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HomeMy WebLinkAbout0163 OLDE HOMESTEAD DRIVE - Health 163'OLDE HOMESTEAD; A=043-001 io\\oLOT 35 r o�f3- col, oI60 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owners Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection 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. A. Inspector Information Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal,,Systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation.by" V e Local Approving Authority 4. ❑ Fails 4/,45�( 9/11/20 Inspecto ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving.authority_. Please note: This report only describes conditionsj.at the time'of inspection and under the conditions of use at that time.This inspectiondoesnnot address how the system will perform in the future under the same or different conditions of use. #ice t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owler Owners Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): i t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will ass inspection if with approval of the Board of Health): Y P p ( pp ) ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owners Name information is required for every Marstons Mills MA 02648 9/11/20 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ or Cesspool privy is within 50 feet of a surface water p P Y ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The se system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or Y P 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp;doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owners Name inbrmation is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. 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 i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts (P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c� Commonwealth of Massachusetts rp Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �a 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom permit on file Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped 1 year ago per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Septic tank and leach pit per age of home, new d-box and leach trench added 1998 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5inso.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owners Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 16"feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g Sludge depth: 6" I Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace-1/4" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle >2" 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 163 Olde Homestead Drive Property Address Mike Owier Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle from m f cum to bottom of outlet tee or baffle Distance om bottom o s Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): H-10 D-box is 2' below grade, no adverse conditions, there are 2 discharge pipes, the one to the leach pit is about 1" lower than the one to the trench, flow goes to the pit t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owners Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type. ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 30' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system I Type/name of technology: t5im p.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ro Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leach pit and the trench were video inspected, the pit is damp at this time, the trench is dry, no indication of past hydraulic failure 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5in:p.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts � - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owners Name information is required for every Marstons Mills MA 02648 9/11/20 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 TO WN QF BARNST LOCATION LE � J YII.L.AGE f 1/�r - _ SAGE # d L ---__ASSE,SSOR'S MAP&LOT INSTALyEit'S &PHONE NO. r to-eti, - SEPTIC TANK CAPACITY LEACFIING PACILTTY: (type) NO. OF BEDROOMS 3 .BUILDER OR OWNER PERMTTDATE: J Y. COMPLIANC DATE: _ Se aration canes P Distance Between,the: ''L�" ---•mac----_';: Mum Adjusted Groundwater Table and Bottom o Private Water Supply Well and Leaching Faciii f��g Facility on site or within 200 feet of Leaching facility), �any Wells exist Feet Edge of Wetland J J within 300 feet of ching Facility(If any' exist Feet Furnished by leaching facility) Feet �d I ,.. ' N Commonwealth of Massachusetts F Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name information is required for every Marstons Mills MA 02648 9/11/20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high 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: n/a Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: 4' seperation per compliance on file ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping puts the site at 78'msl and nearby surface water at 44'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mike Owner Owner's Name in`ormation is required for every Marstons Mills MA 02648 9/11/20 page. CityrFown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 1►� No. / f70 Fee — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Di- o.5ai stem Conotructton i3ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l�3 /� Owner's Nam�hd ss and Tel.No. Assessor's Map/Parcel Installer's N e,Address,ano Tel.No. Designer's Name,Address and Tel.No. ,1 M au^_ Type 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank -1 bd Type of S.A.S. Description of Soil Nature f Rep 'rs or Alterations Answer when applicable) 4,6t" 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 off:[51e 5,of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this d ofMaltboej i Signed Date �—r 7—F Application Approved by Date % Application Disapproved for thewowihireasons Permit No. Sty_&o Date Issued No. / d - (tea Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I/ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mie;paar *p!tem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. / 1 — J t Owner's Name;-Address and Tel.No. Assessor's Map/Parcel Installer's Narge,Address,and Tel.No. Designer's Name,Address and Tel.No. Type 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 _ gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature�jof))Rep 'rs or Alterations nswer when applicable) X W -7. 3o. X' 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 offitle f the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B•ard of5hlth7 Signed � ,/, Date �- Application Approved by 0 Date '1 —/lv -98 Application Disapproved for the MowinY reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(N)Upgraded( ) Abandoned( )by T") at /% "—_;. I� / / has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. fig' &C V dated Installer Designer The issuance of this pe t shall not b construed as a guarantee that the system-will function as designed. Date 7 Inspector --------------------------------------- No. — boy Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS MiOpogar *pgtem Construction Permit Permission is hereby granted to Construct )Repair��U��pgia�de,( )Abandon System located at l :> a /,7"/ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: ct Approved by ,s:� v 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED'PLANS) 4 hereby certify that the application for disposal works construction permit'signed by me dated ? , concerning the property located at A eets all of the following criteria: ti • There are no wetlands located within�l00 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) Sb B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: LICENSED SE TIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert --� I 1 ' I '. ti r ♦ Y ��4 �.. o ' +. � , 3v � �-Sx � ��, � �� •. `�• �,y �� � �� Bk 29920 Ps 139 �45867 Cn m ' r .A . tT, NOTICE; The Town of Barnstable recommends that the applicant seek legal advice to prepare a properly worded deed restriction document. DEED RESTRICTION WHEREAS Michael and Stacy Mike of ' (owner's name) 188 Morgan Farms Drive, South Windsor, CT 06074 (address) is the owner of 163 Olde Homestead Dr., Marstons Mills, MA 02648 located (address) at 163 Olde Homestead Dr., Marstons Mills, MA 02648 MA (hereinafter referred to as 163 Olde Homestead Dr., Marstons Mills, MA 02648 and being shown on a plan entitled "Subdivision of Land in Marstons Mills MA, Property of Michael and Stacy Mike r et al, N/A duly recorded in Barnstable County Registry of Deeds in Plan Book 412 , Page 39 0/r on r Land Coui t PIan IVi ruler NIA WHEREAS, Michael and Stacy Mike as the owner of said lot has (owners name) agreed with the Town Of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, deedr NOW, THEREFORE, Michael and Stacy Mike does hereby place the (owner's name) following restriction on his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1 163 Olde Homestead Dr., Marstons Mills, MA 02648 may have constructed (address) <tnnn the lot.a house containing no more than �" 3_ ( ) bedrooms. Michael and Stacy Mike agrees that this shall be permanent deed (owner's name) restriction affecting the house ,located on 163 Olde Homestead Dr. MA, and being shown on the plan recorded in Plan Book 412 , Paged 39 Or on Land Court Plan N/A For title of see the following deed: Book 27849 , Page 201 Or Land Court Certificate of Title Number N/A Executed as a sealed instrument 66832 day of 11/26/2013 + Owner's si ature Owner's signature Owner's signature COMMONWEALTH OF MASSACHUSETTS ss 20k(, Then personally appeared the above-named C i C' MIC -f,&ck m known to me to be the person who executed the foregoing instrument and�,,,,,,,p,,;,, i acknowledged q„S 1l�,•+ �,( • ,e the same to be�free act and deed, before me, �.<� jcPi �;°• ' �1y 2023 •,�, `�L .c" o. 44 Notaryl v> �, •� %! n y ;:•'�';' Public . �'°� o�' `' My commission expires. �sOvq�®dqg11pr�o1 ��, DE80RI►H J L1FM/!N � � Notary Public Gmt eion� (date) My January 20, 2023 WANSTADLE REGISTRY OF DEEDS deed John F. Meade, Register i TOWN QF BARNS LE - LOCATION �`` VILLAGE - . SEWAGE # i' ASS INSTALLER ESSOR'S MAP& LOT .'S NAME&PHONE NO. m r YC"r SEPTIC.TANK CApACrry LEACHING'FA C II.I7'Y• • (type) NO- OF BEDROOMS BUILDER OR OWNER ,J PERMTTDATE: COMPT, ^ Separation Distance Betw - IANCE DATE: een the: Maximum Adjusted Groundwater Table and Bottom of LeachingF :.`.,._. Private Water Supply Well and Leaching Facility acility on site or within 200 feet of leaching facility) Feet (H any wells exist "< Edge of Wedand and Leaching Facilityty 'F (If any wetlands exist a Feet within 300 feet of leaching facility) Furnished by Feet f i r -- 3 C -------------------------------------- j A A dz.. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's Name E�a�astahLe)XW ,t D ,p�_ MA 02648 9/27/13 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Citylrown State Zip Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and the the-o 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 ortiite sewage disposal systems. I am a DEP approved system inspector pursuant tc Sectionl-3.3401f Title 5(310 CMR 16.000).The system: -a ® Passes ❑ Conditionally Passes ❑ Fails il ❑ Needs Further Evaluation by the Local Approving Authority 9/27/13 Ins ors Sign re 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. 163 Olds Homestead Dr.•03108 Title 5 Official Inspection FormVbftoee Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments N .'` 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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: Pumping suggested every 3 yrs to prolong the life of the system B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: n/a ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed 163 01de Homestead Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 { Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: n/a C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 163 Olde Homestead Dr.•03/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 15 I t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 163 Olde Homestead Drive Property Address Mcintyre Owners Name Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria 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: n/a 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 ❑ ® 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 1/2 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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 163 Olde Homestead Dr.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments t 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, 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. 163 Olde Homestead Dr.-03/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 City/Town 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 ❑ ® 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? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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)] 163 Olde Homestead Dr.-03fO8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .�g 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Occupied Date Commercial/industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a 163 Olde Homestead Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b yy< 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: No history given 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1986 per as built Were sewage odors detected when arriving at the site? ❑ Yes ® No 163 Olde Homestead Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 18"feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 12"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: 1000g Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness trace Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured 163 Olde Homestead Dr.•OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 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.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): n/a Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a 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): n/a 163 Olde Homestead Dr.-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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 in average condition for its age Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 163 Olde Homestead Dr.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leachingtrenches number, length: , 9 ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments note condition of soil sin f( signs o hydraulic failure, level of ponding, damp soli, condition of vegetation, etc.): Leach pit has 1/2"of effluent in it at this time, sidewalls appear clean, no indication of past backup 163 Olde Homestead Dr.•03/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts ugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's iName Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection D. System Information cont. Y (cont.) Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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.): n/a 163 Olde Homestead Dr.•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 =;assessing As-Built Cards Page 1 of 2 A, TOWN OF BARNSTABLE LOCATION_LOT �ll 1- Dt� .,�g��,. SEWAGE#_9kr'7 VILLAGE _ {Ma;S-�e'�s Mn:Ay ASSESSOR'S MAP& LOT4-.` 3-1 (�INSTALLER'S NAME&PHONE NO. Z,T,p�:.s�i� ?7 f , 1040 jSEPTIC TANK CAPACITY 1 � �-L-EACHING FACILITY:(tnm) L���L ��.4 ` (size} 4,OQ�S (�1hs �O.OF BEDROOMS PRIVATE WELL O UBLIC WAT'BR BUILDER OR OWNER__j.•y fj1 � ►�1 .�_ Lo. DATE PERMIT ISSUED._1dT �S(, DATE •COMPLIANCE ISSUED: S 7 VARIANCE GRANTED: Yes No v� 31 8 . 13 ' I hq://www.town.barr�stable-ma-us/assessing/HMdisplay.asp?mappar=043001016&seq=1 9/22/2013 6-0 i r. D 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 163 Olde Homestead Drive Property Address Mcintyre Owner's Name Barnstable MA 02648 9/27/13 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: >12' feet Please indicate all methods used to determine the high groundwater 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: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: per elevation of home 163 Olds Homestead Dr.•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 I- NOTES: 1.)CONTRACTOR IS TO VERIFY ALL EXISTING CONDITIONS rxNx rse 8 DIMENSIONS IN THE FIELD 2.)CONTRACTOR TO VERIFY ALL INTERIOR&EXTERIOR MATERIALS, DETAILS.&FINISHES IN THE FIELD WITH OWNER • 3.)ROUGH OPENING HEAD HEIGHTOF WINDONS AT FIRST FLOOR TO BE 6'4-ABOVE SUBFLOOR B B 4.)ALL CONSTRUCTION TO CONFORM TO TSD CMR MASSACHUSETTS A6 A6 STATE BUILDING CODE,BTH EDITION AMENDEMENT&IRC2009 NEW 5.) 110 MPH EXPOSURE B—ZONE II PATIO NEW 6.)ALL SHEETS OF PLYWOODWALL SHEATHING TO BE INSTALLED VERTICALLY, SCREENED OR HORIZONTALLYW/BLOCKINGAT EDGES,TEDG -FIELD NAILING • PORCH 2.)ALL LVL LUMBER/BEAMS TO SE 1.%LI380 LOAD rvw.re°I - 8.)SEE CERTIFIED PLOT PLAN DEVELOPED BY WAR WICK ASSOCIATES FOR ALL PROPOSED&EXISTING DETAILS 9.) FOLLOW ALL MANUFACTURER'S SPECIFICATIONS FOR INSTALLATION OF _ All SIMPSON COMPONENTS 1o.)ALL CONCRETE USED FOR FOUNDATION WALLS,FOOTINGS&SLABS NEW§ DECK • TO SE—PSI VERIFY ALL PLUMBING&ELECTRICAL DETAILS W/OWNERS ON THE SITE sa°w• DURING FRAMING CONSTRUCTION ---- 121 TIMBER FRAMING TO BE SPRUCE/PINE/FIR NO.2 GRADE 13.)FOLLOWALI REQUIREMENTS OF THE IID MPH CHECKLIST SUPPLIED FAMILY -_-- '°--• `—� I I I *. ROOM 1 1 14J FOLLOW ALL REQUIREMENTS OF THE ALLD T ILSWITHTL INE GY SULATION q REM Of, CLOS. EFFICIENCY REQUIREMENTS&VERIFY ALL DETAILS WITH THE INSULATION II KITCHEN OP INSTALLERICONTRACTOR. a 31 ° �5�,/ 18.)ALL HEADERSTO BE}2.8,,UNLE-OTHERMSE NOTED 9r+A I uux° I - IECC2012 RESIDENTIAL ENERGY EFFICIENCY DETAILS CL P 'HALL •, y CLOS. NEW II ram.a . r°N�°e'I• .re a + .BATH/ WWKSHOP-AYOvl CLOB. S.�eMrmeO: v KmE mDETECTOR ©CARBON MONOXIDE x oDETECTOR (DHEAT DETECTOR LIVING tE ROOM 'p. 'p.fn rr ________ e6 _ If ,.. ..mxc�ex�ex m newne.exra ALL NEW vo° H p ivmxo . NEW � o a COVERED PORCH NEW ^ wx°.•e e.a ..1e.w: rv�GARAGE s I✓� C A6 4 A A A6 A6 § >-9/j rl FIRST FLOOR PLAN 8Q®COTUIT BAY DESIGN,LLC NEW ADDITION/REMODELING FOR: SCALE: DRAWING NO. 43 BREWSTER ROAD MASHPEE MA.02649 1/4"=1•-0" PH.(506 274-1166 MIKE RESIDENCE A 1 FAX(so�)5395402 DATE: 163 OLDE HOMESTEAD LANE MARSTONS MILLS, MA 7/22/2016 I e B Ae As I CLOS. MASTER EXIST O ICLOS. 1 BATH r___ BATH I EXIST. - -f--------$ BEDROOM LIN. _j HALL EXIST. a GAMEROOM EXIST. ROOMBEDRO MASTER OM CLOS. I I a NEW I GARAGE I I A6 § A A s A6 A6 SECOND FLOOR PLAN B[Z*jCOTUIT BAY DESIGN,LLC NEW ADDITION/REMODELING FOR: SCALE: DRAWINGN°.: 43 BREWSTER ROAD 1/4"=1'-0 MASHPEE,MA.02649 FAX(608 279-940 MIKE RESIDENCE /� FAX(60%I s39aw2 DATE: /', 163 OLDE HOMESTEAD LANE MARSTONS MILLS, MA ..--T„ E d, 7/22/zois • 1 2-- APA NARROW WALL BRACING METHOD EOR W+60NRV BLOCK FOUNDATION EXIST. GARAGE -,__E.­ -1-7 I J L -U-TOPENING ur IN_ST F FOR CRAWL-BASEMENT NT SPACE ANCHOR BOLT DETAIL TYPICAL DECK DETAIL TIl I 10-M EXPANDED GARAGE Ll 1.1 ff I P., rT LLIi-i 7T q> I F­ ---------- ---------- FOUNDATION & FIRST FLOOR FRAMING PLAN Ea Q*M COTUIT BAY DESIGN,ILL NEW ADDITION/REMODELING FOR: DRAWING NO.: 43 BREWSTER ROAD MAIIIEE MA 111141 P. =R'Lob)6395402 .­..ftO :A"" MIKE RESIDENCE ."E DATE 163 OLDE HOMESTEAD LANE MARSTONS MILLS, MA /22/2.6A5 TYP.ROOF CONST. TYP.WALL CONST. v........ �Rc^sue SCREENED GARAGE PORCH cw IL LF "w o w���°::�"o: wwo�n o. SECTION @ GARAGE e BUILDING SECTION @ SCREENED PORCH A6 Qe: � e uazeezweo �s .o.r.n.veeu. nT. BUILDING SECTION @ PORCH A6 BQ�COTUIT BAY DESIGN,LLC NEW ADDITION/REMODELING FOR: SCALE: DRAW'NGNO.: 43 BREWSTER ROAD 1/4" MASHPEE MA.02649 PH.(608 2'741166 MIKE RESIDENCE /� G FAX(60T 63s5402 DATE: /'�V 163 OLDE HOMESTEAD LANE MARSTONS MILLS, MA w„�,,„wen T/22/2o1s TOWN OF BARNST *. LOCATION LE - 3 VILLAGE - . . 'SEWAGE # T T— t_ '. INSTALLER'S NAME PHONE NO ASSESSOR'S MAP a LOT - 0 SEPTIC:TANK CAPAC rrY - LEACHING FA l CILITY: (hype) j!� IT NO. OF BEDROOMS.OOMS 3. BUILDER . OR OWNER . J PERMTTDATE:4- //„ 9c1 COMPL Separation Distance BetwCE DATE. 7 s een the: .Maximum Adjusted Groundwater Table and Bottom of Leaching Private Water Supply Well and Leaching Facilityhtng Facility �rf�eton site or within 2Oo feet of leaching facility) (If anywells exist Edge of Wetland and . , Leaching Facility(If any _J within 300 feet of leaching facility) wetlands exist Feet j Furnished by Feet I l�- ��� fU C J I 1: N-s�cS �-e�c No. / — O Fee . ) y, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUB,LIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pplication for Mi-4pozat 6pe;tem Conf�truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. l 3 <Q_Qe /�_���Q "`C Owner's Nam d ss and Tel.No. Assessor's Map/Parcel Installer's N e,Address,and Tel.No. Designer's Name,Address and Tel.No. , P M crw� Type 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank --' 4^16 Type of S.A.S. Description of Soil Nature f Rep 'rs or Alterations Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of itle 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d oggaltivi Signed ` �"_ Date,!'/'—�'7— f Application Approved by Date c! —/lam -CI Application Disapproved for the WowiQ reasons Permit No. S &0 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY_ ,that the O,n-site Sewage Disposal System Constructed( )Repaired(; ) Upgraded( ) Abandoned( )by at / _ = =� �' 'x r %i` ��l ' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 5;1' &0 L/ dated , Installer Designer The issuance of this pe t shall not b*construed as a guarantee that the syste will tunction as designed. Date 7 - c' Inspector Commonwealth of Massachusetts MMI . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 163 Olde Homestead Drive Property Address Mcintyre Owner's Name hLe)'r-wz " MA 02648 9/27/13 City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City[Town State Zip Code 508.272.6433 Telephone Number B. Certification =1 I certify that I have personally inspected the sewage disposal system at this address and th*the ' information reported below is true, accurate and complete as of the time of the inspection. Abe insp`'ection was performed based on my training and experience in the proper function and maintenance_,of or-mite sewage disposal systems. I am a DEP approved system inspector pursuant tad Section 71S.3401f Title 5 (310 CMR 15.000).The system: .� ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9/27/13 Ins ors Sign re 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. PD/�3 163 Olde Homestead Dr.•03/08 Title 5 Official Inspection Farm: Vrface wage Disposal System-Page 1 of 15 I t 1 W TOWN OF B.ARNSTABLE `LOCATION Lo+ " 0L SEWAGE # VILLAGE ASSESSOR'S MAP & LOT• INSTALLER'S NAME & PHONE NO. J, f. io4o SEPTIC TANK CAPACITYd��, 0 LEACHING FACILITY:(type) Lzpc L 1- (size) ` ,0061 ilw" { O.OF BEDROOMS PRIVATE WELL O PUBLIC WATER. BUILDER OR OWNER �•Y f .�C l`•,.Je\ �. DATE PERMIT ISSUED: la0 yi -T DATE .COLiPLIANCE ISSUED: G - .3 a S 7 VARIANCE GRANTED: Yes No c i 1 . 7, r_ 3 TOWN OF BARNST i�LEJJ'` �LuOCATION 34 ` U�"SEWAGE# VILLAGE=� '� .' `✓ ASSESSOR'S MAP,& LOT�►{3 --7��-gyp INSTALLER'S NAMF,'-&PHONE NO= 'SEPTIC TANK CAPACITY LEACHING FACII.TTY:,(type) ��� d X /�• 1 NO.OF BEDROOMS',���, u BUILDER OR OWNER . PERMITDATE:_�J - ZL_COMPLtIANCE DATE: Separation Distance Between,the: =y,_`, Maximum Adjusted Groundwater Table and Bottom of Leaching Facility % Feet Private Water Supply Well and Leaching facility (if any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by a �� fk�d � �� ASSESSORS MAP NO: Q.,� #3- PARCEL NO.: Fim .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............._0F......64.�.. Appliration for Dhipasal Works Tomitrurtion rantit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: t— ..................................... .. Location-Ad_ress t No. .... . ....... ............................................ ..... ..... . ......................................... 0,,.cr Address - -- ------------------------------------------- --------- -----------.-.------------------------------------- I Address U< Type of Building Size Lot__20 D.5_fo..Sq. feet Dwelling—No. of Bedrooms-----------%3.............................Expansion Attic Garbage Grinder aOther—Type of Building ............................ No. of persons._..._.__.__......._.._...__ Showers Cafeteria Otherfixtures ......................................................................... Design Flow............ .........................gallons per person per day. Total daily flow......t-30_0.....................gallons. 1:4 Septic Tank—Liquid capacity./00gallons Length.....�?....... Width......42....... Dia ffi'�eter------------_-- Depth................ Disposal Trench—No.................... Width._I................ Total Length..............I..... Total leaching aica---------------------sq. f t. Seepage Pit No-------I------------ Diameter......If ...... Depth below inlet.......k......... Totalleaching area....a.049...sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by... -------A)aAZU_-C- .�..................... Date.....3/j 1P./9�, -_----------- Test Pit No. 1-------!;n----minutes per inch Depth of Test Pit.................... Depth to ground water________________________ G14 Test Pit No. 2................minutes per inch Depth of Test Pit..._____............ Depth to ground water._____...............__. 04 ...............1 4 0 1 T,-, - __L, ­ Y ----- . ................................................................. Description of Soil... 0. J Z U ............................. .............. ..................................................................................... .................................... I ----- ....................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ...............................................4 Agreement: The tmdersimagrees t6install the aforedesc ed In *vidual Sewage Disposal System in accordance with : the provisions of'T'iE ersig 5 of the State Sanitary —/Th i ned further agrees not to place the system in operation until a Certificate of Compliance has b sue board o health. Signed.. ................................................... X? -------......*** ..b­... Application Approved By............711. . ..... w ........... . ......................................... ...... .. Date Date Application Disapproved for the following asons:.............................................................................................................. ......................................................................................................................................................................................................... Date Permit No.---........ .. Issued_ .?....................................... ....................................................... Date -113- 21 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........:Ta-1,(.A. .............. .......................................... Appilration for Uhipoiial Warkii Tawitrudion "rnnit V Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -3 L'-�Y. ........ &/La&2,n......tt(�� .....61�u..... ------------------------------ Location-Address - or o , o _"7 ............................................. .... ......................................... Owner Address . .. ..........j Address Type of Building Size Lot__.2LL.r_&5_fa...Sq. feet U Dwelling—No. of Bedrooms...........3..............................Expansion Attic Garbage Grinder PL4 Other—Type of Building ............................ No. of persons.........._......._.._....._ Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow...............55.........................gallons per person gFr day. Total daily flow.........3.3.0.......................gallons. 04 Septic Tank—Liquid'capaciry&d4Lgallons Length................ Width......lo........ Diameter-___-___.___---- Depth................ Disposal Trench—No..................... Width-....__............. Total Length............. Total leaching area-------------------sq. ft. Seepage Pit No...._.t------------- Diameter.....ff............ Depth below imlet.......4........... Total leaching area...,Zv<).....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by._4L).f?2.!.......JLAAI_& .Ck�...................... Date ................ Test Pit No. I-__- _._._.minutes per inch Depth of Test Pit.................... Depth to ground water_________.___._...._.___. f-14 Test Pit No. 2................minutes per inch Depth of Test Pit.............._..... Depth to ground water.......___.._._.....__._ M ........ A i ..... ................................................................. 0 Description of Soil... ..... ......................................:--------------------------- U ............................ .........1. 3 ' LUd.........Zax-lZb--------------------------------------------------------------------------------------- -----------------------------------KA�: ---------- ---------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ Agreement: vi�lual The undersig Pgjr-e ;es to-install the afored ;ibed ln# Sewage Disposal System in accordance with in u ersigned further agrees not to place the system in (, TI the provisions of T1,2 5 of the State Sanitaryi C p operation until a Certificate of Compliance has bl. issu y t e board health. 7 Signed...T------ ------------------- .... .................................. V5? Date,,- Application Approved By........... 7. ......... .. .......................................... ...... Date Application Disapproved for the followinpeasons:.............................................................................................................. ........................................................................................................................................................................................................ Date PermitNo......................................................... IssuedL....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH' /11.................0 F.... 44 "o ............................................ Terfift;katr lif-Tautpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed �) or Repaired by............ ........�414 )I-f- ---------------------------------------------------------------- Installer at----- lllaz-1'�A ------------t7�2A&. Zlx ........HULL-12...........................................- has been installed in accordance with the provisions of TILTIL 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated----_-------------------- ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE....................2L:=A..(..........—S..?..................... Inspector........0`6 ...... . .....%o... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ............OF......da/n.-v -f a-14�........................................ N0..................... FEE....................... Khapospi Workii TDOnotrudion "amit Permission is hereby granted.......... o......Lt.` ............................................................................ to Construct or Re air an Individual Sewage ,irspo.s.a.-I....Sy.-s-tern at N o..A 0- .......�J&.PLW_aad...._,6 L.J.A�............HAA,9.. ,Q.........H4..&........................ street as shown on the application for Disposal Works Construction..'Permit No............ Dated........_____.__........................... ................ . .............. 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