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HomeMy WebLinkAbout0150 CONCORD LANE - Health nr� lox, t Mars*ons.Mlls '�� `' , ��.� - r 'A! '122 -= 123 - �;� f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE 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: Owner's Name: Owner's Address: Date of Inspection: Name of Inspector:(please print)toil l l avv l�iUtf3;-Ea ) &iz Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, 1A Telephone Number: t5081 775-8776 CERTIFICATION STATEMENT 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 Ci•1R 15.000). The system: t/ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: lei%� 1� '�-- Date: Z -A The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Hearthor 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 seat 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 2oflt r. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: I'D- 0 C2� '* ., ©S u Owner: l 0%0� Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: ' One or more system components as described in the"Conditional Pass"section need to be replaced or reps ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans r yes,no or not determined(Y,N,ND)in the for the following statements.If`Slot determined"please expla n. The septic tank is metal and over 20 years old*or the septic tank(whether meta;or not)is structurally unsotj ad,exhibits substantial infiltration or exfrltration or tank failure is imminent System will pass inspection if the exist' g tank is replaced with a complying septic tank as approved by the Board of Health. •A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indi acing that the tank is less than 20 years old is available. N explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or obs cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appr val of Board of Health): broken pipe(s)are replaced. obstruction is removed distribution box is leveled or replaced ND ex lain: e system required pumping more than 4 times a year due to broken or obsttuacd pipe(s).The system will pass ins ection if(with approval of the Board of Health): broken pipes)are replaced obstruction is rte w%cd ND explain: Pagel of l 1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:-�5o Li N`L-ycc� Owner* b2,C Date of inspection: 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 fa ing 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 sy rem 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 I 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 frotd 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 Ifailure criteria are triggered.A copy of the analysis must be attached to this form. 3. (her. P 3 Page 4 of i 1 OFFICIAL INSPECTION FORA—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: kC5D G>C(-X6 Owner: RUoe �— mt1; Date of Inspection: D. •stem Failure Criteria applicable to all systems: You st indicate'jes"or"no"to each of the following for all inspections: Yes o 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 4"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private vatcr supply well with no acceptable water quality analysis.IThis system passes if the well water analysis, performed at a DEP certified laboratory.,for eoliform bacteria and volatile organic compounds indicates that tine 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. Larg Systems: To be con idered a large system the system must scrve a faei'ity Avith a design now of 10,000 gpd to 15,000 gpd• You must dicate either"yes"or"no"to each of the following: (Tlie foll wing criteria apply to large systems in addition to the criteria above) yes no le system is within 400 feet of a surface drinking water supply e system is within 200 feet of a tributary to a surface drtn)ing water supply e system is located in a nitrogen sensitive area(interim Wellhead Protection Area-1WPA)or a mapped one Ii of a public water supply well if you h e answered"yes"to any question in Section E tlue system is con id red a significant threat,cr answered "yes"itiSection D above the large system has failed.The owner or operator of arty large system considered a significa# threat under Section E or failed under Section D shall upgrade the system in accordance with 3I0 CMR 15.304.jhc system owner should contact the appropriate rcgional'oflice of the Department. 4 : II Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 150 COV\C9f7l LQ-/v Owner:Qj6elrl��Uf--1 Date of Inspection: v Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes ,Jo ,/ Pumping information was provided by the owner,occupant,or Board of Health VWere 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 NIA) _ Was the facility or dwelling inspected for signs of sewage back up? t/ 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: l�rj Ca-r C bk--6 (21- � Owner: \�o { t` Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): a-uc f Number of current residents:_7— Does residence have a garbage grinder(yes or no): rv/ Is laundry on a separate sewage system(yes or no): [if yes separate inspection required] Laundry system inspected(yes or no):2--6 Seasonal use:(yes or no). f_v Water meter readings,if available(last 2 years usage(gpd)): I Sump pump(yes or no): x-a t d D OO Last date of occupancy: a COMM /RANDUSTRIAL - Type oCeent Design fl on3l0CMRi3.203): gpd Basis of (seats/persons/sgft,etc.): Grease tr (yes or no): Industriallding tank present(yes or no):Non-rani discharged to the Title S system(yes or no):Water mgs,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: v 2- Was system pumped as part of the inspection(yes or no): /L p If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYP�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): `7 s'— 9 l.71 S� 3 0'1�' Approximate age of all components,date installed(if known).and source of information: Were sewage odors detected,when arriving at the site(yes or no): /'U 6 !'Igc 7 of I 1 OFFICIAL INSPEC"I•ION FOI01—NO.1- FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEIVAGE DISPOSAL SYSTEM INSPECTION 1t 0101 PART C 51'SI•EI11 INFORMATION (conlinucd) Property Address:)5� C(,*t'(� �tvncr. � •�`� 11� + �ai� Date of Inspection: BUILDING SE1VE (locale on site plan) Dcpdi below gta Materials of cot truction:_cast irun _40 I'VC_oUur(explaill). Distance from rivale tt-ater supply Well or suction tine:_ Cununcnts(u condition of juutts,venting,evidence of leakage,etc.}: SEPTIC TANK:_(locate on site plan) Depth below grade: 1 Material of eonstructivn:_ vncrclt ntetal frbuglass pulyetltylerte _vll►cr(cxplain) If tank is metal list age:_ ccrlificatc) Is age cvnfirnttd b} a Certificate of Complian n Compliance(yes or u):_(attach a copy of Dimensions: C " F i. . h b ' Sludge depth: ,{ —3 Distance from lull of sludge to butlunl of uullct Ice ul bafllc.. ,r Sewn tl►iekness: •, Distance from top of scum to cup of outlet tec or bafllc Distance horn bottom of scum to bvuont of uullct tee or battle: I low were dirncnsium determined: p -7,^` �( Comments(oil pumping rccwnmcnJations,inlet and outict tcc or bafllc condition,sttuctwal uitcgtity, liquid levels as related to outlet utvert,evidence of leakage,etc.): ce— C;IIEASE TIU11':____(I arc un site plan) DcpdI below grade: hlaletial of eonstru lull:____t.uuucte metal Gliciglass__pulycthylene _other (caplaitl): —' Dimensions: Scuts thicknc Dislancc fro I top orscutn io lop of outict icc or bafllc: _ Distance G III botlunt or scull,to bullunt of outlet tcc or bafllc: Date of I I pumping: Cullum is(on pumping fccuummidatiutts,inlet and uullct Icc or bafllc conditwA.sh uctutal inlcbtily,liquid Icvcl, as rcla cd 10 outict invcrl,nidcncc of Icakag,c1c.): Page 8 of l I OFFICIAL INSITC711ON FON61—NOT FOR VOLUN•I*AI(Y ASSLNS(1ILN•l-S SUIISUIWACE, SLWAGl DISPOSAL SYSTLpI INSI'ECI•ION FOl(N1 PAI(T C SYSTLAI IN110101ATION(continued) rroptrly Addrt,s:)5Q ' &'—Cl �R\tt�� J L l Owner: J�j' C`10--, Uatt of Inspection: 3 _ 0 g TIGHT or 11 DING TANK,.' (talk"lust be pumped at time of ill speuion)(lucate oil site plan) Depth below ade: Material oft nstruction: cunude___ tiietal_fiberglass ` tiulyelhyfene otliei(explain): Dimensions- Capacity alluns Dcsigll Flo galluns/day Alarm Pic nt(ycs ui no): Alum Icy 1. Alann in 1vukin• uidcr ` Date of las(pumping: 6 [J'cs yr mu): Cumulenls(condition of alarm and flua►switches,etc.): ulsrluuurloN uox: �/ ; ___(f presalt must be opeiled)(loeaic on site plan) DcpAl of liquid level above oullcl invert: o II\ (� Cvnunults(Holt if box is level and distrit,utiun to outlets equal,any evidence of solids cai •over an leafage into or out of box,ctc.): n y cvidcmce ur U u.t K 5 y UEIl: (lucate on site plan) ng order(ycs or to): ng order es ( ur noe condition of pump chaulbcr,(olldillun of pumps and Jl'purteriall(cs,Eli:.): Page 9 of 1 1 OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address: 60 t Owner: V O.Hr Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): V{locate on site plan,excavation not required) If SAS not located explain why. T) � e _ P� t/leaching pits,number:leaching chambers,numb_er: leaching galleries,number: t leaching trenches,number,length: 4 G 15 leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): U CESSPOO (cesspool must be pumped as part of inspection)(locate on site plan) Number a configuration: Depth—t of liquid to inlet invert: Depth of olids layer. Depth o scum layer: Dimen ons of cesspool: Matey' Is of construction: Indic ion of groundwater inflow(yes or no): Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials f construction: Dimensi ns: Depth o solids: Cotton nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �50- C&tL-y6- Owner: Date of Inspection: ` I - 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. 6 n + i G I ~ J E F I _ � 4 I � � 3 4-' 10 Page I I of I i _ w OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: )50 COYC�cL ca"'� Owner: u�\ �J�I t Date of Inspection: SITE EXAM Slope Surface water Check cellar. Shallow wells Estimated depth to ground water 1 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) Accessed USGS database-explain: 1 You must describe how you established the high ground water elevation: 11 p 7HE Town of Barnstable O Tp� - . Regulatory Services „,R,,Sr,,B Thomas F. Geiler,Director 9� s AS p,Eo �a Public Health.Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 f This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts;Department of Environmental Protection. Although the Town of Barnstable Health Division received the original /copy of this report; this Division does not warranty the functionality of the septic system in the future not does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a "particul ar ar property would-be ' • P P P Y listed on the"Disposal . „ P Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. I I • COMMONWEALTH OF MASSACHUSETTS EXECUTIVE 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- 150 Concord Lane ? ems. Ostervi e Owner's Name: Bob Murphy Owner's Address: Date of Inspection Name of Inspector.(please print) William . • Robinson Sr. CompanyName: William E. Robinson Septic Service Mailing Address: P O BOX 1 089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that 1 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.1 am a DEP approved system inspector pursuant to Sectir 15340 of Title 5(310 CN'IR 15.000). The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 1 Inspector's Signature:�, , � Date: fma The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health% DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page i Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 150 Concord Lane Osterville Owner: Bob Mur h Date of lnspectlonz Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System asses: have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yeIs,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 exftltration or tank failure is imminent_System will pass inspection if the existing ta�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 expla' O•servation of sewage backup or break out or high static water level in the distribution box due to-broken or •obstruct 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 exp ain: e system required pumping more than 4 times a year due to broken or obstmsxud pipe(s).The system will pass ins ection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND a pWan: d I .Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 150 Concord Lane Osterville Owner: Bob 'fur. h Date of Inspection:: C. F her Evaluation is Required by the Board of Health: onditions 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. S tem will:pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the sy tem 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 sysTur, 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 ace 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 front a pri to water supply well** Method used to determine distance •'T is system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bact ria and volatile organic compounds indicates that the well is free from pollution from that facility and the esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failp criteria.arc triggered.A copy of the analysis must be attached to this form. 3. Othe 3 Page 4 of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 150 Concord Lane Osterville Owner: Bob Murphy Date of Inspection: —6 D. System F *lure Criteria applicable to all systems: You must Indic te'yes"or"no"to each of the following for all inspections: Yes No Backu of"sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discha"�ge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow Require 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 I00,feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. My 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 suppl�well with no acceptable water quality analysis. (This system passes if(lie well water analysis, performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds indicates(hat 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 a e triggered.A copy of the analysis must be attached to this forma (Ye o)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 coksidered a large system the system must serve a faci!ity 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 folio�l ing 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is crosidered a significant threat,or answered "yes"in Section D above the large system has fiu�ed.The owner or operator of arty 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 sysjIemRowner should contact the appropriate regional office of the Department. V � 4 f Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 150 .Concord Lane Osterville Owner: Bob Murphy Date of Inspection: cL -o j Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes -o 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? v — Has the system received normal flows in'the previous two week period? _ _-I./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? v— 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: 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)J 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 150 Concord Lane Osterville Owner: Bob Murphy Date of inspection: —.S'—G FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .-/S�J Number of current residents: 4— Does residence have a garbage grinder(yes or no): /L U Is laundry on a separate sewage system(yes or no)��[if yes separate inspection required] Laundry system inspected(yes or no):pL O Seasonal use:(yes or no): /I/ c--' Water meter readings,if available(last 2 years usage(gpd)): 200 4 — 93,00 0 Sump pump(yes or no): J/u — 2 ,000 Last date of occupancy: F—S•-d COMMERC L/INDUSTRIAL Type of establrs enr. Design flow(b ed on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap pr sent(yes or no):_ Industrial wa to holding tank present(yes or no):— Non-sari waste discharged to the Title 5 system(yes or no): Water met r readings,if available: Last date f occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 26 b Ir Was system pumped as part of the inspection(yes or no): ADO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE F SYSTEM eptic 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 sure oft formation: t5 �/ Were sewage odors detected when arriving at the site(yes or no): � 6 • 1'agc 7 of I 1 OFFICIAL INSPECTION FORA'I—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 1 50 Concord o d Lane Osterville Owner: —Murphy Date of Inspection: BUILI)M/SE ER(locate on site plan) Depth bel : Materialsuction:____cast iron 40 PVC other(explaut): Distanceate ►eater supply well or suction lute: Comments(on condition of juutts,venting,evidence of leakage,etc.): SEPTIC TANK: _ locate on site plan) ) Depth below grade: r Material of construction:_concrete metal fiberglass�,olyetltylene othcr(explam) _ If tank is metal list age: Is age cottftrnted•by a Certificate of Compliance(yes or nu): certificate) —(attach a cop),of i, v ►� Dimensions: 6 . $ 4 Sludge depth:_ Z �/ s Distance from top of sludge to bottom of outlet Ice or bafllc: _ Scum thickness.: ;L Distance from top of scum to top of outlet tee or baffle: ' j 1, Distance from bottom of scum to bottom of outlet tee or banie: Ilow•were dimensions determined:_G J&'d.A. Comments(on pumping recommendations,inlet and outlet Ice or baflic condition,structural integrity, liquid Icvcls as related to outlet invert,evidence of leakage,eic.): ) 6 b-0 Tr s- C S L GREASE TRA :_(locate on site plan) Depth below adc:_ Material of a nstruetion:_eoncrcle_metal fiberglass polyethylene__other (explain): Dimensions Scum Ihic less: Distance bill top—or—scull,WWI)of oullct lee or baffle: Distance .otn bottom of scum to bottom of outlet Ice or baffle: Date of I st pumping: Conune is(on pumping recontrnendatiuns, inlel and outlet Ice or banle conditioA, structural inlegrity,liquid Icvcls as rela d to ou(lct invert,etidence of leakage,etc.): L ' 7 'age 8 of l l 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORAIATION(continued) Property Address: 150 Concord Lane Osterville Owner: Date of Inspection: S-'G TIGHT or 11OL ING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra e: Material of con truction:,concrete_metal fiberglass_pulye illy lefie otiter(explau)): Uimcnsions: Capacity: gallons Design Flo gallons/day Alann pres nt(yes or no): Alarm lev Alann in working order(yes or no):_ Date of last pumping: Comrncnts(condition of alarm and float switches,ctc.): DISTIUBUT10N BOX: ✓ (if present must be opcned)(locate on site plan) Depth of liquid level above outlet invert: O Conunents(note if box is level and distribution to outlets equal,an)-evidence of solids carryover, any evidence of leakage into or out of box,ctc.): �C PUMP CHAMBER: locate on site plan) Pumps in working ord (ycs or no):_ Alarnts in working o der(yes or no). — Commcnis(note c ndition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 150 Concord Lane . Osterville Owner: Bob Murphy Date of Inspection: 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavatiodnot required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: E� aching galleries,number: c ' leahing trenches,number, length: �� r✓ 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.): D CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and co figuration: Depth—top of squid to inlet invert: Depth of soli layer: Depth of sc layer: Dimension of cesspool: Materials f construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): .•7 PRIVY: (locate on site plan) Materials it construction: Dimensions: Depth of solids: Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I I ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 150 Concord Lane s ervi e Owner: Bob Murphy Date of Inspection: -CS 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. AN s� 1 l ' r . 1 e .�✓ l� 10 Page l l of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 150 Concord Lane Osterville Owner. Bob Murphy Date of Inspection: �'_C✓o $'� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water )S 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 ISO feet of SAS) t/Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how yqu a tablished the high ground water elevation: 11 T� TOWN OF BARNSTABLE LOCATION "` 4' ' ll" L'i SEWAGE # 95- 1-1 iS Vhi-LAGE '� (AKE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 775-'Y"Z'Tfl�, SEPTIC TANK CAPACITY �-�- LEACHING FACILITY:(type) CACI f'! (size) aX N k Cc� NO. OF BEDROOMS -3 PRIVATE WELL OR PUBLIC WATER OR OWNER VPr� /���f DATE PERMIT ISSUED: R DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,t Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility EdLye of Wetland and Leaching Facility 'a i rt� 1 A*CO o, No. , ASSESSORS MAP NO'—,`� Fee 3 0..0 0 THE C SACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Migw6ar *pgtem Congtruction permit Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. ,� vd 150 Concord Lane Os / Gila R. Murphy 775-0389 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. P.O. Box 1089 Centerville W.E. Robinson Septic Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder Po) 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 Description of Soil sand Nature of Repairs or Alterations(Answer when applica le) D— Box and Title V Leachtrench Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code an of to place the system in operation until a Certifi- cate of Compliance has been issued by this B f alth.� (�� 9 Signed ! Date / �} Application Approved by Application Disapproved for the following reasons Permit No.� �' Date Issued ——————————————————————————————————————— No. �./ ` / Fee 3 0.0 0 r THE COMMONWEALTA�F MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS I f' ZIpprication for �Dioogal *raem Congtructi0n Permit pplication is hereby made for a Permit to Construct( )or Repair( g)an On-site Sewage Disposal System at: ` Location Address or Lot No, Owner's Name,Address;and Tel.No. t 150 Concord Lane 0,5 <���, R. Murphy 775-0389 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. s P.O. Box 1089 Centerville W.E. Robinson Septic Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder Flo) `. Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures I Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Description of Soil sand Nature of Repairs or Alterations(Answer when a�plica le) D- Box and Title V Leachtrench r Date last inspected: Agreement:, The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code an of to place the system in operation until a Certifi- cate of Compliance has been issued by this B f alth.� Signed Date / Application Approved by 'j Application Disapproved for the following reasons Permit No. �` � 1 Date Issued ' — — ----- ---- . ---�, --- THE COMMONWEALTH OF MASSACHUSETTS ab PUBLIC HEALTH DIVISION BARNSTABLE, MASSACHUSETTS Certificate ofXompliance ` THIS IS Ty CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on by W.F.-1obinson Septic for 150 nan-d sane � as has been constructed in accordance,. with the provisions of Title 5 and the for Disposal System Construction Permit No. dated , Use of this system is conditioned on compliance with the provisions set forth be ow: 1-7 Z-- i No. Fee 30.00 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Itooml *p6tem Congtruction Permit Permission is hereby granted to W.E. Robinson Septic Service to construct( )repair(x )an On-site Sewage System located at 150 Concord Lane Osterville f 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. All construction must be completed within two years of the date below. v��7 Date: 9 ''-' Approved b �d CERTIFICATION OF SKETCH AND APPLICATION FORA DISPOSAL 1VORKS CONS'F1WC'17ON I'EItMI'I' (�VITIIOU't DESIGNED PLANS) hereby certify that the application for disposal works permit signed b me,dated `— r— 7 con'cernin the constructionN E �Y � � property located at l,� U C e � meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are nb private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. r _ c SIGNED : L DATE: ` s LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER ` IAttach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I �� �'.J r _..�; � -� � ( � "VV � �� �, �kc l� l•'3CAT10N �� SEWAGE PERMIT NO. rr . TJa . k'y-s 3 . VILLAGE INS A LLER'S NAME L ADDRESS e Ul DE R �e Olt ,OWNER 1 oDATE PERMIT ISSUED 'kDATE COMPLIANCE ISSUED O 1 / x 33 S`?� ` � D oT No....... .. .�3 F>a..,. j.._.............. ,L� • a i THE COMMONWEALTH OF MASSAZ:HUSVrTS sue` BOARD OF HEALTH 2,3 Lt 4 .RP'9...-.. OF.....-...... ..................... I,e-b , pplirFatiun for Disposal Works Tonstrnrtiun ramit Application is hereby made for a Permit to Construct (><) or Repair ( ) an Individual Sewage Disposal System at: Locati -Address or t No. er 1 tdr e c4- 0.�2r. .. _'� ...._cnr- 1- GJ s eC' �1--.. ..... c a Installer Address U Type of Building Size Lot.��_A.0�___._Sq. feet Dwelling—No. of Bedrooms..... 9:29: ..................Expansion Attic ( ) Garbage Grinder ( ) 'k Other—T e of Building No. of persons............................ Showers Pk Other—Type g ---------------------------- -------- --- ( ) — Cafeteria ( ) dOther fixtures -----•-----•--- -------------------•-•- ••---•-•-••--------•-•-----• •-------•-•--•-••---------•-•••-•--•--....-•-•-•......------ W Design Flow........5.5.............................gallons per person per day. Total daily flow.........33.Q......................gallons. WSeptic Tank—Liquid*capacityl()D..gallons Length—IV—AL. Width..W..A__'r Diameter................ Depth5_'..B_''- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..__................sq. ft. i 3 Seepage Pit No.......1............ Diameter.....I_Q_......... Depth below inlet.......(0.`P...... Total leaching area..Z4?.�___sq. ft. Z Other Distribution box (a/f Dosing tank ( ) - �3 t4 a Percolation Test Results Performed by-__--•J!:k!;: Zest. 0.1.9............................. Date......-_. ____.__---•_______.......... Test Pit No. l..{.z-.._._minutes per inch Depth of Pit...1 `._....... Depth to ground water__Nrn 1­444 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ p' ?esk-•P _N_Qa i 2'' �-�?a*M....:! ._:5� sF: L 12'.__S_�ncA. .. -----••••------- --------•-•-••-•-. o Description of Soil-----......-•--------------------------------------------------•-•-•---------...------------------------------- •------------- x V ...........................••---••-•••-•-•-•----•.........------------....•--•••••-•-•....------•-----....-••-•-••-•----.....----•••--•--•-------••----------••••••-•-•......-•--------•-•-_.._._ .. W ---•-------------------------------------------------------------------•---------------------•-----------------------------------------------------•---•--•------------------------•--•-•-............. M. Nature of Repairs or Alterations—Answer when applicable................................................................................................ ------------------------------------------------------------------------••-----•.........--- Agreement: *11 ' sgned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in t to ompliance has beenrn issued by th�e/board of health.Signe kn t � aiDate provedBy-•••-••--••--•-•-------•-.. ..... •... . _..... 6111jt. ----•--- Date approved for the following reasons: ------------•-----•--------------- ------ ....-----•-•--------------------------------•..__.....-•-----------•---------------------•----------•--••-•-•----•----..-_ ......-•---•---- Date PermitNo......................................................... Issued_....................................................... Date -------- ----- - - -- - - -- -- -- - -- --- -- - - - No...... 33 ..................... +q Sr THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Disposal Works Tonutrurtinn Prrutit Application is hereby made for a Permit to Construct (p<) or Repair ( ) an Individual Sewage Disposal System at: .. Lo ati -Address--q, ,._ or Lo No. .... O ................... =� ---M '`----',J1-`---.L�t -C .:.............._----- I - ner _ Address P- c? .... ............................. t ..................................... � Installer Address Type of Building �� Size Lot__I—Z-1.03---------Sq. feet I•—. ` Dwelling—No. of Bedrooms--------OV RUL..................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -,!...................._--- No. of persons____________________________ Showers ( ) — Cafeteria ( ) d Other fixtures ___________________•______._ W Design Flow.......... _-�_-_•_-••_•_.4..._..•---._gallons per person per day. Total daily flow............... . ____--._____gallons. G: Septic Tank—Liquid capacipy------------gallons Length_!5`_k?_ -• Width.W_10`r Diameter________________ Depth__ 11_1�.`_1. Disposal Trench—No._..__...`___.•_..__. Width.................... Total Length......._-__.-_•____. Total leaching area....................sq. ft. Seepage Pit No.......1------------- Diameter.....0......... Depth below inlet......k.`......... Total leaching area.Z:'�?�P_.__sq. ft. Z Other Distribution box (%,-f Dosing tank ( ) +1 3 `� 0-4 _ ., Percolation Test Results Performed by......................Zes-t `p _.-...__•--•.•_____________•• Date........_ ._ _•.-_---__ .-.._•._... Test Pit No. 1... •_ ......minutes per inch Depth of Pit.}_� _�___••____ Depth to ground water_N "�________. fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water..._____.__________._._- D Description of Soil -•-----•- -------------------------•=----=--•-----•--••-==�-�-�------------------------------•--•--•-------------•-------------------•----•------------- V _----------------------------------------•-----.......-------•--=----------------...- =---•--•-•-----•-----•---•---------•---•---•-................................................................ W -----------------•••---'------•---•----------•--------•---------------•--•-----••------------------•------•-- ------ U Nature of Repairs or Alterations—Answer when applicable_____________________________•-________..-_____._._____._______.._.___.____.___._-_--_•.-_.___- ..•-••••--••--•-----••-•••••••••--......•••-••••---•••••••-•••-•••••••••---••••••-••..............•••••••••••••-----•---•••-----•••--•••---••--•-----•••--••-•---•••-••••••••••••••-•._...----------•••- Agreement: Th mdersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the pr vi _us of TITI., 5 of the State Sanitary Code— The undersigned further agrees not to place the system in ope do until t•'cate oI, ompliance has been issued by the board of health. y 4 � s Signed '�?� .._�-- l.v 1 �.�C.... Applicati pproved By............................... at : - .�..---- . ---•-- ----•-- � ' .-•------ Date Appli tion Disapproved for the following reasons:-----•--------•--•-------------•----•------------------•-------------------------------------------------•-..._ --•................••--••...-••-•----•-•-----._....•-•••-••••--•-•-••-•••-----••...------•---•--•---•••--I--....-•••--•----•-•-•-.._----•-•-•••-•--•-----••••-------••--•-•-----••••-•---•-•••••---••---- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ...............OF......... t'.. .n.5. :..I� •t�•-r_................. t (Intifira#r of Tuutplianrr THIS IS To CERTIFY, That the Individual Sewage Disposal System constructed' -(K',) or Repaired ( ) y ------------•---------------------------••• ••-•-•----•-- •••--------------•---•-•-••-•---•-•-.....-.•.-.........•----•-------•.....-- Installer has been installed in accordance with the provisions of TITIF 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No g ............ dated____ ___________________________,_______-_______ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE S 'STEM W FU CTION SATISFACTORY. DATE.-... l Inspetor_..----------••-•--•----------------------------- ....... ......................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 4.. t�.?.. 1..............OF......... G''� ,s1 ��'- f��� _...__-.•............. fy Disposal Mortis Tnnutrttrtionrrutit Permission is hereby granted....__? U�'______-�:��..•_•_.•�-�-��- .............•--- ---•-------...•----.......•••••...._..••-.•............. to Construct( X) or\Repair ( ) an Individual SSewa e Disposal System atNo. L<: -----tom : r� •c..--------�.....................•...-.---------------------------------•----•----••---------•----------- Street 11 as shown on the application for Disposal Works Construction Permit No __________________ Dated......................_.................... �+. /CJ ([ Board of Health DATE .-•----••---._.....•----.L..-----•••-.......•--••••-•-------- z FOR,/255 A. M. SULKIN, INC., BOSTON 51►.�GLG- F,AMALY - BGpR0OM uo 'GARBAGE Gwr.rDE2 DN%Ly FLOW z 110 X 3.= . SEPT%G TA►JK USE- t000 GAL. o D15Po5n� PIT v5E lvo0 GAL. o ` 50TTOM AREA= 5 p S,F• x t. o 5 o G.P p /3 7 -ToTA1,- 0E5IGN � .g25 9 A o • 7 .o O P i •'TaTAL. DA 1 LY FL-ov( - 33 �• • � ,� D�� . : , PE2COLATIoN RACES I''Icv I 2MIN o�Lt~55, I c DAVID.C. i! TNULIN u No. 2997E .''•\��` c P ` �; Gyp ,[1.. � :s '. Its i Z� op FWD=990 I ,.y�y •8 C en I i / � ♦yr�ST' ,4 1000 tN�. ys0 II Bo X SfiPT�G /7" �; Z IOoo INl, 9S!G TANK I' LEacu • PIT INV.. INV. wlTu iI WA(5uGD CEeTIF►G0 P�.o'r P1..ArJ PRUFIL� O SCALE �j CA L E S/ZZ/ I' 2E 1,4 GE t, CERTIFY 'THAT 'THf= I G� l-n� J 5NC)wN NEREOI.1 COMPL%. 5 YJITN'CNE SID6LIN � ��jT' /Z A w D 5 ET 5,G K R.6 Q O 1 R.E M E.NTH -TOWN or- BAekl15T4??_C AND 14,, 1.10"' i LOCp.TED -WITH►1J NE GLOoD PLA1N •�4T,trD Z7 /97, DATE C2 8AxTE2e. WYE INC. j Tu►S pLQN 15 No'T f3t`5r n ob AN osTEcz.vILL� IW5TV"-uMENT 9-v1_Y �`rNE 01=F5ET5 Suou� �I No-T ©E v5EpT0 DETE.FZ/^I►�E l oT -INE. APPLICAr,;T