HomeMy WebLinkAbout0012 FULLING MILL LANE - Health 12 Fulling Mill Lane
Marstons Mills P
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECT RECEIVED
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° } SEP232002
TOWN OF BAkNSTABLE
HEALTH DEPT.
+:t TITLE 5
OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION S 9
Property Address: 12 FULLING MILL LANE MARSTONS MILLS,MA 02648
Owner's Name: JEFF AND CHERYL ALLEN
Owner's Address: 12 FULLING MILL LANE MARSTONS MILLS, MA 02648
Date of Inspection: 8/26/02
Name of Inspector: (please print) JOHN GRACI L COP
Company Name: SEPTIC'INSPECTIONS IA C, y
Mailing Address: r P.O. BOX 2119 TEATICKET, MA.02536
Telephone Number: 508-564-6813,FAX 508-564-7270
CERTIFICATION STATEMENT
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.'l itle 5(310 CMR 15.000). The system:
X Passes
_ Conditionally s
_ Needs Furth aluation by the Local Approving Authority
_ Fails.
Inspector's Signature: a5 '' Date: 8/26/02
The system inspector shall submit a opy of'this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspecti n. If tl�e 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,cppies;sent to.the buyer, if applicable,and the approving authority.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. :_,,;;`
****This report only describes'.06ditioris 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 form h/I
Page 2 of 1 1
OFFICIAL INSPECT ION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS, MA 02648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26;02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectior: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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. `
B. System Conditionally Passes:`
_ One or more system corr.ponents as desc;ibed in the"Conditional Pass"section reed to be replaced or repaired. The system,
upon completion of the replacemenebf rbdaie,';as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,NC)in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and ov`er'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 pF-ss,inspection`if it,is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years o1d is avzilable.
ND explain: n/a
n/a Observation of sewage back u•p.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 unever.distribution box. System will pass inspection if(with approval of Board of
Health): ;
_ broken p.ipe(s)are replaced
_ obstructi n is removed
_ distribution box is leveled or replaced
1
ND explain: n/a
n/a The system required pumping more,;:oan4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board.of Health):
_broken'ppe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 11 ,.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
E , ; 'CERTIFICATION(continued)
Property Address: 12 FULLINd'MILL LANE MARSTONS MILLS, MA 02648
Owner: JEFF AND CHERY.L:ALLEN
Date of Inspection: 8/26/02
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 er►vircnment.
1. System will pass unless Board of Health determines in accordance wiih 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
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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 fo�de-ter'mine distance n/a
"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: ,
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Page 4 of I 1 t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS,MA 02648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26i02 .
D. System Failure Criteria applicable to all systems:
You miLq indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or pondingof 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 '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS;cesspool or privy is below high ground water elevation.
X Any portion of cesspo`olidr privy is+within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspoof,"Or;pri•vy 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 th},t no other failure criteria are triggered. A copy of the analysis must be
attached to this forma
(Yes/No)The system fails. IGhave 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.
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ytt i I
E. Large Systems: ¢
To be considered a large system the system must serve a facility with a design now 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) e systems.`in addition to the criteria above)
yes no
X the system is within 400,feet,of a surface drinking water supply
4i.'y t...;;3 `.7
X the system is within 200 feet_of a tributary to a surface drinking water supply
X the system is located in a nitrogen s' nsitive area(interim Wellhead Protection Area—IWPA)or a mapped
SY
Zone II of a public water supply well
If you have answered"yes"t to any question in Section E the system is considered a significant threat,or answered
jj" tei`ifl,.as failed.The owner or operator of any lwge system considered a significant threat
yes" in Section D above the large sy
under Section E or failed under Section•D shall upgrade the system in accordance with 310 CM 15.304. The system owner
should contact the appropriate regional office of the Department.
"
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Page 5 of I I
• i.•:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 FULLING MILL LANE MARSTONS MILLS, MA 02648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26/02,
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No j, `�
j
X _ Pumping information was,provided by the owner, occupant,or Board ef FG--alth
_ X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal Bows in the previous two week period`?
_ X Have large volumes of water been introduced to the system recently or as;,art 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
h
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information. For exampL2, a plan at the Board of Health.
X _ Determined in the field(if any a the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
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Page 6 of 1 1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 FULLING MILL LANE MARSTONS MILLS, MA 02648
Owner: JEFF AND CHERYL ALUN
Date of Inspection: 8/26/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR;15.203`(for example: 110 gpd x#of bedrooms): 220
Number of current residents: 2', to ,
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): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):n'fa� Z�`0
Sump pump(yes or no): NO
Last date of occupancy: n/a �, t o t)D
COMMERCIAL/INDUSTRIAL.,. ,
Type of establishment: n/a
Design flow(based on 310 CMRt15.203): n4gpd
Basis of design flow(seats/,persons/sgft,etc.): n/a
Grease trap present(yes or no): NO`
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the,Tihle 5 system(yes or no): NO
Water meter readings, if available: n/a'
Last date of occupancy/use: n/a
OTHER(describe): n/a r
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons�-- How was quantity pumped determined? n/a
Reason for pumping: n/a, ,
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TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
_Privy =,
_Shared system(yes or no)(if.yes,attach,previous inspection records, if any)
_Innovative/Alternative technology.. Attach a copy of the current operation and maintenance contract(to be obtained from
Ir'„ a .y. .
system owner)
_Tight tank Attach a copy of the bEP approval
Other(describe): n/a
Approximate age of all components,dA"e'installed(if known)and source of information:
1989 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
y ,
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Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(conti;iued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS,MA 02648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26/02
BUILDING SEWER(locate on site plan)
Depth below grade:30"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER {
SEPTIC TANK: X(locate on site plan)
Depth below grade:24"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: IOOOG L 8' 6" H 5.',,7" W'4',10""
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 16"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING-EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan),
Depth below grade: n/a
Material of construction:_concrete=metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
�* X
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Page 8 of 1 I
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OFFICIAL INSPtCTIONI FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS,MA(-u�8
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26/02
I
TIGHT or HOLDING TANK: (tank mast be pumped at time of inspection)(lo::ate on site plan)
Depth below grade: n/a
Material of construction: concrete—me tal fiberglass_polyethylene_other(exp!ain): n/a
Dimensions: n/a !
Capacity: n/a gallons
Design Flow: n/a gallons/day:--
Alarm present(yes or no): N/A, t
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a ? .
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEZVEL WITH BOTTOM OF PIPE
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 STRUCTURALLY SOUND
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
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Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(con'inued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS,MA 62648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type f k
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a ` 'leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a :,innovative/alternative system
Type/name of technology: n/a
a
Comments(note conditiod ofsoil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): 'l
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. PIPE COMES IN PLOWER THAN NORMAL. LEACH PIT HAD 3' OF LIQUID IN IT AT TIME OF
INSPECTION. STAIN LINES SHOW PIT HAS NEVER HAD MORE THAN YIN IT. BOTTOM IS AT 9'.
CESSPOOLS: (cesspool musf'be pumped as part of inspection)(locate on site plan) I
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a j
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil, signs cr,rydraulic failure, level of ponding,condition of vegetation, etc.):
n/a ,
PRIVY: (locate on site plan)
r
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a 1
Comments(note condition ofpil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS, MA 02648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26/02
SKETCH OF SEWAGE DISPOSAIJ_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.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(contiaued)
Property Address: 12 FULLING MILL LANE MARSTONS MILLS,MA 02648
Owner: JEFF AND CHERYL ALLEN
Date of Inspection: 8/26/02
SITE EXAM
_Slope
_Surface water
_Check cellar
_Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
3
NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local a c'avators, ii--stallers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established`tne high ground water elevation:
HAND AUGER- 10+FT.
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' 11
L — 06
TROY WILLIAMS
SEPTIC INSPECTIONS to
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
co `
6 COMMONWEALTH OF MASSACHUSETTS 9 rd�
EXECUTIVE OFFICE OF ENVIRONME AFFAIRS ��
DEPARTMENT OF ENVIRONMENTAL �y OTEC > y
ONE WINTER STREET, BOSTON MA 02108 (61 �292-5500 �`lEO
0
3
1999
VNpf�F � RUDY COXE
RE4a Secretary
ARGEO PAUL CELLUCCI AID VID B. STRUHS
Governor 41 Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO
PART A
CERTIFICATION
Property Address: f a F J Name of Owner J G 0 t.
MG�r.5 to:, S M; 5 Address of Owner: l96. o", Q 7�
Date of Inspection: /Q 8
Name of Inspector:(Ptease Print) Troy Williams v6 y8
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Troy tiMiliams Se tip c Inspections
Mang Address: 19 Hummel Drive, So. Dennis, MIA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
\ Fail
Inspector's Signature: �J i1,e� I/��L�C U Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to ift '
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
revised 9 /2 /9P P.- I, r„
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (confirmed)
Property Address:
Owner: 12 Fulling Mill Lane,Marstons Mills, MA
Date of 41spec60n: Jane Scha'kel
October 8, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A.- SYSTEM PASSES:
V/ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:A,1/4
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.
Indicate yes, no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20i years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s►
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
— The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 12 Fulling Mill Lane, Marston Mills,MA
Owner: Jane Schakel
Date of Inspection: October 8, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N//l
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WTTH 310 CMR 15.303(1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
12 Fulling Mill Lane, Marstons Mills,MA
Property Address: Jane Schakel
Ownef: October 8, 1999
Date of Inspection:D. SYSTEM FAILS: A1119
You must indicate either 'Yes" or 'No' to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: A/(/,
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised
9/2/98 Page 4ofll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 Fulling Mill Lane, Marston Mills, MA
°"rnef= Jane Schakel
Date of 1pec_: October 8, 1999
Check if the following have been done: You must indicate either 'Yes" or "No" as to each of the following:
Yes, No
_v/ _ Pumping information was provided by the owner, occupant, or Board of Health.
v _ None of the system components have been pumped-for-al least two weeks and-the system has been receiving Trormal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection.
�C _ As built plans Ihave been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_C _ The site was inspected for signs of breakout.
�C _ All system components, excluding the Soil Absorption System, have been located on the site.
✓ _ The septic tank manholes.were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable!
/ [15.302(3)(b))
The facility owner(and occupants,if different from owner) were.provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 12 Fulling Mill Lane, Marstons Mills,MA
Dace of Inspection: Jane Schakel
October 8, 1999
RESIDENTIAL: FLOW CONDITIONS
Design flow: /10 g,p,d./bedroom.
Number of bedrooms (design): c-;� Number of bedrooms (actual):,.Z
Total DESIGN flow aao —'
Number of current residents:
Garbage grinder(yes or no):6/p
Laundry(separate system) (yes or no):/VD; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):_Vo,
Water meter readings,if available(last two year's usage(gpd): y8 = �rj o00 5 // /� 3Z�oL.
J
Sump Pump (yes or no): 1/G
Last date of occupancy: d« tee,•-A ,
COMMERCIAL/INDUSTRIAL: N19
Type of establishment:
Design flow:_ apd (Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: /�
/tea .. r o.. /a. t t ri-j H r ✓.
System pumped s part of inspection: (yes or no) O
If yes, volume pumped: gallons
Reason for pumping:
TY F 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed W known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) A10
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 12 Fulling Mill Lane,Marstons Mills,MA
Date of Inspection: Jane Schakel
BUILDING SEWER: October R, 1999
(Locate on site plan)
Depth below grade: do
Material of construction:_cast iron_�A0 PVC_other (explain)
Distance from private water supply well or suction line iv/n
Diameter_ y„
Commments/: (condition of joints, ventiryg, evidence of leakage, etc.)
t
SEPTIC TANK:
(locate on site plan)
Depth below grade: �8 ,
Material of construction: itconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Js.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:_ S�X �j 'X 6 /0 o 0 �(o
Sludge depth: !r
Distance from top ofsludge to bottom of outlet tee or baffle: �'
Scum thickness�/I;- (c�rcr.
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: / �
How dimensions were determined: P/p bc..
Comments:
(recommendation for pumping,condition of inlet and outlet es or baffles,depth of liquid level in relation to et invert,structurat integrity,
ew nce of leakage,etc.) } ;� -lam U M d Ll` �
r
✓r'X i✓� o drril.✓, p to �� a� ✓✓ c �Jv�
CG �_
GREASE TRAP: 5►
(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:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 12 Fulling Mill Lane,Marston Mills,MA
Data of Ir'P"e 011= Jane Schakel
October 8, 1999
TIGHT OR BOLDING TANK:A/ 17(Tank must be pumped prior to, or 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
Alarm level:-----7 Alarm in working order: Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
(locate on site plan) /
Depth of liquid level above outlet invert: /6O e
Comments:
(n if level end distribution is equal,evidence of solids carryover, evidence of leakage i o or out of b�o/x; etc.) v (�.1.ac
v�� `� v, o✓�C i r t d r-r�t✓ vu i � lb I.J �/'�r o..� � � S y
PUMP CHAMBER: /111/9
(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.)
revised 9/2/98 Page 8ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Ownef: 12 Fulling Mill Lane,Marstons Mills, MA
°atc of"`peG i—: Jane Schakel
SOIL ABSORPTION SYSTFl.ti(SA 8 �1)999:
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number: O he �x Iva'.
, t '� H
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields, number, dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic ailure, level of ponding, damp soil, condition of vegetation, etc.)
AQ
( ti I : `
CESSPOOLS:� /! ar o i c. /�` s
(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(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: IV119
(locate on site plan)
a
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revis
ed 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Date of Inspection:Date 12 Fulling Mill Lane,Marstons Mills, MA
D o
Jane Schakel
October 8, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM: —
include ties to at least two permanent reference landmarks or benchmarks J'
locate all wells within 100' (Locate where public water supply comes into house)
rro P f
I000 w l to
LPN
3 °
�s
revised 9/2/98 Page 10ofII
I
, _ I
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(co►6rvued)
Property Address:
Owner: 12 Fulling Mill Lane,Marstons Mills,MA
Date of Inspection: Jane Schakel
October 8, 1999
NRCS Report name
Soil Type_
Typical depth to groundwater i
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep_
SITE EXAM Slope v/
Surface water
Check Cellar
Shallow wells ?
►
Estimated Depth to Groundwatero?PFeet
Please indicate all the methods used to determine High Groundwater Elevation:
t
Obtained from Design Plans on record
V/ Observed Site 1Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
I
Checked FEMA Maps
Checked pumping records
Checked local excavators,installers 1
Used USGS Data !
I
i
Describe how you established the High Groundwater Elevation. (Must be completed)
4. I < ✓L La.r c�t r/\ U h / G.,h s"i a�.a c� h O
0,
✓6k cX Q_ / w N G le—.G-
10 G�w. -�c J� 6 1,,L-,� ►'+o ►+,c u,.� � r J
P36 f G.�o�/c vv� Ck J
� G�'ev�� �G. -{ti C..a h � v� N•.a�� .5 r-'fJwS �vU✓y„(� �
Q leG`lo/vwr �d Q ► / L
a..�-�-r r t-• c,.r L u. "//��i v/„1 c
I
revised 9/2/98 I
Page 11 of 11
FUTO
rWN OF BARNSTABLE
LOCATION z'vi/K Mi// SEWAGE # ®�p
VILLAGE IV 07,,/6 ASSESSOR'S MAP & LOT 0� � --DqD'
INSTALLER'S NAME & PHONE NO. tle 6 C--w,
SEPTIC TANK CAPACITY goer 4., /
LEACHING FACILITY:(type) (size) swo G-4
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 5<�4'f.
DATE PERMIT ISSUED: ^ L"
DATE COZIPLIANCE ISSUED: 91
VARIANCE GRANTED: Yes No
No...97:: 2 Fmc...o�i..5
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
1 �e� .........._:......OF..............0.,
ApVfirFatton for Utiplaii al Works Tonstrnrttun Prrmit
Application is hereby made for a Permit to Construct (Vf or Repair ( ) an Individual Sewage Disposal
System at:
_ ----...•--•---••----••---•--•-•----
Location r Lot No.
---cJi_NI_=........�°.: .. t .�.-•.................. ... �"%...... .... =. ....
ner .-� .-•----
Addr s
--------•- _�. -------. - -----------------------------•-•------ _ 1�W&., ....5 X.,_mme!4:4----•---•-----•••-•-•-•-
Installer Address
Type of Building Size Lot.l31__�0.-:_._Sq. feet
Dwelling—No. of Bedrooms............ ..........................Expansion Attic F—j- Garbage Grinder (--�
` Other—Type of Building
p-1 yp g No. of persons...... _............... Showers (t ) — Cafeteria E--)
04 Other fixtures -------------------------------- -- -
d --------------------------------------------------------------
W Design Flow.......10�...........................gallons per person per day. Total dail flow......AAa.......................gallons.
WSeptic Tank—Liquid capacity_gallons Length................ Width_._.__._____... Diameter................ Depth................
x Disposal Trench—.\To_ ____________________ Width.................... Total Length...................k, Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
GX. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f4 ----------------------------------•-----••-----••------•••---------.._._..-•-•-••-•----...---•--_............................................................
0 Description of Soil........................................................................................................................................................................
x
U ------------------------------------------•-----•----•---•-----------•------•-----•---••-•---•-----•-•-•-•-----•--------•-------••--•---•-----•------•------...........................................
W
---------------------------------------------------------------------• .---------------------------------------------------------------------------------------------------------------------------•----
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
-----------------------------•----------------------------------------•----•---------•-•-•--•------•------....------------•-------•-----•-•-------------------------•-•-------------•--•-•--••....._..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 1 i
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ued y the oard of h th.
1 -�•9
Date
Application Approved By---..-----( ^^ .. G�� < �� �Q ~ate-^ -
Date
Application Disapproved for the following reasons:................................................................................................................
----------•---------•-----...----•-----------------------------------•---------------........-------...-----------------•--------•--------------------•-----------------------------------------•-._.._.
Date
PermitNo....a--7-`•--7Q-&-------------------------- Issued--•---------------------------------------------------
Date
r?�
�.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.. tri1'f OF. > /................
Apliliratinn for Diupuuttl Works Tonstrn.rttun ramit
Application is hereby made for a Permit to Construct (,-X) or Repair ( ) an Individual Sewage Disposal
System at:
All 1-1-INI:
11,
.................-..--...------------------------•----f....------------ ------
Location-Add_ess or Lot No.
rf
-•--....._........._ ....
Owner .-- Address
a .. At / �r 11/,61.1�11 S/ /vt. rlri ' J
......................................................•__.._...._..._..__.......... ..........................................................
PQ installer Address
UType of Building 1 Size Lot -;.._.� ---••-_Sq. feet
Dwelling—No. of Bedrooms..........._.............................Expansion Attic (—) Garbage Grinder ()
Other—T e of Buildin lh!// !� �f1rl. No. of persons ................... Showers r� — Cafeteria
a YP g- = - = P ( ) ( )
Q' Other fixtures -----------•--- ---•--•-----••• .
W Design Flow......?Lf ._......gal.............................gallons per person per day. Total daily flow...... .n�r__..................... Ions.
WSeptic Tank—Liquid capacity-_r/o...gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below in-let.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--_----__--_-----_----.
1s4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•--•-•--•••-••--------------•••-••-•-•---••-•-•••-•••••••------•----•-..................---•------..:..._...-•-•-•-•.....-••••----••-------•-•--..........•.
0 Description of Soil...................................................................................................................................................--...................
x
V ••-•-•-••••-•••--•••-----••---••-••-••-----•-••-•-•-••-••••-••••--•-•----•--•--•••-•...................................•---•-•--•-•••-•--•-----•---•••••-••--•••••-••-•-•••-•••......-••-•----------•--.
W _
UNature of Repairs or Alteratioris—Answer when applicable______..,:__'.:.:.:............................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T_111 T-1,2 ;of the State Sanitary Code—The undersigned further agrees not to place the system in'
operation until a Certificate of Compliance has been,issued•.b the board of health.Signe� f
f Y
= -
t Date � t
Application Approved BY . S -
Date
Application Disapproved for the following reasons-................... •.......--•--•-•••••-----••---•-••----•--••-••-••••-•-•---------•-•-••--•-•----•...-•-•--
Date
PermitNo._Z 7.....240--6--------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
- j BOARD OF HEALTH
OF 9,Aj?N5Tje9B4.1_F
�rrtif irtt�e oaf f�unt�rltttnr�e
by �U-S IS TO ERTIFY That the Individual Sewage Disposal System constructed') or Repaired ( }
rf�il•-- �AL-7-6 . lr .r !>Li'rt�s , '� ------
1Installer
at. --------6----- ...........................................— L" �- 4AA1 E' /'�I1913 STZ��!'U':-�'_._..!''' � :1-
has been installed in accordance with the provisions of T i T%.E j of The State Sanitary Code as described in the
application for Disposal Works Construction.Permit No... ..'_.__��.r�__...... datei------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT i HE
SYSTEM WILL FUNCT ON SATISFACTORY.
DATE..................... :-. ...^. Al................................ Inspector..............----------- -----------..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
� OF HEALTH
"' L N OF..(, .�r IVS�� ............................................
4-7
0.5)
. ....... ....... ... FEE...-•-•-------.....----.
Rspo al Workn Ta.unutrnrtiun amit
Permission is hereby granted•--2�d II/U ..'
to Construct (X) or Re air ( ) an Individual Sewage Disposal System
at �.T .��-....-.....V f_..1'�.�,� �.... N..4=� ,�'I 7?Slt� ._.�l-.f_L .,........................•......
as shown on the application for Disposal Works Construction Permit No. �.. Dated..........................................
......-•---......•................... oard of Health
-•j-- ---
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
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