HomeMy WebLinkAbout0020 FILLY WAY - Health 20 FILLY WAY,MARSTONS MILLS
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COMMONWEALTH OF MASSACHUSETTS 9
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EXECUTIVE OFFICE OF ENVIRONMENTALRS d®
j DEPARTMENT OF ENVIRONMENTAL P ECTfR � I,P
DIVED
? ONE WINTER STREET. BOSTON, MA 02108 617-292 _5`00
2 5 1999
TOWN OF BARNSTABLE
WILLIAM E..WELD.< (i Q HEAIJHDEPT. TRUDY CORE
Governor U Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM B ' I Commissioner
PART A
CERTIFICATION.
Property Address: 20 Filly Way Address of Owner: Michelle Mango
Date of Inspection: Marstons Mills (If different)
Name of Inspector: WM E Robinson Sr
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic SerV; M=
Mailing Address: PO Box 1089 , ntPr V; 1 1 A* MA 02e32
Telephone Number; 5 0 8 7 7�,_R 7 7
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
r✓ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails \�
Inspector's Signature: L„.,..�- Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] PASSES:
7have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B YSTEM 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.
Indi a yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/Avww.magnet.state.ma.us/dep
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1
I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
�r+ S SU FORM ,
PART .
CERTIFICATION (continued)
YP rope rty,Addressal '20 Filly Way Marstons Mills
Owner: Michelle Mango
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due`to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
C) RTHER 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 20 Filly Way
Owner: Michelle Mango
Date of Inspection: pJ—
D] SYSTEM FAILS:
You ust indicate ei;!;er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
LBackup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
LDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s):.
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LAR E SYSTEM FAILS:
You m st indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The o ner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
require nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST ..
Property Address: 20 Filly Way Marstons Mills
Owner: Michelle Mango
Date of Inspection: /I—1
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout. .
_ All system components, excluding the Soil Absorption System, have been located on the site.
11� _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
L/ _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
I
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)] -
it
(revised 04/25/97) page 4 of 10
L Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART-°C'
SYSTEM INFORMATION
'iPioperty Address: 20 Filly Way MarstonssMills
Owner: Michelle Mango
Date of Inspection: yl—lam q f
FLOW-CONDITIONS
RESIDENTIAL: ,
Design flow: L e .p.d./bedroom for S.A.S.
Number of bedrooms:`/
Number of current residents:
Garbage grinder (yes or no):__Ae p ��
Laundry.connected to system ( es`or no):>.
Seasonal use (yes or no):V 1996 59, 000 gals
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump (yes or no): /e, 1997 bb, 000gals
1998 36, 000 gals
Last date of occupancy:
COMMERCIAL/INDUSTRIAL:
Type of stablishment:
Design fl _w: gallons/day ...
Grease tr present: (yes or no)_
Industrial ante Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water me er readings, if available:
Last dat of occupancy:
OTHE : (Describe)
Last occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System mped as part of inspection: (yes or no)_,& a
If yes, volume pumped: >;allons
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)L
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C:,..
0. SYSTEM.INFORMATION (continued)
Property Address: 22 Filly Way Marstons Mills '
Owner: Michelle Mango
Date of Inspection:
BUI ING SEWER:
(Locat on site plan)
Depth low grade:
Materi of construction: cast iron _40 PVC_other (explain)
Dista ce from private water supply well or suction line
Dia eter
Co ments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grader ray
Material of construction: oncrete — —metal Fiberglass Polyethylene —other(explain) W x
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: G 6 A 6
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: y
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: ) O
How dimensions were determined: i'�^-
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, epth of liquid level in relation to o tlet invert, structural
integrity, evidence of leakage, etc.) a1�O Q.a ��A. � � 6�s c�� Gar+- y
A 4 & 1.y :zI w► i
GREAS TRAP:
(locate site plan)
Depth low grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene—other(explain)
Dimensi ns:
Scum thi kness:
Distance from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date of I ast pumping:
Comme ts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrit4, evidence of leakage, etc.)
(revised 04/25/97) Yage,6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
• SYSTEM INFORMATION (continued)
Property Address: 20 Filly Way. Marstons MIlls
Owner: MIchelle Mango
Date of Inspection: ///.r 9
TI T OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(local on site plan)
Depth low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ions:
Capaci gallons
Desig flow: gallons/day
Alarm level: Alarm in working order_Yes; _ No
Date o previous pumping:
Comm nts:
(conditi n of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_v
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, eviddeenc f solids carryover, evidence of leakage into or out of box, etc.)
PUM CHAMBER:_
(locate on site plan)
Pumps working order: (Yes or No)
Alarms working order (Yes or No)
Comme ts:
(note c dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Filly Way Marstons Mills
Owner: Michelle Mango
Date of Inspection: ,/—/—dl_�7_ _
SOIL ABSORPTION SYSTEM (SAS): V
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type;:..
leaching pits, number:
leaching chambers, number.
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs
f hydr lic faire, level of ponding, condition of vegetation, etc.)
/ .S�� h-� � C,l L l . G 17r2-
CES OOLS: _
(locat on site plan)
Numbe and configuration:
Depth-t p of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimensi ns4of cesspool:
Material of construction:
Indicatio i of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comm nts:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on ite plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(raviaad 04/25/97) Page a of 10
4 ,
F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 20 Filly Way Marstons Mills
Owner: Michelle Mango
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
c3�ci�
t/
(revised 04/25/97) Page 9 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART
SYSTEM INFORMATION (continued)
Property Address: 20 Filly Way Marstons MIlls
Owner:
Michelle Mango
Date of Inspection:
x
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained.from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in yo r own words how you established the High Groundwater Elevation. (Must be completed)
6J 8 �V �GaRe(�� / 9
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(revised 09/25/97) Page 10 of 10
L
l TOWN OF BARNSTABLE
LOCATION�d F-Illu i nz SEWAGE # ��. 7�
VILLAGE ASSESSOR'S MAP & LOT/-!5-/-dLf5?
INSTALLER'S NAME & PHONE NO�641 ?4�/'rrx4T X, V-'
SEPTIC TANK CAPACITY /LSt- (2/
eaD
LEACHING FACILITY:(type - I/,�U� �f?.i�r�;Am �C (size
NO. OF BEDROOMS
'7` PRIVATE WELL O PUBLIC WATER
BUILDER _Ra[ OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
No
VARIANCE GRANTED: Yes _
i
i
0
0 3 ,.
0
No. Appnom ��� ` F�$...�®...............
COMMONWEALTH OF MASSACHUSETTS
T P OA R® OF HEALTH
OWN OF BARNSTABLE
Appliratiutt for Di►ipnittl Worbi Tongtrurtiun Permit
Application is hereby made for a Permit to Construct ( ) or Repair (D<) an Individual Sewage Disposal
System at: ��� S
- Location-:\d m55 or Lot
-- --------
L J_A14`�?U GU-4 1
-----------------------------------------•------------......----••---------•-•..........� L....................
o,cner dress
---•----•--•...........l..---.•...--------•-----------•------------------------- GJv49.'� ./ /!/Ill t�
......•--_---- --•-.------
Installer Address------••---------------•-----
��oou "
d Type of Building Size Lot__ __l._.___..._..Sq. feet
U Dwelling— No. of Bedrooms............. ---------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
dOther fixtures .---------_------------ ------------_----------------------------------------------- .............................................................
W Design Flow..................- _..._.-__----gallons per person per day. Total daily flow_..-_........_.�YW---................gallons.
WSeptic Tank—Liquid capacity�...gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench--:�o. ........1........ Width.....77___------- -Total Length--_- ... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet..... Total leaching area..................sq: ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---------...............
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a, --------------------•---------•--------------------------....._...------..........-------•-••................................................................
ODescription of Soil........................................................................................................................................................................
UW ---------------------------------------•--------••----•-............._.....----------------....-•-------•-----•------------------•--•--------------••--------------------------------
Nature of Repairs or Alterations—Answer when applicable----i4'�_.___.._. ...f .�`T ...... *
..........�-�.... ...........%�_---••-Fad....r..j�--.......�- ......-�------. 5� >.................................................. ` '
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance s en ' su by e board of health.
_ ` u�
Signed ....... ........................... ...... .................................... . .. ........ ......... ........ g!..7n'..
J Dare w
Application Approved By ...... . tr�` .....-T -... � -. . 7..---'-��
Dace
Application Disapproved for the following reasons: ......- . .. .......... . ............................ ......................
....... ............................... ......-------------------------------------------------- ---------------I-----------------------------------------------......................... ........................................
Permit No. ..... ........... ... Issued " ,
Dare
,:3:......::..�....��~r"_� _....�.�. _�a..r•,w„r�,-�..,�:.-.o..�..,._.Wa..-......mot-..�,....;...:..;:....1�;.;: '' -�.+ --�'�.—�-•---v+----•�-d.--�-..-
- �.-^..n'�,,,-.�'- - b.`...r....+.c,-.w'.'-.+-��.........�-..'..-...se, ✓yam y _..,1
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No. ' .......... . �� FEs...�O...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
. pphratinti for Diripini t! Works Tomitrnrttnn rrm t
Application is hereby made for a Permit to Construct ( ) or Repair (DC) an Individual Sewage Disposal
System at: , r
....................................................... - _ .......
�= � 'a6e. .: .
Location-:\ddress a.
�. L -2o //! t/ Gum`� IAt I�� s:�C c ,a - --•---...... -----•--- ---- -- ------- ------------- ` .-•-------.......,..
owner Address
a ,�-=•6•2—t ,?�c67,. •--- G�, l ! JC TiQ! ��rJ .4>L �9-_d-U� , ••'�hi ' 'iUIIGI�.. .•
Installer Address �.
U Type of Building - Size Loth •-.Sq. feet
Dwelling— No-of-Bedrooms................�---------------------Expansion Attic (•; ) Garbage Grinder ( f )
aA-�
Oth& Type of Building ........................... No. of persons Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------------------------------------------- -----•------•••--•-••••-••---•-•--•-•----•---................
W Design Flow..................-S ..............gallons per person per day. Total daily flow...____......_y.'. ...................gallons.
WSeptic Tank—Liquid capacityl��...gallons Length________________ Width................ Diameter................ Depth................
x Disposal Trench--No. ....... ........ Vb'idth...._77.......Total Length-_-- �� ./.._. Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet..... !___.. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----------------------------- ............................................ Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 •---••-•--•--••------•------------------------•-••-------•---•----•-•-------------••-•-•-...._.............................••----------.............-•---.---
ODescription of Soil........................................................................................................................................................................
V ....••••••••-••--••••---•---••-•-•.........-•-----------•-•--••----------•---•-•-•---•••-•------------•-•--•••--------•-•------------•••---•--------••••-----•---•-•-••-........--•.....................
UW ..---••----•----------------•---•--------•--•--•-•......--••--------••--._._... -•----•-----•--••------•--••------------------•----•-••••---------------••-•----••••••••••..._.._•-- ._..._.......
Nature of Repairs or Alterations—Answer when applicable-----A: ........... !J��'C.S r ........ .........
s_-_S J3,J£.• � .STi.`1 - .j.� Z ------ 5C- ..................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Signed ..........//...Lv� -'(----.: .� 1 '� ............
...... ........ y
Dare.A..........
Application Approved By .. .-`...F=................ --
Dare
Application Disapproved for the following reasons: ..........................................�:. .. .......... ...........................
................... ................................................................ ... .................................................--........................................ .......................................
Dace
Permit No. f+`".. ... Issued ...... -" X ''' �
.....
IDace
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Q�rr#ifirate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (N—'- )
by......... ............................. .. . L_. Z �' ...... ; a-�0�
.................................._................... ... .......................
laa jk,
at ---------------------._---------------------------)o ..4-� .` ...._......G.1/1 Ll/.... ZiCI.S i7 .,....✓ '4
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. _..'` ......__- dated .`� .� -c-�, .�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE... ....... t`.... , . .. . . ........ Inspector :.... -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE �a
FEE.---••-•....--
............
Dispoo 1 Worhp Tamitrurtiaan f rrmit
2i-Q LC.-,77 W c.! /ri,)
R��
Permissionis hereby granted................................................................................... ..........................................................
to Construct ( ) or Repair (` ) an Individual Sewa e Disposal System
atNo..........................................------------- ....•--------- �=-'�--------ln/.�f*.-/-------------1 .----Z..................................�
Street �f
as shown on the application for Disposal Works Construction Permit�No���_ _ Dated_---._
rt- ''
•- :-
Board of Health
lDATE------ -------•--...-----------•---------------:-------•--------------------
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
LOCATION l,c��' �^ \\ l i.� SEWAGE # 6 a
�LLAGE ASSESSOR'S MAP & LOT \S b
'`INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY SO Q
LEACHING FACILITY:(type) \@ 5 (size) 6
NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE
BUILDER OR OWNER L �� �,� SO�� O
DATE PERMIT ISSUED:
DATE . COI-iPLIANCE ISSUED: C
VARIANCE GRANTED: Yes No ��'
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