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HomeMy WebLinkAbout0080 SEA ROBIN ROAD - Health 80:Sea;Robin Road r Marstons Mills P A 122',045 f Commonwealth of'Massachusetts Title 5 Official Inspection Form. Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is required for every Marstons Mills MA 02648 12/12/11 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be alfiered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections ffi Company Name P.O.Box 896 Company Address East Dennis MA 02641 C'�Y/Town State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification r 0" I certify that I have personally inspected the sewage disposal system at this address and thatthe <u/ 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 �`-� `i' Title 5(310 CMR 15.000).The system: C:. ®' Passes ❑ Conditionally Passes ❑ Fails ;Needs Further Evaluation by the Local Approving Authority i G 12/12/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection_If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 TNe 5 Official Inspection Fort4rfacge Dispo al System• ge 1 or 17 Commonwealth of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is Marstons Mills MA 02648 12/12/11 required for every page. Cityrrown state Zip Code Date of tnspedion B. Certification (cont.) 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. 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Cwner Owners Name information is Marstons Milts MA 02648 12/12/11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont): ❑ Observation of sewage backup or breakout.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 Q ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ® Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is required for every Marstons Mills MA 02648 12/12/11 page. Citytrown State Zip Code Date of inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply_ ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well*". Method used to determine distance: **This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's dame information is required for every Marstons Mills MA 02648 12/12111 page. Cityfro= State Zip Code Date of[nspeotion B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool,or privy is within 100 feet of a surface water supply or ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a:private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must ber attached to this forma ❑ ® 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 etast 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. For large systems,you must indicate either"yes"or"non 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. t5ins•11/10 Title 5 Official Inspeclion Form:Subsunace Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Foam Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Fume information is required for every Marston Mills MA 02648 12/12/11 page. City/rown 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(d any of the failure criteria related to Part C is at issue ® ❑ approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flaw based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 330 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments s 80 Sea Robin Road Property Address Judith Griffen Owner Oaanef s Name information is required for every Marstons Mills MA 02648 12/12/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 Seasonal use? ED Yes ❑ No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of Date occupancy: Die CommerciaUindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.fL,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: t54ns•t tf10 Tide 5 Official Insgecdon Form:Subsurface Sewage DtWwa!System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Foam s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is Marstons Mills MA 02648 12/12/11 required for every page Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 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!/A system by system operator under contract Cl Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form A s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is Marston Mills MA 02648 12/12/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known)and source of information: 11/05/86 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: �2 Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): 1.4 Depth below grade: feet Material of construction: ®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 1" Sludge depth: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection I`orm Subsurface Sewage Disposal System forth-Not for Voluntary Assessments 80 Sea Robin Road Property.Address Judah Griffen Owner Owner's!dame information is Marstons Mills MA 02648 12/12111 required for every page. City/Town state Zip Code Date of tnspection D. System Information (cont.) Septic Tank(coat.) Distance from top of sludge to bottom of outlet tee or baffle 30'r 1, Scum thickness Distance from top of scum to top of outlet tee or baffle Tr Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid atoutletinvert.. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑ fiberglass ❑'polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5 rrs•7 7110 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owners Name information is required for every Marstons Mills MA 02648 12/12/11 page. City(rown state Zip Code Date of inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection) locate on site plan): Depth below grade: Material of construction: ❑concrete ❑metal 0 fiberglass ❑ polyethylene y ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Attach copy of current pumping contract(required).Is copy attached? ❑ Yes. ❑ No t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 L Commonwealth of Massachusetts Title 5 Official 'Inspection Form Subsurface Sewage Disposal System.Form.-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's flame information is required for every Marstons Mills MA 02648 12/12/11 page. Cify/rown state Zip Code Date of Inspection D. System Information (cunt.) 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 box was level and fight with no sign of carryover. Pump Chamber(locate on site plan): Pumas in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5Offiicial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is required for every Marston Mills MA 02648 12/12/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Type: IR leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length:. ❑ leaching fields: number,dimensions;. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc): This system has a 6'x6'precast pit surrounded by a foot of stone.The pit had V'of liquid with a stain line half way up the pit. 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 Yoins-1 M0 i ale 5 Official inspection Form Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 80 Sea Robin Road, Property Address Judith Griffen Owner Ownees Name information is Marstons Mills MA 02648 12/12/11 required for every page cityrrown state Zip Code Date of fnspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding.,condition of vegetation, etc.): t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Co mmonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System.Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is M required for every arstons Mills MA 02648 12/12/11 page. CitylTown state Zip Code Date of Inspection D. System Information (cont.) 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 L(*3 4s � �4 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Vw Title 5 official Inspection Form. s Subsurface Sewage DisposalSystem Form-Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Plume information is required for every Marstons Mills MA 02648 12/12/11 page. City/ro✓n 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: 8.8 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed:: Date ® Observed site(abutting propertylobservation 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: I augered to12.0 feet and found no water. I adjusted to 8.8 feet. Bottom of leaching is at 8.2 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ol Subsurface Sewage Disposal System Form Not for Voluntary Assessments 80 Sea Robin Road Property Address Judith Griffen Owner Owner's Name information is Marstons Mills MA 02648 12/12/11 required for every page. Cityrrown State Zip Code Date of trspeetion E. Report Completeness Checklist ® Inspection Summary:A,B,C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 17 or 17 Permit Number: Oats: Completed by., HIGH GROUNDMATER LEVEL COMPUTATION Sim Location: �J S eR.. l d` C Lot No. Owner- Adder: Contractor. : Notes: STEP I Measure depth to water tail to nearest i/iQ ft_.Y....---.-_.-_---_. —_.-_---- STEP .2 Uang Water Levi Rangy Zone acid Index won Map locate site wW determine: Appropriate index �B Wi star-level rangy zar:s........_......__....._............ STEP 3 Using monfty'rePart'lkwrant Plater Resoumes Candi wtW' determine cx.•rrertt depth to venter leitel for index Well_._...___...._.._ STEP 4 USM Talde 3f V totem Adjustments for index well{STEP 2A),cullell depth to wvw level W index well-(STEP 3). and water-lewd mane(STEP 28) . STEP 8 Estimate depth w high wafer by subtractliM tNt wamr- Ievel adjustment(STEP 4) from meenived depth to water 0 Newelat srte�;sTEI't) .. ...........__.........._.�...__..._..__--•-- .__._.._---..._.._.....__..__.� � COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY:ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTE FOCEiVED PART A CERTIFICATION AUG 0 2002 Property Address: TOWN OF BARNSTABLE HEALTH DEPT. Owner's.Name: Owner's Address: A �s fJ Date of Inspection: Name of Inspec or- (plea a rint) r Company Name. Z'��- ,„mq Mailing Address: MAP "YA O--toye PARCEL © 4 5 Telephone Number: LOT `Z'Z 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ails Inspector's.Signature: - Date: —9000 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. Title 5 Inspection Form 6/15/20.00 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS s. SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION (continued) Property.Address: Owner: Date of Inspection: pa 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 i 45.303 or in 310 CMR 15.304 exist:Any failure criteria not evaluated are,indicated below, n 310 CMR 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, v�ill pass. Answer yes;no or not determined(Y,N;ND)in the for the following statements.If not deter mined" pleaseexplain. 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 ekfiltration or tank failure is imminent:System will pass inspection if the existing tank is replaced with 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 than4 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 I 1 OFFICIAL.INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: U Owner , Date of Ins.pecti ,� OOoZ 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".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 I 1 OFFICIAL.INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE''SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: < �-,3, aadl Owner:. Date of Ibspectio D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nq� _ 1/ Backup of sewage into facility or system component due to overloaded or clog SAS or cesspool — Discharge or ponding of effluent to the surface of the around or surface waters due to an overloaded or J cloaaed SAS or cesspool V Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or / cesspool i/ 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 iri 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. Anyportion of a cesspool or privy is within a Zone 1 of a:publicwell. 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.] (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 facilitywith 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—I WPA)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 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ��LE� ijl /UTA Owner: Date of Inspecti / C� Check if the following have been done. You must indicate"Yes"or"no" as to each of the following: Yes No Pumping.informaticn.was provided by the owner,occupant; or Board of Health V/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) V _ 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? V _ 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: Y no • /— Existing information. For example, a plan.at the Board of Health. V _ 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)] Page 6 of 1.1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION Property Address: Owner: Date of Inspecti /3 000 0;L FLOW CONDITIONS RESIDENTIAL ✓ Number of bedrooms:(design): Number of bedrooms(actual): 3 DESIGN flow based on 3 TO CMR 15:203(for example:`110 gpd x of bedrooms):732 Number of current residents: 02 Does residence.have a garbage grinder(yes or no): Is laundry on a separate.sewage system(yes or no): ,[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no.):�— � / Water meter readings, if available(last 2 years usage(gpd)): �/✓��' Sump pump(yes or no)• Y Last date of occupancy: COMMERCIAL/INDUSTRIAI- -- 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: Was system pumped as part of the iSspection(yes or n If yes, volume pumped: gallons--How was quantity pumped determined? Reason'for pumping: TY"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 fiom system owner) -Tight tank _Attach a copy of the DEP approval _Other(describe): roximate age ofall components, date in -led(if kno �n and source of information: Were sewage odors detected when arriving at the site(yes or nod/jf�- 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM..INFORMATION(continued) Property Address: Owner: Date of Inspecti a 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:Zlocate on site plan) Depth below grade: 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:/(',S,X k g ° Sludge depth: /b a �/ Distance from top of sludge to bottom of outlet tee.or baffle:2 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: How were dimensions determine Comments(on pumping recommerfdationi, inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert evidence of leakage tc.): l0 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.too 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: e Owner: Date of Inspect' n: 2 Q a ;TIGHT or HOLDING TANIJ:, (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:_Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ` Comments(note if box is level and distri ution to outlets equal, any evidence of solids carryover,any evidence of eakage ipto or out of b x; etc.): le 01,01 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.): j 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner Mu Date of Inspect' n: (�a SOIL ABSORPTION SYSTEM (SAS),--�i_ flocate on site plan,excavation not required) If SAS not located explain why: TYPe eaching pits,number: 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, FD cam, it 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.): 9 Pace 10 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: id Owner: ` 'hA Date of Inspecti / C:;100,2 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 buildinc. I 9 nLP 10 ` Page 11 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) , . t �� Property Address: &�. �S& Owner: . Date of Inspecti oOoZ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water 2 7 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 1 D0 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) vy Accessed USGS database-explain: You must describe how you established the high ground water elevation: U 11 Permit Number: Date: Completed by:. H"Ci GROUND-IiVA,-E•R LEVEL COMPO T A I ION Site Location: �6a XO/Vle -al, (d�j i��/�`C� Lot N`o.. Owner: - �, ,sa�/Q'sv Address_ ' Contractor: ( / CG �s� Address: �° /� 5:✓y%f� Notes: STiR. 1 . Measure depth<to•watertable .. to <�t3<� 2 month/day/year I STI E:P 2 Using,Water-Lave l.FI-ange Zone i and Index Well::Map:locate site.an•d•deternine: —� 5d � L✓3 O�ApPro.Pri ate.indax w.ehL.............._...._...._....._...........__....._. ,..�• v Water-level �_nge_on'e.._.........._...._..... - - - u i STD Using•monthly.rwperk:"'Cu rent ' - Water Resources-Cenditions" determine current-Ceotn'i0 Oy /O� I �j)� water Invel for'in 46:< well ........................... l` .� month/year STEP. 4 Using:T aole.oa-VOaterjevel Adjustments : for index well (STEP 2A),_curreent death' I t to waterlevel fora i•rdex wel.l {STEP 3•}, and water level zone (STtP 2B) determine'wa'tsr-level-adjustment ..............._.........._.... .......................................... ......_...... ' STEP 5 Est rnate•depth to-'high water by subtracting th.e •rvater--• level adjustor=nL.(S:T EP 4-) from measured-.depth to.water levelat si �.(STi=P'1)'._..........-_...........................:................................._...........7....................... �� I©® �,0®.1170/ TOWN OF BARNSTABLE LOCATION , � t \fib;ry 1\,�, SEWAGE # ' VILLAGE AZ I .�5 ASSESSOR'S MAP & LOT L22L- INSTALLER'S NAME & PHONE NO.&,43 �bO SEPTIC TANK CAPACITY f ,S o D b NI 1 LEACHING FACILITY:(type) 1ea,J4 Ea-s, ,J (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER S Vrq pa,� DATE PERMIT ISSUED: O DATE . COMPLIANCE ISSUED: jt /-7 VARIANCE GRANTED: Yes Noj pr I y � � � �`� �6- - �, -� ,�- <�. FEB ......... THE COMMONWEALTH OF MASSACHUSETTS VA D OF HE LTH ...../... C­_................... Appliration for Disposal Works Tonstxurtion Frrutit Application is hereby made fora to Construct or Repair an Individual Sewage Disposal System at: 1,6_7 ..................�.Aq........./e�........... ..........................I.7±2L..... ........... ........................................... o tidy s 0� 40C . . ...................... ............ -7------ d r ......... ..................... ....... .. ............................... .......... .............. ... . ............................ Installer Address Type of Building Size Lot..Z.0,1_9.2...Sq. feet U Dwelling—No. of Bedrooms..............._................_.......Expansion Attic Garbage Grinder P4 Other—Type of Building ........................1�..... No. of persons............................ Showers Cafeteria Other fixtuxes -----_--------_------- ----------�Wm----------------------------------------------------3-��--------------------------------- Design Flow................ .gallons per er dAy. Total daily, flg)v................... ...0..............gallons. LA.... Width----- Diameter---------------- Depth.... .. ..7. P4 Septic Tank—Liquid capacity- -a- .gallons Length__7 ?;t? Disposal Trench—No. .................... Width........Y.......... Total Length.;...._.......... Total leaching area....................sq. f t. Seepage Pit No-----------/------- Diameter.......1.2..... Depth below inlet......... Total leaching area,33.1. ...sq. f t. Z Other Distribution box Dosing tank ( ) o-4 � : .9-Ja Percolation Test Results Performed by.Zqf;V4-.4- .. - ..j..a—iJeCAK1.4ate..... ....... Test Pit No. 1.......c,L_minutes per inch Depth of Test Pit___-__ Depth to ground water----------ev!n......... 44 Test Pit No. 2......;=. _minutes per inch Depth of Test Pit.......ZJ01". Depth to ground water.._......_--______- P4 --------- ................................................................................................................................1,............................. 0 Description of SoA*l.......A'V.i ......... ......k.3....!it--------0. 3,6-- P4W....t- ..... ist.1.0 ........................L240..... ............................................................................ ................................................................. ...................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------------------------- ......................................................................................................................................................................r........................ Agreemer,t: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIME 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compl* nce has yl bee issued bypoe board of,health. �e �V Id igned IJINAZ 141fo oflav .........I.., --- Da e CAp lication Approved By.............. ................................................................ ........ ...... D to Application Disapproved for the lowing reasons:.................................................................. ................................. .........................................................................................................................7.............. "............................................................. Date PermitNo......................................................... Issued_'..................................................... Date L — - - _ a No-----------------------=- FRB.........................._. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ........ --. _ �....... Appliratiaan fear Uiglosal Workii Tunstrur#iun Prrutit Application is hereby made for a Permit to Construct ( Jr) or Repair ( ) an Individual Sewage Disposal System at: -� Location-Address or Lot No. ......................_.......................................................................... .........--•••--••---............._................------...............--....................•-- Owner Address .................................................................... .............................................................. ................................. Installer Address �} �� Type of Building Size Lot__;.-_'-!,,Z __..____..Sq. feet Dwelling—No. of Bedrooms.................d_____.._.___.....______._Expansion Attic ( ) Garbage Grinder ( ) '444 Other—Type of Building No. of persons............................ Showers — Cafeteria a Other fixtures ...................................... W Design Flow.................................... ..gallons per persoi3 per day. Total daily flpw.............. _ ...............gallons. / 1<_ :--- Diameter=--------------- Depth_..L Z'_ W Septic Tank—Liquad capacity_...:_:_ gallons Length._j�._�_ _ Width x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..........1....... Diameter...... _._.__ Depth below inlet........ .._..... Total leaching area..} 9....sq. ft. Other Distribution box (,,e Dosing tank ( ) ; 2 Z Percolation Test Results Performed by_ "±L:_XL._. _ :;-.r° ?`'i± q` J........................' ate......._z:___s .:_ __�,__r_____._.. `�a Test Pit No. I.....��___minutes per inch Depth of Test Pit______f_t;;:.:.... Depth to ground water.......... Test Pit No. 2......�L_..nainutes per inch Depth of Test Pit....... _%`>:_`.. Depth to ground water...........—........... .. ....................................................... 0 Description of Soil----- .2 4----:.f .........j" '........"„ 3------ -- s'r:��}'✓1 r r.�_ar1/t-- � -----`---`--- -='-'-4-------------------------------•. ._...------------•---- -• ------------•--- --------•- W ----•---------------------------------------------- --••••-•--••--•....------------------••--•------------------------------•------------------•--•---•---...._......--- VNature of Repairs or Alterations—Answer when applicable...___.......................................................................................... i -----------------------------------•-----------------------•------------•------------_-----------------------------------___----------------------------------------------•----------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in'accordance with the provisiotis of TITi.- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by he board o�health. Signed-- •-----------•------------- Jl.... ...� as4Ap placation Approved BY .._...... �14t gj Application Disapproved for the Bowing reasons----------------------------••--•------------------------------------------------•---...........•-----•---------- --•---...---...•••-•--•-•-•...••---•--•-----•-----•.......................••-----..._....._._..._......------•---....-••-•---•--•-----•-•-•-------•-----•---•----------------------------------••---•--- Date PermitNo......................................................... Issued.............................................----------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trtifiratr ,af Tantliliunrr THIS IS TO C T_IFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ........................ t x?..4_ a-° ........... ------•----------------------- j p� Installer •e has been installed in accordance with the provisions of TITLE 5 of Pe State Sanitary Coda as ribed in the application for Disposal Works Construction Permit No.........W................... dated_... /_�1 _____________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.........--•................. �F ....�.....•---.........----•------ Inspector `--�••------------_-------• ._... 2 Z - C-As THE COMMONWEALTH OF MAS94�iR"4Jt9 "ErPTTS..i+e-..�--^ � BOARD ='OF HEALTI IN 57RICT THE SYSTEM WA5 INSTALLS P6 _ Q ..........................................OF..........:. ..................._..ACC63 �311�10E-T-O.K.A.N. z?. No. .... 4...0 ' FEE.. ................... Permission is hereby grant --" ..-------�=^•.V-I+Q-!=!------. (E c�!t�.i��...S....... to Construct ( ) r Re air .�an id al Sewa a Disposal System Street / as shown on the application for Disposal Works Construction Permit N�_'-O �D'ated.._._�,1_Q ...........•.... --------------------------------------• - ) p r o Hea DATE....•... �r-t- --• .4.................................................. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS