ ---------------------------------•----.-•.. -_------.----.......---------•-------------------•-------•----------------------------------------------------------•-------------------------•---- Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `..... . :.:t _ . .........OF......... <.> :.'a;!' :` -................. f�rrt�f�rtttp of f�la�t�rl�ttnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (X or Repaired ( ) by............. ..� l' f.....c_. ,: `? ` �...•. -------- ....................•-------•... Installer f T 7-t- '1 .F ti �1�1`G r \ - 1/►�lx 1�ra ;( J✓F .j 1 l at......... �.._... .�.. --••- _ -----•-•- i- has been installed in accordance with the provisions of TI T 1 5 of The State Sanitary Code as described in the r 12y C'-.-,JI dated---.-fir application for Disposal Works Construction Permit �o..��a...___;�.___:.___�_____________ < THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. D.kTE. . .•---•--•--------- Inspector........................................... ................................... e THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ��-- W. f__ Z3 ` L a. j FEE........................ �t��n� . � nrk� �.ttn,�t�nrtilan rrntit Permission is hereby granted...... ° ..._ ...__. ._ ':k.................................................... to Construct ( or Repair ( ) an Individual -Sewage Disposal System r at No. r ► � -l :h- - - ` � t� ; \a' y {- " = ---------------------------•--. Street as shown on the application for Disposal Works Construction Permit�NZ-j fDat _.- r,: :_r ::fG.' Board of Ith DATE .f -:--.'--"__:f� < --: FORM 1255 HOBBS & WARREN. INC.;. PUBLISHERS •t a.c 4 Ti�d�ESEP '/.G. 7'As1/ .: ao Fr. r,/N. RB u i � - x fo P: I�9IN. " G/e.4D� 24 ®<.9ivvF G'o/ge L '< SNA&Z gj BR'06/Gj 7, TO 4,gA4 oE: GONCPCTE 4pPl�C P/PE hrEAYy CAST /RO/Y COI/�R.S/ A� LL &E USDA �_ LCIe�, /�+ /•9/N. ?ITCH • G'Od�ERS YB `-Gib/VEJoVA Y ; � p OER a .. 2 e MAN. CDNC�E•TE. =_ RCLEA-N .SANG ° BAG'.!_�,F'%L L 4'CAST 2'LAYER IRON P/PE 1000 ^~0 0 0 0 0� OF d► M/N.P/TCN GAL. , 1 • • • • .:• • • ' A o V4"PER IrY SEPTIC TANK D I ST, to Al Ali O)e1 • • .. • -3,`• e e w a a WASHED S7YJNE l ° = o v p 1 e •EvFFECI"%V g o 1 e • DEPTf/ ° • • e • o , WASHED STONE o Coo c e • • . • • • • e e D e p PR45CA5 T SEEPAG E ; . . INV40APT ELEVATIONS o ► o e e • • e • , • 1 ' e o P/T OR EQ[//V. + /NYERT AT EU/LD/NG �G' GFT 6 D/f1M. alot SFF T�IEILLL a-�` INLET SEPTIC T.4AeK S 5" FT L �/0 >j C_ OUTLET SEPTIC TANK 5 FT. INLET D/STR14041T1DN BOX 5 y' FT. SECT/ON 4F GROUNo W,ITER TABLE 007LEToI57'R/6[/Tio/v BOX 5'y, � FT. SELVAGE O/SPOSA L SYSTEM • - INLET L EACH/NG P/T y Cl FT. T�I$UL�4TlON t LEAC/I1 VG A'/T 'DES/GN CR/TE/�?rA SEAL-E = %4 �" _ /`- O� OJMENS/ON�► y FT. O/AMENS/ON AFT. NUMBER OF BEDROOMS i 7. 4 GAReAGEO/SPO.SAL !/NIT so// ` LOG ' TOTAL E1T/M.4TEO FLOH/ 3 3 O G•4L.1DAY SO/L TEST lot/ SOIL 7E'S7-.1•2 JSO/L.TEST - A/UMBER OF Z,-AC.VlNa P/7- _- / .S �`FLE✓. 7� O �^-ELE'1! •GATE OF SO/L`T_EST y/> S/DE LLAGH/NG PER P/T /-fr P SO FT. 60TTOM L6ACH//VG PER P/T_sL_$Q, RESULTS./�//TNESSED BY f k � �� 1 s TOTAL ZZACHING AREA 2.6 C _ 1- • s` r P�`R COtATioly jIArE SQ• FT. AWltC04.A7'ION RAyE 1k2 M/N.1/NCH. RESERt�ELEAC'NIN6ARE/+�SQ. FT. !% ofMAs y Lor 3 v- "Cli✓T.ST { `s K l �``, ROOF` yes t fa. .. :t,.,� . ..��� �. r- �a+�•. '�°ice �]Y '-'�^�o- d'y.��� NO GROUND N"47-&,R ENCO(J/VTL�RLO a , x r lY7k �io GRO UMO Lt/ATER AT EsLJEV ///^�/q� vf�l� � -mac• s,yt -Ul u ;�., 5".:y,. ,.....F .1'!: %'• S .� .°',`4 Yr.,.+v ,c .,. .c yQq-4r4. �• fi '.9'.-'!±{ •I.a_.�.. �.' �.. y� ''�.M�•,yT %}4 f.r'G, .di .yl a r s •u� % 'r !"� d * .t tC{ 4 r tS�or it 7 f'i' '9s i daa' - y CYi� �t �, sfY 1e'�Yt.,rl ti' �, ,t 'tt r.,r � :.d ♦y 'i� � x: 7 t tt� �-.^ .1s" + y � G ( s •�, Y 't 1 dt,p� :� t ..'� t 'w.' k Th •.�hr",t, �� r s r :"l,rE Sri v' t > ¢t 4 ) t ter^ s. r)r r C to > r , `r - } °`� A �' •.r a t �4 i 13 rX r K r -t x.. ,`.. r ✓J+R,. 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' ', {T�r2_ )' `' htya r t r • 'L�.f // Y ,./ I t Y � '� Y-��_ �,ky!t lw i„>F.:� �5 tdr v ',!• T t` J a k " ,� + cr� �,v L`�; -> t ¢y'�_' rtn "•` '� �-i�;C?^ ;,tY nC f-i, S + x s ..a i' r 5� sue, •'y {°i r y d �hF K O F M,,s, , r 1 'e k ,f tt$ fi - 1 �' k r s +�.• +"' i at + sy 'f 8 r�' H'' P �, N0.22162�' k � ��++ } a , OGN,Q`" L rt' :" `aY ? vpvpo a�� i K �g� t �x ss, 6� 10E911FIED PLOT J4PT�.:��7. VI4Tl� ri A fit! ONA1. �; q 3 t a '�"� F,.Q.jT a EVAT1 O�t Lo T 3 � t o {0 �- __ - MA-4,s 7-0AS Mi, E f +vx r rr 3m� ' lf �J ' 1 'ri,•fOf 4'`3r Y r i {a j x� '� n t .(.'� '.Fi S�3 g�AY� s.� '" s ' rl "t r � F ri" t e;' t > ,a, `A fi� � r: 1 { '•7 •.l _�b S '�` fi,� � it "�� �, bF '� a}. t ".�� (r :' ty. �1,,J - n /� �r j. r.. " 4� � i kkr .,;",� '� R'4;�G:�"Tt.x .svg7" .1F• 4 > f rp�,, :SALL't :/N.r. �i/t' ®ATE �i 1 � '''P toY•I et '- .f� f 1� T •C+'it^.Y�✓+i�(w �� I. CERTlff,/tn' � EY, TF.,i! � t7. ,,'. �{ �, � +1��`i�i4 eo �'� ''®iJl�®DP1Ga � ► . ~ �t a ry YI 40N FORM 8 TO �'WE a OF BARN �yt 3r h� N E�8 vv i l{{s t© rFYj,� Y^'#,. /� "+'�}`RT!R� „A,'1� L� l•.r ..-`,S-.y ,"lil�� fi � i fix.,, Y'i7 <� 1is c 9HEE'f 0 �T ,.g� r �.. y t s i +.. f. ♦,•' � �Y��W i EYtt�,:��d'ir£ 1 t � �'.� �rf 3¢L. {"t k�Y} � � - .L C7�y.'! ti .' a}t �i .v:r 1_.r �k Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 0(pplitation for Disposal *pstem Construttiun permit Application for a Permit to Construct( ) Repair(j�j Upgrade( ) Abandon( ) ❑Complete System [`Individual Components Location Address or Lot No. $54 F4,1A9j_5' MN( Owner's Name,Address,and Tel.No. Assessor's Map/Parcel057(.0log,g, PLt)JT 51 /2 "mil Xf-I Installer's Name,Address,and Tel.No. 508-4'77-32 77 Designer's Name,Address,and Tel.No. CA®i=-W LD E C.t-� "A 1 Gd & 5T- 1�pe of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) LAC-6 C.LAjt_T i=A,444 kj PU&C— i� —L-)6J V Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig Date t V" Application Approved by Date /26 Application Disapproved by Date for the following reasons Permit No.t �6 /!9:7' Date Issued Noc /w. .�/" 1 \ z`r Fee THE COMMONWEALTH,OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Disposal 6pstem (Construction Permit Application for a Permit to Construct( ) Repair(� Upgrade( ) Abandon( ) ❑Complete System [Individual Components Location Address or Lot No. FLl N j_S—r M N( Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 10 oZ 6 57(o T55qC RrL X'T S O«57ua.1$ Are l Installer's Name,Address,and Tel.No. 5og'14'77-88*71 Designer's Name,Address,and Tel.No. ft—WrG(P&SES (-LCC NIA1 S Cv C'1 S'P. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) f Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) LA<-r-- t:AxA+K &RUS t✓ �M _04J 4 1zuowkeG 64Akc-- gKc -m 1)-&9 ZA, � i n-60X RE�� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Sig _ Date //6 'Application Approved by Date CJi Application Disapproved by Date for the following reasons r Permit No. Date Issued (U ---------------------------------------------------------------:----------------------------------------------------------------------- Q Q j THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS i U r Certificate of Compliante i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired� ) Upgraded( ) Abandoned( )by GA�PE�vc�� �� � c� at F�aU - S7 HkS c-ubs MI" has been constructed in accordance with the pr vis'ons of Title 5 and the for Disposal System Construction Permit No;. /�> / /dated Installer Q14&W(nf ��A✓ICxr�QLSC—S (.L_C.. Designer NIA #bedrooms �✓�� Approved design flow gpd The issuance of tjs ermi t iri d hall not be construed as a guarantee that the system willlo, as designDate Inspector V� -------------------------------------- - -- No. AJQ�/ 5 Fee /t/ .a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS VspoSal 6pstrm Construction Vertu Permission is hereby granted to Construct( ) Repair(& Upgrade( ) Abandon( ) System located at j 5q F-LtAjT Sr A4,0smus M,..S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must tcorVetel /within three years of the date of thi permi. Date ! Approvedby