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HomeMy WebLinkAbout0017 SAWMILL ROAD - Health 1 T Sawmi Road Marstons Mills A = 063 055 Lot 361 - - � L t rt A i i I I it II .T WN OF BARNSTABLE _LOCATION SAW,�w��� I`� SEWAGE# ' ''VILLAGE ASSESSOR'S MAP&PARCEL Gd oS"S� INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY r/nUU LEACHING FACILITY:(type) (size) NO.OF BEDROOMS 3 OWNER ��Te 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 �D�� SA(k 4 i as y 3 3a. as Prep()-1-)9 � Replace 3'2"x winclowwith 3'4"crank ' _1/�✓) same size Replace TT double hung baywindowwith window - 6'French door Window replace 36"w x 36"h with rr, more narrow Open up door 1'10"w x TY way curtntly Replace 3'W x H window Ren)Dve non- 30.'to 7'o i non- IoadbeeC,tbg 11'wall load be g Shorter rin 3'ter T with Awening wall windows VW x V5"T CookTop I Hood -- 9- e!7 13'-0" Gerymg aemmn CD �I n RI I rn �- fV ICI I.I. N --- I x x III � y x P Open u side of x x # P x x ' stairway by removing 4'of non load bearing, Replace T W x _ 3'10"T with n- Shorter Awening Replace single windows T W x window T W by 3' 1'5"T 10"High with a 2' 10"Wby4'9"H 11 I r — Replace single Replace single window 3'4i W by window 3'4"W by 3'19'High with two 3'10"High with two 2'10"Wby 4'9"H 2'10de by by side side de side by side separated by stud separated by stud and trim and trim 261.00in. 41.67in. 42.07in. 81.00in. 83.24in. L j T—U. CIltIWl511lr 0 09 (00 LO c i � c III 0 r tY' 'fi 1 IO O l _____-_-_r r 13'-0" A 51w9an I i � .--.- ---_..79.961n. co — 148.25i t OLl I i N ` � - All RR i � R X RR R � R a i r COMMONWEALTH OF MASSACHUSETTS EXECU "IVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 17 Sawmill Road Marstons Mills. NM 02648 Owner's Name: John Matel ; Owner's Address: ? '/ Date of Inspection: May 23, 2007 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing:Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: _(508)862-9400 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-i? approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes <I ? Needs Further Evaluation by the Local Approving u hority F s tV . . . Inspector's Signature: Date: M 30 200 c7 r- rn The system inspector shall sub r,apy cf this inspection report to the Approving Authority(Boar 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 systei.i 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 page I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Sawmill Road Marston Mills, MA Owner: John Matel Date of Inspection: May 23, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have no: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 mo-e 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 nz)t 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 s0stantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replayed 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 f Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 17 Sawmill Road _ Marston Mills. MA Owner: John Matel Date of Inspection: May 23. 2007 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15:303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic.tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private.water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Metihod used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for colifonn 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: 17 Sawmill Road Marston Mills MA Owner: John Matel Date of Inspection: May 23, 2007 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 %z 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 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 Systems To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system.in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Sawmill Road Marston Mills. MA Owner: John Matel Date of Inspection: May 23, 2007 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 facilit y 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: 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: 17 Sawin ill Road Marston M31s MA Owner: John Matel Date of Inspection: Mav 23, 2007, RESIDENTIAL FLOW CONDITIONS i Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: I Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n1a [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)): Private well Sump Pump(yes or no): No Last date of occupancy: Currently occupied 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: Never pumped-per owner 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: Installed on 6112179-per as-built card Were sewage odors detected when arriving at the site(yes or no): No 6 i I Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Sawmill Road Marston Mills, MA Owner: John Matel Date of inspection: MU 23, 2007 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: 15" 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 gal.. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 6" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Corn ments(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 tank was under a.vorch and the outlet cover was under a stair footing Recommend installing a riser or replacing the stair footing GREASE TRAP: .None (locate on site plan) Depth below grader 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: 17 Sawmill Road Marstons Mills MA Owner: John Matel Date of Inspection: May 23, 2007 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. There was.a slight belly in the D-box to the nit 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 f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Sawmill Road Marstons Mills MA Owner: John Mate1 Date of Inspection: May 23. 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: I-6'x 6'(1000 gal leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching,fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level.of ponding, damp soil,condition of vegetation,etc.): _The nit had 2'ofliauid on the bottom The scum line was at the same level There did not appear to be any signs off' allure CESSPOOLS: Ngne (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): Cominents (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: Conunents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 • li • Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Sawmill Road Marstons Mills MA Owner: John Mate.1 Date of Inspection: May 23, 2007 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the.building. �faL� a � Q t 3 a ay 13 3 3a as 10 r • Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Sawmill Road Marstons Mills, MA Owner: John Matel Date of Inspection: Mav 23, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 50+/- feet. Please indicate(check)all methods-used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local.Board of Health-explain.- 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 tonozraphic and water contours snaps the mans were showing approximately 50'+/ to Around 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 i TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE PART A RECEIVED CERTIFICATION . Property Address: 17 Saw Mill Road AUG 1 :4 2002 Marstons Mills,MA TOWN OF BARNSTABLE Owner's Name: Ralph Chesnauskas HEALTH DEPT. Owner's Address: Same ^� Date of Inspection: 7/29/02 S4 Name of Inspector: (please print)Janet E.DuPont Company Name: Wind River Environmental ff lty Mailing Address: 120 Great Weston Road � South Dennis,MA 02660 Telephone Number: 508-760-4827 PARCEL * ®�� LOT _ '�G 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: M I k—�v Op. Date: �02 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. 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. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 Inspection Summary: Check A,B,C,D or E/ALWAYS WAYS 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: _X_ 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: _X_ 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): No back up observed but sides of D-box are crumbling broken pipe(s)are replaced obstruction is removed _X_ 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: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. I 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. the Board System will fail unless y e oa d of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The System has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone I of a public well. _.._ _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] No (Yes/No)The system falls.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered"yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X_ _ Pumping information was provided by the owner,occupant,or Board of Health X_ Were any of the system components pumped out in the previous two weeks? _X_ _ Has the system received normal flows in the previous two week period? _X_ Has large volume of water been introduced to the system recently or as part of this inspection ? _X_ _ Were as built plans of the system obtained and examined?(If not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? _X_ — Was the site inspected for signs of break out? _X _____ Were all system components,excluding the SAS,located on site? X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? _X_ T Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _X_ Existing information.For example,a plan at the Board of Health. _X_ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)J OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3T Number of bedrooms(actual):_3_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_330gpd_ Number of current residents: Does residence have a garbage grinder(yes or no):No Is laundry on a separate sewage system(yes or no):No (if yes separate inspection required] Laundry system inspected(yes or no):____ Seasonal use:(yes or no):Yes with occasional winter use Water meter readings,if available(last 2 years usage(gpd)): 29,000 gal.2000 and 21,000 gal .2001 Sump pump(yes or no):No Last date of occupancy:Current COMMERCIALANDUSTRIAL 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):T Water meter readings,if available: Last date of occupancy/use: GENERAL INFORMATION Pumping Records N/A Source of information:Barnstable BOH 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: _22 years old Were sewage odors detected when arriving at the site(yes or no):No OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 BUILDING SEWER(locate on site plan) Depth below grade: 30" Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:Over 20' Comments(on condition of joints,venting,evidence of leakage;etc.):Pipes appear to be sound with no signs of leaking SEPTIC TANK:_(locate on site plan) Depth below grade: 12-14" Material of construction:_X_concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 1000 gallons Sludge depth:minimal Distance from top of sludge to bottom of outlet tee or baffle: 2'+ Scum thickness: 0-2" Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined:Probe Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tank appears to be sound with no signs of leaking, concrete baffles in place GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: . Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction; concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: _ gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be o ened)(locate on site plan) P Depth of liquid level above outlet invert: Liquid at outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): _D-box is beginning to crumble along both sides,and it was recommended to owner that it be replaced. He was going to have replacement done. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number:_)1)pit 67'deep_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):_Pit is 33"below grade with an 18"riser,pit contained 15"of water 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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection: 7/29/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. L) • / f r Ll 76 G FB OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 17 Saw Mill Road Owner: Ralph Chesnauskas Date of Inspection:7/29/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: _Checked with local excavators,installers-(attach documentation) X_Accessed USGS database-explain: Topozone.com,and USGS on-line groundwater monitoring well information You must describe how you established the high ground water elevation: Site is located at approximately 90 A.S.L.per Topozone.com Bottom of SAS is 9.3' below surface. Site is directly across street from lake. Steep drop to lake level. Topozone.com shows average level of lake to be 44'A.S.L. Site is monitored by USGS groundwater monitoring well SDW 253 Zone B Well levels for 6/21/02 show required adjustment of 7.8' for Maximum Potential High Groundwater 90'—(9.3+7.8)=72.9'A.S.L. If lake is at 44' A..S.L.then there is a separation of 28.9'+between bottom of SAS and Maximum Potential High Groundwater LO C ION SEWAGE PERMIT NO. �'Q w ds,4 - 3 (� 6 VILLAGE INSTA LLE 'S AME b ADDRESS YC t U I L D E 9 OR OWNER YC,6 DATE PERMIT ISSUED V/ �Z DATE COMPLIANCE ISSUED We�� (� Y � / 1, 3 � 3 . �� 1 �� No.:... � :` J I n ....... IVI+ THE COMMONWEALTWOF MASSACHUSETTS PARCH LaS BOARD OF HEALTH LOT 3�,Jr,._�� .-n1............OF............. .1�.l�L..S rA..J�L Appliration for Bifsvoiial Work Tonotrnriion Prrutit Application is hereby made for a Permit to Construct or Repair anIndividual pp y ( ) p ( ) Sewage Disposal System at: s..... c-`-5------------------------—®�----•-2d.K...---------..........---....--- or Lot No. —� ._........n!�2:__. �.5..0 � .`t..s•• •-••...........- 3 .......f i.l .aw.t9........ ,t' e_1..... Owner ddress a ....._...... - ...............................•---------...._.....-•-•-•--------- ........._.............•:e.,4l. ......r .. Installer A ......................... ress Type of Building Size Lot.9�6..:25'5.._._Sq. feet V Dwelling—No. of Bedrooms........................ .Expansion Attic (Nv) Garbage Grinder (w©) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures -----------------------------------• ---------------------•---------------------------------------------............ ----------- W Design Flow.......... 1 .......................gallons per—pin per day. Total daily flow.........�_ �2___. _......_._..gallons. WSeptic Tank—Liquid capacitylew-•gallons Lengths .. WidthAe. 47_" Diameter................ Depth-s .`�. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....Z........... Diameter... ..'....... Depth below inlet_. .4>�. Total leaching areaA ....sq. ft. Z Other Distribution box (r-'J" Dosing tank aPercolation Test Results Performed Test Pit No. 1_A�L .....minutes per inch Depth of Test Pit..../2Z....... Depth to ground water.. ........ Li, Test Pit No. 2-_G-Z-...minutes per inch Depth of Test Pit___t r....... Depth to ground water.-me m.6 _._._... R'+ •-•-...._... ...-••-•.............•---••..-- ----............_-•--- .........-•----....._........................................................... O Description of Soil........ ........elNQ......... tom_ SO_. - .........'z�.._..r .2. CO/925 V18 .............4_.V-,0•----- .h.t v4c ............................•---. p `3ca.;V'e '. .................... UNature of Repairs or Alterations—Answer when applicable............................................................................._.................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'I;'M 5 of the State Sanitary Co The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be ed b he board of health. Signe -- -- ... ........................ f/ ate Application Approved By........ Date Application Disapproved for the following reasons------------------•----........---•----------•-•--•-•---•------------------------..............-•------........_ -•--•-•-•--•------------------•-----.......-----...----------.............-----------•-----•------•--•--.-•----------•--•••-------------------•----•------•-•--•-•••-•-••-------•---••••--•----•••.••--- Date a PermitNo......................................................... Issued-....... '.:` 711....................... Date L� kfeA V i to 3 1 40 C ION / S E W A G E PERMIT NO. VILLA E I s N TA LLE'S AME i ADDRESS Y 7- ® UILDER OR OWNER i I ` DATE PERMIT ISSUED 6 r DATE COMPLIANCE ISSUED 00 .. .1' ...... Finc..........ef ........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C/CQ./V..........OF.............31 , :f�?. 1. .. 1: :. ............... Appliration for Disposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct (' ) or Repair ( ) an Individual Sewage Disposal System at /Z. ! l C c S ..... ................ ................................ t' n-A e s or Lot No c .. W Owner / fQyJ��.�+ �q Add s ............... . ..................... ....::..-----. ---------------------.- ................... � ... ��S.,�a........................ . .... Installer less = Type of Building Size Lot.: �.ZM....Sq. feet U �`* 'rt N* Garbage Grinder (No Dwelling—No. of Bedrooms..._....._. ...................._.__.Expansion Attic ( Other—Type of.Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other xtures •--••-•--•••--•-••............ .• - W Design Flow.........._.�� ...... ._gallons per-perszni per day. Total daily flow....... . ..................gallons. W Septic Tank—Liquid capacity e"iP gallons Length .�s _ Width..1' 0 Diameter...... ......... Depth x Disposal Trench—No. .................. Width_:. ........... Total Length.....:... ....... Total leaching area....................sq. ft. Seepage Pit No.....oO.. ....... Diameter ...e. ....... Depth below inlet-... Total leaching areas' ,4PV...sq. ft. Z Other Distribution box ( to-)" Dosing tank ( ) `-~""' 1f + f, ��i►+'"' aPercolation Test Results Performed �.�...A .� ... Date.. ./4 4H �If2.? ,.a Test Pit No. L., ."�'-...minutes per inch Depth of Test Pit.....4L_'-....... Depth to groundwater A��je��":....__. Test Pit No. 2---`5:. .�:t..niinutes per inch Depth of, Test Pit.... sr.e....... Depth to ground water._AVAe v.d......... ....................... ............ O r ,, �A 7, r y Description of Soil.....---C� --- •--------'�:.���----....I.9�v�r?-----.....,�'r/./�'�rp!.�":--•-------'�- ^:!'.,�.._... t�191�.X.� U •---------. -----------------•----•-----------.----•- •- --• ------------- U Nature of Repairs or Alterations—Answer when applicable..____.., ... .... ....... ......... .............................................. -•---------------------------------•------------------------------------'----------•••--•----------------- ---------------------------------•---------------•---- ---- Agreement ' The undersigned ,agrees to install`the aforedescribed Individual Sewage Disposal System in accordance with the provi�io I":iis oti SoTthe State Sanitary Co The undersigned further agrees not to place the system in operation until.a Certificate of Compliance has be ed b e byoa d of health. f h f _S.ign . ----•-•-••... ..-•••--••...............•_ .. -• ...... .-- Date !y Application Approved By..... Z. 1 -" ,�- • . . .....-------•---------- j._ lot - Date ..- ----,;r Application Disapproved for the following reasons---------------•-• --••--••---#-•-•---•---•-•-•--...•-•--•-•----•-••----...................---•--_. ,/w --•----•-•-•...............•------•---------•------------•------------_----•------•--•--•--------...-•----------------------------------------------------•----------------------------......--•---._--- " Date PermitNo.......................................................... 'Issued.........................------••---•-••-•----•---•--- Date THE, COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,, ..............); .... � F...::.. I. .. ,fir, , rj.:...........t............................... (�att, iratr of Tomplianrr,, T S IS Ty CERTIFY, That the.individual Sewage Disposal System constructed ) or Repaired ( ) by ------------ -------------- ---------------- -- ------- r f Instal r f � .... has been installed in accordance with the provisions of TZ j of The State Sanitary Code as described in the ... _ application.for Disposal Works Construction Permit N ? i:Zd.d............... dated._... _-_�lr ~^ ".� _..... THE ISSUANCE OF THIS CERTJkFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TAT THE SYSTEA+I''WILL FUNCTION- SATISFACTORY. DATE.... '.- ..�..? �.......................................... Inspector... c��t-tom* ............................... �. s THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH as..... O F.......... ........................................... ......................J . � �� � FEE-1� Disposal' or M r trftd rrnti Permissio ,,n hereby granted-- 1 - -•-•------------------------------•----•----.......--------------.........••-•...... .. ........---_-•--- to Construe ) or Repair/ ) an I vi al Sewage sposal Sys at No..` .. StrAZOV ............... eet' as shown on the application for Disposal Works Construction Per No...... ....... ... D ed.,t:_� 'r ....•....... ............. �It�G --•---•..............� r of Health DATE.... .a.. - •7 FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS ••^ f No. Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for 30tgpogaf by.5tem Congtruction Permit Application for a Permit to Construct( )Repair)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.17 Owner's Name,Add ss and Tel.No. Assessor's Map/Parcel /n� y�A� /�SI 7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. »j . O67 YZ8- � s Type of Building: IR 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 r. Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) f,-) &T 74:47- A19,hy Date last inspected: Agreement: The undersigned agrees to ensure a construction and m ' tenance of the afore described on-site sewage disposal system in accordance with the provision of Titl 5 f rd En iro Code and not to place the system in operation until a Certifi- cate of Compliance has bee iss b . is B ea Signe /" Date Application Approved by / ) Wev -Z Date J6 Z Application Disapproved for the following reasons Permit No. Date Issued 12 No. O I Fee I THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC"HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zl#pticatton for Mt5poof *p.5tem Conotruction Permit Application for a Pednit to Construct Repair Upgrade Abandon El Complete System ❑El Individual Components Location Address or/Lot No. Owner's Name,Address and Tel.No. \ 'Assessor's Map/Parcel Aw5�Iavy /y/A 00";4 7/ /17 Installer's Natne,Address,and Tel.No. Designer's Name,Address and Tel.No. r 7110-e-5 /P 6, 0, 709,wb �30 /,7-9 _rbr- %0 Type of Building: 2-2/ 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 of Repairs or Alterations(Answer when applicable) Date last inspected-- Agreement: The undersigned agrees to ensure e construction and in"' tenance of the afore described on-site sewage disposal system in accordance with the provisio of Till 5 f not to place the system in operation until a Certifi- cate o iron Code and to ��; /cate of Compliance has bee iss b is B d ea Signe �,D I W,-- -Date Application Approved by X- :U Date Application Disapproved for the following reasons Permit No. OZL/6 ' Date Issued 4 W62 V4;_I� ———————-- ——————— -—————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded Abandoned( )by D at 7_41 has •e constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No, led Installer_7:3V&)P WoVA e- AiG ,O -Designer The issuance of this h 11 not be construed as a guarantee that the sktoeill functT* n\akd� �signed. Date U Vmts_s M Inspector t i)A -- ---------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS it PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS ]Diqoat *pMem Con!5tructton_Permit Permission is hereby granted to Construct Repair )Upgrade( )Abandon System located at /7 /,) D IF 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. rmi Provided:Construction must be co -p eted ithin hree years of the date of thi;R Date: —Approved by JIN 5 - PROP WELL ST HOLES 1.5 t �/ QpXr ' F MA RCN 5 ,19717 PAUL MURRAY - I 5P4CTOR -TEST �o,� CH ELEV,. 25. 9 HOLE @ 'rES? ..- ... .._ HOLD . �... .,,....e. , LOAM AN D 61 i S UQ 5014.. yOr `y t 2 A IV,0 Cr RAVEL. "q NO L-M T�2 NCC3UNTE REA LOT 36/ - - - - A-6 33.5 a, •� . . C.13, A SSUM. 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