HomeMy WebLinkAbout0180 RACE LANE - Health �l80 Race Lane
�Marstons Mills.
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COMMONWEALTH OF MASSACHUSETTS
a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF.ENVIRONMENTAL PROTECTION
TITLE S
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION _
Property Address: 180 Race Lane l
Marston Mills. MA 02648
Owner's Name: Robert Hallet
Owner's Address:
Date of Inspection: January 3, 2011
Name of Inspector:(Please Print Gordon Bumpus
Company Name: Gordon Bumpus
Mailing Address: P.O.Box 1105
Osterville,MA 02655 --;
Telephone Number: (508) 776-2345
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage.disposal system at this address and that the.information reported;
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a_DEP ;
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: r?
✓ Passes rt
Conditionally Passes
Needs Further Evaluation by the Local.Approving Authority
Fails
Inspector's'Signature: Date: January 12: 2011
The system inspector sha Cubmit 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.
Notes.and Comments
****This report only describes conditions.at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 paged y '
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 180 Race Lane
Marston Mills. MA
Owner: Robert Hallet
Date of Inspection: January 3. 2011
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. 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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined";please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a.Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2 ,
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 180 Race Lane
Marston Mills. MA
Owner: Robert Hallet
Date of Inspection: January 3, 2011
C. Further Evaluation is Required by the Board of Health:
t 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 CNM 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 an
Y PP Y)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 180 Race Lane
Marston Mills, M4
Owner: Robert Hallet
Date of Inspection: January 3, 2011
D. System Failure Criteria applicable to all systems:
You must indicate either"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 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 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. [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.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system'the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the-system.is within 200 feet Uf 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 180 Race Lane
Marston Mills, MA
Owner: Robert Hallet
Date of Inspection: January 3, 2011
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 detennined based on:
Yes No
✓ = Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation.of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 180 Race Lane
Marston Mills. MA
Owner: Robert Hallet
Date of Inspection: January 3. 2011
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc:):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water.meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unknown
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy"of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
system installed on 1011811985- per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTIONIORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Race Lane
Marston Mills. MA
Owner: Robert Hallet
Date of Inspection: January 3, 2011
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
:Depth below grade: 20"
Material of construction: ✓ concrete _metal _fiberglass polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 y_al.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 611
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions detennined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.).
Tees were present. The liquid level was even with the outlet invert. There did not appear to be anyssigns of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 180 Race Lane
Marston Mills, 11,4
Owner: Robert Hallet
Date of Inspection: January 3, 2011
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level. No solids were present.
PUMP CHAMBER: None (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.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Race Lane
Marston Mills. MA
Owner: Robert Hallet
Date of Inspection: January 3, 2011
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 1-6'x 6'(1000 gal.)with 2'stone-per as-built card
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Commments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
The pit was dry. The scuin line was 4'up from the bottom. There did not appear to be any suns offailure.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11 s
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Race Lane
Marston Mills. MA
Owner: Robert Hallet
Date of Inspection: January 3, 2011
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A-
r (3
v a aS1
_ O 3
10
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Page 11 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 180 Race Lane
Marston Mills, MA
Owner: Robert Hallet
Date of Inspection: January 3, 2011
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 +/- feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours snaps, the maps were showing approximately 20'+1-to ground water at this'
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
11
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p TOWN OF BARNSTABLE �+
LOCATION �� I^ C� l e SEWAGE# 1��
VILLAGE M. ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I On
LEACHING FACILITY.(type) �' PeT 0(4o' (size)—off"J70AIL
NO.OF BEDROOMS 3
OWNER R. /41AI1
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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 �Sptt;U n
Loi I P I-SO
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3 5-7 ��
Aj -*- /-S o r G'o� �;r -- 9/ 7 ;----
L•O,C A.T':ION /$0 1?oc«e 4cf,,ye SEWA G E PERMIT NO.
VILLAGE
I N S T A LLER'S NAME i ADDRESS
JOHN A. AALTO BACKHOE SERVICE
West Barnstable, Mass. 02668
0 U I L D E R OR OWN ER
r5l par m e^ -h0
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED F-
io _ Ig _
-rowry
�'Ro�tPT
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1/77 9P_
No..................... FZB.. ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/.?a"111.3 4/4 4,
..............OF..........................................................................................
Appliration for Disposal Works Tomitrurtion Prrutit
Application is hereby made for a Permit to Construct or Repair (/,<an Individual Sewage Disposal
System at:
/W Aice 10k,e AVIWI................................................................. .................................................................................................
........1,91on 0 ddress - / r4, No.
............................... .................... ---.......f:...........................................
. . ..............
Owner Add e s
"T S."9R.Me................................. ..........
Installer Address
U Type of Building Size--Lot............................Sq. feet
Dwelling—No. of Bedrooms.._.........................................Expansion Attic Garbage Grinder
a
P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria
<P4Other fixtures .......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow--------------- ........................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width....._...._..... Diameter__-_____-____- Depth.._.._..........
Disposal Trench—No..................... Width............... Total Length.....................Total leaching area.'..................sq. ft.
Seepage Pit No..................... Diameter.............__..... Depth below inlet.............._..... Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit._____._............ Depth to ground water.__.............._.._._.
fiq Test Pit No. 2................minutes per inch Depth of Test Pit................_... Depth to ground water.-__._..............__..
9 1, *-------------------------------------------------*----------------*---------*-------------------I------*..............................................
0 D' 1 tdon of Soil................................................................................................................ ..
U .... ...................�i
�4 script
.................................................................................................................................................... ..................................
....................................................................................................................................................................... ...................
U Nature of Repairs or Alterations—Answer when applicable.......
.................................................................P .........9...../��V__ ---------------
.....464.c:
Agreement: .10
The -undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'111THF, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b(E"ssuSo by the board of health
Signe ....... . ......... ...... ..................
Datc.
Application Approved By................................ ...........
Date
Application Disapproved for the following r ns:.................................................................................................................
............................................................................. ....................
-------------------- --------------------------------------------------------------------
Date
C)_/,6 9_�M
Issued........... ........................( �5i..........
Permit No............Q. .......V-7 1 - Date
No.......................f Fes$.......`...._...............
THE COMMONWEALTH OF MASSACHUSETTS
-�� BOARD OF ,HEALTH
1� `'✓ ............_OF.....!.+'Crf��5 4-1411
....................................................................
,��r lir�tfi�an f ax i n tt1 parks Tomitrnrtiun Prriftit
Application is hereby made for a Permit to Construct ( ) or Repair (,<an Individual Sewage Disposal
System at:
-- .. ......_. -------•-_...
�g Lo 'on Address or t- No. 1411,
------ -------- •- ----..._........... .....--•••--•-•---_._.. .._...........---- ----
Owne .. yl. Addr��e��s��
-
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—Type T e of Building No. of ersons____________________________ Showers
�W YP g ---------------------------- P ( ) — Cafeteria ( )
dOther fixtures --------------•-••----------------------- ------------•••----••---•--------•---•----------------------...._-_.... _
W Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................. Width................ Diameter________________ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fr4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+ ---------------------------------------
•••-•-------------------
•------------
-•••-•-•----------------
-----
---------------------
•---------------------------•--
O Description of Soil...............................................................................................................................................................=
V .------------------------•-•-----•--•-----•------•-•-----..-.---•---•--•-----------...----•---•-•----•----------------------.•.--------------------------•---------------•------------•-----...._._..•••-
W
----•--------------------------------------------------------------------------------------------------•--••-•-------�----- --- j -y
!a; ! ..�0 t eY h C Q
U Nature of Repairs or Alterations—Ansvyer when applicable......../.7-, _.._.f__.__.r!`____ _::._�_.40__. y___ ____......
•--
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b en -ssue by the board
............
of ��"_'4
Signed.•------= ---•----_-- ---------------•- ...I!e................ -
DarF
Application Approved By...................
f j -
Date
Application Disapproved for the following rev
e ns:......................................... -•---•••--------••----•--•-------•.---------------••--`.........-
.. ........ ................. ..... •-----------...------•-----••-------._......---------•-•-•-------------•••-•--------•-•••---••-------------••--------------••-•----- •-----••---------
Date
-/k
Permit No............. .................. Issued_._..-------�-� -6_.._.._ '..-----...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................17........ ....................................................
Tnt firate of` ampliFanrle
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by------------------------ 1 L ...........................................sr --- ------------•-•----....----------_.... -......-------------...----•-•---•_..
Installer
has been installed in accordance with the provisions of TITLE r of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__ j__________________ dated_..................._.........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST UE®AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................10..._.................•-•••-•--•-•••------------_._._. Inspector.. --
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Q ...........................................OF......................................................................................
No........................ FEE........................
Disposal Mirkii nnstrnrtivit rrntit
Permission is hereby granted..........Zalf.IQ....... 2A-LT.ja......................................................................................
to Construct ( ) or Repair (-K) an Individual Sewage Disposal System
' .............................................
at No
Street
as shown on the application for Disposal Works Construction Permit No...................... ated......... � "�.�....-Y_o_.3
---•-•------------•---------------
--, Board of Health
DATE _ .� .` ------•----•--
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
Ls0'C A T:10!t
S`E W'.A C E PE°RMI`T NQ:
V;i L.A CIE
a
I.NST A I�IER'S' NAME i A.D'DRE,SSf
;.
_ JOHN A. AALTOf'.BACKHOESERACE °
West Barnstabie, Mass.r-02668
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