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HomeMy WebLinkAbout0120 GREAT HILL DRIVE - Health 120 Cheat Hill Drive ' _ Marstons Mills I L-AA= 174 - 037 e ,I I u cljmo� him r Corn �037 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ✓ea.Y r Property Address Owner Owner's Name information is S required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. I Important:When filling out forms A. General Information on the computer, S use only the tab 1. Inspector: key to move your cursor-do not I+ ,� use the return N`'�a'1'��^ e f key. Name of Inspector Company Name 9 Lid^- /Zv Gh Company Address Cityrrown State Zip Code Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Kpasses ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Insp or's SignaturOVDate 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. �O Y Mrs-3/13 Tille 5 official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address r C'[ 4ic- r Owner Owner's Name information ieG��J 1� l� required for every T / �"��/ 4 Z6 1 Z •:��/G / page. Cityfrown State Zip Code Date of Inspection 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): Lt5im /13 Title 5 Official Inspection Fomc Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface rlSewage Disposal System Form_-Not for Voluntary Assessments p / Property Address Owner C ( vZ p 1 Owner's Name information is required for every '��'�� �4i3l e- ,/' page. Cdylrown State Zip Code Date of 1 spe tio� n B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is le veled or replaced ❑ Y ❑ N ❑ ND(Explain below): i ❑ 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-313 Title 5 Ofiaet inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is / / required for every A-r N j 4,to/L page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 EB No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Lam" 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 I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. r 12 0 t ,ems.+ 1-1 /2-t`v� Property Address Owner Owners Name - information ig required for every �` `r14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ®/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Eg--' Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Eg/- Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ EV Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ [91' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 1300"' 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 be attached to this form.] ❑ E?,-" The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 0/ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"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•3113 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 Property Address CIye-4 Owner owner's Name information is 13`�r t4 jh,/_�J1,e- (� required for every -� page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ®/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E3,"" Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Eg,.-- 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. ❑ [V Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E9'00K 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 be attached to this form.] ©/ 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 exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � s Owner Owner's Name information is � '�� L9 J Z required for every j U t 5_A'/rJ_ page. Cityrrown State Zip Code Date of trispection 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? [tx ❑ 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: Ea ❑ Existing information. For example, a plan at the Board of Health. ❑ Isr/" 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): ?� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•3113 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 e Property Address �[ Owner ( `✓� rT! Owner's Name information is required for every ` �d id page. City/Town g/ State Zip Code Date o—f spection D. System Information Description: 51 Number of current residents: Z Does residence have a garbage grinder? ❑ Yes 9--RTo Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes 9--Vo Laundry system inspected? 9—Yes ❑ No Seasonal use? ❑ Yes U.--Pd'o Water meter readings, if available(last 2 years usage(gpd)): Detail: �� f 3 � /tl�► /C Sump pump? ❑ Yes [L}-1V"o Last date of occupancy: L=-y`�"'`-� Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address . Owner Owner's Name information is required for every �'�"164} page. City/I own State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ Lg 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'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is `' _ required for every I y"� 7 �lO[� ,!� �(� L page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes 9-lgo- Building Sewer(locate on site plan): Depth below grade: Ll feet Material of construction: ❑ cast iron 940 PVC ❑ other(explain): ti 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): Depth below grade: 3r 9 f 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 J��� Dimensions: �l r� Lr 6 r f 1C it tf'73`�s' Sludge depth: t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Dispose)System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,. 1.7 0 beef- Property Address t( 'e LT / Owner Owner's Name information is A,� required for every ( �` '�"i �� T Q f✓ Z_ S' /r page. Cityrrown State Zip Code Date 6f Ins'ection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness .t Distance from top of scum to top of outlet tee or baffle G r� Distance from bottom of scum to bottom of outlet tee or baffle g — How were dimensions determined? S `- f +� Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I've, Owner Owner's Name information is L '�� / required for every � t�V f +r h 1-� °� O,7G 7� ! 6 lS� page. Cityffown 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 fiberglass ❑ ❑ g ss El polyethylene El 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systemm Form-Not for Voluntary Assessments Property Address Owner O wner's Name information is required for every EA,-o jok we- page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 r t 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.): gt11�:(.a Ct / �ij C`i i. Gv T v v 'c Q•2.,S —) s !L 4c— Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2-J� 4 M 1 � Property Address C it, Owner Owner's Name information is firv,I �/� �� bZ 6 I Z-required for every -'- page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers number: ZF ❑ 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.): v lli® i--a 1'r VV t , of K7� l �- ex cew i-VI t? •s t. d c:e•'�t r� � 44c,., 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 t5ins•3113 Title 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 y I L D >� Property Address C— Owner Owner's Name information is required for every i, w 0 Z-G T e- v//G/,/S' page. Cityffa.m State Zip Code Date of Inspection D. System Information (cont.) 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (so Property Address i ve-�fi Owner Owner's Name information i every required for every b to /W 0z'6 3 2 page. Citylrown State Zip Code Date of Insifection 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 �rPf� ,, '6,�� iJ✓'Ili-2 (.Jt✓�G„p T "T Al t CY /oov-ti ,r I 32.s' 3 q0' 6., o z Ll 3 y/r3 � � h h( e 49 j' Mns•3/13 Tide 5 Official Inspection Form:Subsurface Sewage o.lsposal System•Page 15 Or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is B pv✓'Vl k,1 A� required for every !v"1 page. CitylTown 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: `U feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, da te of design plan reviewed: y- Date ' ❑ 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: You must describe how you established the high ground water elevation: %A J, c/ Before filing this Inspection Report, please see Report Completeness Checklist on next page. Mns•3113 Me 5 Of<dal Inspedon Form:Suosurrace Sewage oisposai System•Page 16 or 17 f ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is // / required for every � � �j� � �TG�� �'e- ! ZG / 5-- page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist El"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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BAPNSTABLE e.C- `-11/ LOCATION I�� ��� SEWAGE # VI.LLAGE C' t � 114,01-P&t22� __ &SOR'S MAP & LOT — `? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY L` ��C ,l° l LEACHING (size) (S FACILITY: (type) �`�-� i�����iG2C NO. OF BEDROOMS__ BUILDER OR OWNER — PERMITDATE: COMPLIANCE DATE: (A.-q bq Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . I *-3'-d� TOWN OF\BARNSTABLE LOCATION laO Grc, SEWAGE # VILLAGE CQ✓1Te,-✓116 ASSESSOR'S MAP & LOT INSTALLER'S NAME&Pe 4"' SEPTIC TANK CAPACIT LEACHING FACILITY: (type) 3' Ce% 4c fS (size) W ' 4 ST0AJL NO. OF BEDROOMS 3 •BUILDER OR OWNER RANI C1 VAI, �PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / I Feet Furnished by S<n_'I(. S, tl�on For (�Te'tvo 1 A ' io 3i- 3� Aa- 30 a A3- 16 3 O TOWN OF,iAtNSTABLE �j� '✓ LOCATION )02oTr'- �/� �/,�• SEWAGE # VILLAGE JJ &&eff- �ASSESSOR'S MAP & LOT ®,3 ..INSTALLER'S NAME Si PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)� ,�� (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNERQ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I �� x I I �!� . �j 3 .:-. � , �� �q � � � i �° , . gs. J _ ... � , , r . 3 ; ® �a _. G � � '2 L/ LOCATION 47""- 0 SEWAGE PERMIT ' NO. VILLAGE INSTALLER'S NAME a ADDRESS due U I L D E R OR OWNER DATE PERMIT ISSUED d - 3 + _ 85 DAT E COMPLIANCE ISSUED y N �' �. ��j Z 1 Lo�-� � III • �-�.,,� Sv � . �� }} � TOWN OF BARNSTABLE C, br1�Y �N�•:- l� i _ Ft LOCATION �( `111V SEWAGE # Z,a�i • (,�, 1 ' VILLAGE nn a l�'!10 fPYWESSOR'S MAP & LOT_ `1 - INSTALLER'S NAME&PHONE N0. 6tk\%b,\kC cif® a63• « SEPTIC TANK CAPACITY LEACHING FACILITY: (type). \Nl�1C (size) L_Z � � 10�11 NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: �FA-o ra COMPLIANCE DATE: .�`� • b� Separation Distance Between. Maximum Adjusted Groundwater Tab p to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by W 0th i i i v I . I i i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION FAILED INSPECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 120 Great Hill Drive Centerville, MA Owner's Name: Ray Civetti Owner's Address: Same Date of Inspection: January 27 2001 Map:174 Parcel: 037 Name of Inspector:(Please Print) James M. Ford RECEIVED Company Name: James M. Ford Mailing Address: P.O. Box 49 Osterville,MA 02655-0049 " ' ` - F E B-0 5 2001 Telephone Number: (508) 862-9400 TOWN OF BARNSTABLE HEALTH DEPT. CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes N Further Evaluation by the Local Approving Authority ✓ F ils Inspector's Signature: 32 Date: February 2, 2001 The system inspector shall su a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ***This report only describes conditions at the time.of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION (continued) Ir Property Address: 120 Great HilA;rwi7J*)Zi 00 11,1, _ -`;•s. . ✓rr- Centerville. MA ­ Owner: Ray Civetti 1 Date of Inspection: January 27 2001 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 completioii'of the replacement or repair,as approved by the Board.of Health,will pass. ye, =rmin"ed(Y N ND)'in the . 'for the following,statements. ements: If"not t determined", please Answers no��o r'not de . .. .. explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or 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 obstruction is removed distribution box is leveled or replaced ND explain: The stem required pumping more than 4 times a year due to.brl - ~--•�-•- �, � P p' g oken or_obstructed pipe(s).-T'he sY stem will _.._. .._. pass inspection if(with approval of the Board,of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 I -- i Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .:::... ...:. .:; CERTIFICATION (continued) 120 Great Hill Drive Property Address:_ Centerville. MA Owner: Ray Civetti Date of Inspection: January 27, 2001 - - 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: x. 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 120 Great Hill Drive Centerville. AM _. Owner: Ray Civetti _ Date of Inspection: January 27 2001 D. System Failure Criteria applicable to all systems: You must indicate either`yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/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 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 Tess than 100•feet but greater than 50 feet from a private water analysis, asses if the well water , supply well with no acceptable water quality analysis. [This systemp Y 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 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either`yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet 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 I1 of a public water supply well If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B _-.:CHECKLIST Property Address: 120 Great Hill Drive__ _ Centerville. MA Owner: Ray Civetti Date of Inspection: January 27, 2001 -: 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) I , ✓ Was the facility or-dwelling inspected,for signs of sewage back up? Was the site inspected for.signs of break out ,r ✓' Were all system components,,excluding the SAS;located on site.?.,r ✓ 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 stem Absorption S SAS on the site has been determined based on: P Y (SAS) 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 ;t+ Page 6 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYST•EM INFORMATION Property Address: 120 Great Hill Drive Centerville. MA Owner: Ray Civetti Date of Inspection: January 27, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes.or no): No: [if yes separate inspection required] 3 Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2000-84 000 gals.; 1999-80,000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAIJINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): _ Qud= Basis of design flow(seats/persons/sq$,etc:). - s Grease trap present(yes or no): } r no t es o present holdi ng tank _. .. Industrial waste g p (y ) ._-,-- _ ... ......_.. Non-sanitary waste discharged to the Title 5 system(yes or no):_. - Water meter readings,if available: ' Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: ______gallons--How was quantity pumped determined?_ Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach.a copy of the current operation and maintenance contract(to be obtained from system owner) -_..._.._ ;Tight,Tank. Attach a copy of the DEP approval Other(describe): 3 ,•.... Approzirriate age of all components,date installed(if known)and source of information: _ Sep 14193-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C >Y' SYSTEMINFO"RMATION (continued) Property Address: 120 Great Hill Drive " .._._ '2� .:... __ as'a Centerville. MA Owner: Ray Civetti Date of Inspection: January 27, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron 40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 30" 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):, . (attacha`copy of certificate) Dimensions: 1000 gal. ? 1 Sludge depth: — Distance from top of sludge to bottom of outlet tee or baffle: — 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 determined: — 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 full up to the cover and backing up from the D-box GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from.top of scum to top of outlet tee or baffle: - Distance from bottom of scum to bottom of outlet tee or baffle: - Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition',structural'integrity,liquid-levels as related to outlet 7 _ L , . Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM'INFORMATION (continued) Property Address: 120 Great Hill Drive Centerville. MA Owner: Ray Civetti Date of Inspection: January 27 2001 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete metal fiberglass _polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): -='DISTRIBUTION BOX .> ✓ < .(f.present_must:be opened)(locate;on site plan) Depth of liquid level above outlet invert: Up to the cover Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D box was level There were no signs of leakage The liquid level was up to the cover backing up from the leach field. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 f I Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSAM' "INFORMATION (continued) Property Address: 120 Great Hill Drive Centerville. MA Owner: Ray Civetti Date of Inspection: January 27. 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-infiltrators w/2'stone-per as built card leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: _ Innovativelalternative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Dug down to the top of the infiltrators Liquid was above the infiltrators and was filling the hole.. The systemmas in hydraulic failure CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: s 1 Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None locate on site plan) ( P ) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C -SYSTEM;INFORMATION (continued) Property Address: 120 Great Hill Drive Centerville. MA " Owner: Ray Civetti "��`" "' 'Pareel. 037 Date of Inspection: January 27, 2001 "- 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. .. •rr. rt, . _:_Y..,..?.._;._.,., _:.....,__ � t.:_..1 l �. X 1' t i") . r1 � t ti!4 . •• S i tc( 4s s t ii a OLD 3 Al- ay 3a, 13a- 39 f13- 3� t33- 53 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'SYSTEM INFORMATION (continued) Property Address: 120 Great Hill Drive .......- 'Centerville, M4 Owner: Ray Civetti Date of Inspection: January 27, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) ✓ Accessed USGS database-explain:topographic map and water contours map You must describe how you established the high ground water elevation: Using the Barnstable topographic map and the Cape Cod Commission water contours map,thle maps were showing approximately 50' to j?_roundwater at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection andlor this report. AsBuilt Page l of 2 TOWN OFBARNSTABLE C_ LOCATION ZQ ti- nn`4' SEWAGE# VILLAGE o /�'ld�i P J!"AESSOR'S MAP&LOT-12U--tl:��7 INSTALLER'S NAME&PHONE NO.62kt\Q--0NlC6 '69h IS' `, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) rl``�& \r\�h���C (size) Lk �X � tc%" NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: b�1i`pl COMPLIANCE DATE: (A-'I 6q Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by , rRvc�' HOME • o , h � 13•�o" lq 3 ga s' 3 5b http://issgl2/intranet/propdata/prebuilt.aspx?mappar=174037&seq=1 5/10/2017 yy :: No. Fee 't THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: s PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Migoml 6potem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. r� i L; '. Owner's Name,Address and Tel.No. Assessor's Map/Parcel installer's Name,Address,and Tel.No. S, Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(-A)'� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5 k k t 6 k�j Type of S.A.S. Description of Soil Alterations Answer when a licable Nature of Repairs or AI e ( p ) 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 and not to place the system in operation until a Certifi- cate of Compliance has been i Led by this I oard of H Signed Date � '`�� /�J Application Approved Date Application Disapproved for the following reasons Permit No./����'" Date Issued 15�—— No. �i a��`tl� + Fee(�GLlae7� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: "Y s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS,,,, 2pprfcatfon for Miopaaf *pgtem Con.5tructfon Permit , `Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. t /a o G 14 ; 1 I.fZ CZcy c;v� Assessor's Map/Parcel + ) 0 3 Installer's Name,Address,and Tel.No. jr I r,pf. 5. Designer's Name,Address and Tel.No. , Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder(A) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. t Plan Date Number of sheets Revision Date Title Size of Septic Tank e-k c �,k k O 6 y Type of S.A.S. Description of Soil; Nature of Repairs or Al erations(Answer when applicable) �f cTr S X 3 O 1.e.C,c.1�.. 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 and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of He � 'I� /01 Signed Date c Application Approved . 04 W Date ec Application Disapproved for the following reasons Permit No.4 " Date Issued !� "' l THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS C,ertifirate of (Compliance THIS IS TO CER that the.On-site S`eiwage Disposal System Constructed( )Repaired ( _Upgraded ( ) Abandoned( )by G` C t v-c at Cs 01 y Nn 1 > f" I-7-4 of'Ci-' has been constructed in accordance with the provisions of Title 5 and the for Disposal S stem Construction P t�o?l—�194 dated� Z 7 Installer on'cc Designer The issuance of this permit shall not be construed as a guarantee that the s+stem ill f,action as 'esigned: Date LI 1 V uI Inspector 1AL I (57 No. @ -------------------------Fee "'"+5 v" THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mf6poar 6pgte �)!Pgrade ongtructfo t permit Permission is hereby granted to Construct( )Repair( ( )Abandon( ) System located at t D,b Cs 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. Provided:Construction must be completed within three years of the date of th 12ut. r Date: '�! Approved �' 1/6/99 NOTICE: This Form Is To Be Useld,For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, , hereby certify that the application for disposal works construction permit signed by me dated f �� /G , concerning the property located at l 2c) 1 V meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no.wetlands within 100 feet of the proposed septic system There:are no private wells within 150 feet of the proposed septicisystem 1 Toere is no increase in flow and/or change in use proposed >< There are no variances requested or needed. The.bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation, Please complete the following: A,) Top of Ground Surface Elevation(using GIS information) 0D B) G.W. Elevation +the MAX. High G.W.Adjustment«• 13 DIFFERENCE BETWEEN A and B , SIGNED : DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert rt .1' L, j � �� �� J ��4.��L G 0 �ac t � � I�`� J y-�`.'. '1 '�' h ,-1P T OTHER FA !-::ii i`1 TLE �Tw�;T T I ME IJ'=,HGE T,I,C`lE i 10L)E F'4IaE=; REtiI_lf_T :�-DG { a1 1"}=1EI r 7 _-27 f'tg.r, _:413,FM k_;I_i,57 ,T . t 11 CI[: + r } x A.}:},:}t}.?+'.'+'+'d'+.,, } :.F:} } }':+':+,+'::}'}' ::+-'f;i+;': f;+;:f.;+':{.f,.`+:.}:?f.?+i'f•"r f} } 1::+'•+h,.+.+::+..} +..♦ +.},:,'+':,::+;:+':};: + ;+•''.}:p.:}:L:,};:?'.+;k¢c'.+' +',ki k +„}.:{..+-}; i -_- -' ------------------t ---- -------------------—--------.-------------- -- } 1.-;7u fj it lot 4 _ f "r Tr '�..-4a�._:.,a a..:rM1.4 r'- /....n 1 S.r�_ - -�_-•_r^-.•---y+- .,�. 'r�T`� � . "+`»,/ :L .1 err .. a , -- `✓ J ���Ysf a � e✓'G�_y k-CG-'� )i.'w4� .� 4, ✓t L�''i +'1 C."� i r /.f":..• a:°-»ti'�4(!`, ,J .f �t t.+.0 c"ty?�.r-kh K. vr'�?^T+,�tI' w4 r ' n ' c � . .nci L,O i y i i I� �VC .../ 6 . LA I 7z TZ, tA 0 - ---� Wit__ �-;--���------�W �,----=-- -v__- ------- • r -- -- ---- - (� •-_�--- �-v ---� �—(�✓° '$'d-'-�v-p--�-,-�-tom/7` �'"7-�/f�-`=� /-" �-------- ------- ---—--�-. --�- —�� �f lJ J � , +ems __........—�-N'C�c�_(�y .%O�-t• ) � (��r/ C��y}✓� 41 f-[.0 r�`v''�G�� .._ �- .-r----�-- CM r 8m ~ ' ------------- A, _�q THE oowwomvvsAcr* or mxseAo*ussrrs V8 '/ -\D (/� } . � � BOARD~ ��=~""" ^ x / ----.OF- ��������/�'................................. � �����m���� ��° ��~ �o�~� ��~ �� ���� �� ~- �,�-�---_�--_ -__ _ '_� �~ -_-~-- ~~�--_-_�--,- ram~- Application is bcrcbv made for u Permit to Construct (/,��, Ilcpaiz ( ) an Individual Sewage Disposal System -`�- '----'_~-_---'_'--------------'--,------ ----_ jo'-� �-�� ......................... ----'' . ..... ..ua4- ....... Address Installer Address I}pc of Building Size Loc -7.��Sg feet Dwelling--No. of Bedrooms..--.. ...............................Expansion Addo ( ) Garbage Grinder (Ko) Other--Type of Building ............................ No. of persons............................ Sbmrezu ( ) -- Cafeteria ( ) {]t6cr -'-------------_---_-_' 'Design Flow...................��.. ............gallons per yccyoo per day. Total daily flow-.-...��8.9l...................gallons. 04 Septic Tank--Liqoid Length---------------- Width................ Diameter---------------- Depth................ Disposal Iccuc6--No. .................... Width.................... Total Length.................... Total area----_-__-sq. f t. Seepage Pit No-------' Diaoetcr------- Depth below inlet.................... Total leaching area..................sg f t. Z box ( ) Dosing tank ( ) Percolation_ _ -_' Results_ ^� Performed -'_-.--- �-���_- '--- --'_- ---__'__-_'_' Test B6 No. per mch Depth o Test �mBt..� ' D�& m �o�6 ~a�. � �Ico Pit !-oioutcoyer inch Depth of Teo Pit-------------------- Depth to ground water.. ..���. =- P4 . '-_ -. . 0 Description of S �1 --_---'-'--_'__--------------.-_--_.--'-__-'-_-.---_------'__--.---_-'-__-_- U Nature of Repairs or Alterations--Answer when .------_-._----_-----.-_-_-'--.-'_- ----`------''-`-'---'-''--`---`-----`-`--`----------'-----`----------------`--- AQrecmcut: The undersigned agrees to install the ufore6escribe6 Individual Sewage Disposal System in accordance with the provisions ofZ[TL LE 5 of He State Sanitary Codc- The undersigned further agrees not to place the system in operation oodl u Certificate of Compliance has been issued 6y the board of health. --------- -- Dt -------'----- / Application Approved D��-. 'LJ-'1-�u/���.�.----..-..----------'- ----`�'----al ...O.'s ]J um= Application Disapproved for t following reasons:................................................................................................................ --------'---`-'------`----'---------------`-`------------`-----'-------'----------'--------`-- ��roz� No.'_ �� . /_ Date ______ _ �t Yr 17, e .............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH Appftraft�u for Dispaii al Works Tnmitrn.r#iun ratuff Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ..-0..�.eltus.slt 4./ .....I.o.....-C Location A dress or Lot No -•� y _..... . .._ ?Y ..5.. ! ...... s"'i. "ee''V!d..:e-......... Owner Address a ..........�_ .�,� J.S 1,01 ----------------------------��� .� ............................................... Installer. Address d Type of Building Size Lot. J.,`.'__9Z�--..Sq. feet U Dwelling—No. of Bedrooms.._.... . .....................Ex ansion Attic Garbage Grinder Other—T e of Building ...... No. ofpersons—......................... Showers — Cafeteria a' Other fixtures ---------------------------------------------- ---•----...---••-•-----------------------•-- --- $ ..._:. loos. W Design Flow................. .. ......gallons per person per day. Total daily flow____._....:; _ gal WSeptic Tank—Liquid'capacity� ..gallons Length................ Width................ Diameter............=... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total.leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank '-' Percolation Test Results Performed by. �_��tl.'_ ':.y>_ aTest Pit Noel ,,5__._._minutes per inch Depth`o`f Test Pil . ._ _..._. De h to ground water-sty%---•..----__.(14 Test Pit N _ :'.._minutes per inch Depth of Test. Pit--- ............... Depth to ground water--------------�•---- a -••-•-•--••--••--•-•-------••--•-••-••••.......•--••------------------•-----------------------.....•......................................................... D Description of Soil----- CA is-1 �---------------- --------------------•--•------------............--•----------•-- W ----------------------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------•--------------------------..........-•--------•-•----...---•••••••••----•--•••-••-•-----•----------•----•-----•••••---••-••-•--•...................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITILj 5 of the State Sanitary 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- ....................... .._dA t_ �_.I� Date Application Approved By......._ ih.. Date Application Disapproved for t following reasons:------•-------------••----------------------------------------•---------....................................... -----------------------------•---...-----••--•--------------------------•-•----------------•---•------. -,.-•-------•------------------•-----••-.................................................... d ! r Date Permit No.........<WS-'-'"t.�� _..---•--•-----....... Issued---•-----•-d .3j..-'�--?-3............. Date THE COMMONWEALTH OF MASSACHUSETTS LL BOARD OF HEALTH o 3/...040....................OF.... .' .. ./..'f.................................... Trrtifirtttte `11f TuntpliFanu THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (for Repaired ( ) by---- -- •..... ............ ....•-----------•- -----... .........._ �' � y Installer at has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNeeCTION SATISFACTORY. DATE.............� _I-.,1_.....25..--------.......-------•------------ Inspector..---...--- ... . •------------.------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f ®^ ,, f ' --/� ?.... O F..., ......!"� i'.i.. ----...... No..--- ..._. FEE.... ... .......... ifillosal 10orkil nliir ion rrmit r Permission is hereby granted---- e!a�t.S, l....Ve7?:5( -(--•-•--------•------------------------------------•-----.......----................... to Construct (4.�Il Repaid ( ) an Individual Sewage Disposal System at D Street f as shown on the application for Disposal Works Construction Pe it-No...<?.0 A Date ._.__._.�"3-_L_- �- ..... 4 _----•-----•----------- Board of Health DATE.............. ...�r_-•----------•-------------------- FORM 1255 A. M. SULKIN, INC., BOSTON ~�e rf Vi o-t) 011 Aq off' •��' �ZI'�'' 'r" v� �.O T � .:��crS�\ �• Rom' • SY� :�� .� '/Y,;; r.....� Q PC ! ` 'gyp✓' G.r�t'' �'�. r_�Q 1 '.1r '^^� 0 r j f Lt? "^ 6 / �v7 .� 0 \< a C) 2 � . OF ORSE v, rj9l� ►, r2 P No.1095k1 O 1 fC�7✓J^s/ �^rLG � ff7uJ5 Cqq, _ CERTIFIED Pl.O�I' PLAN Lace, r c � S p/Zvpvs �rNt ski E1L<+Z �,� % R cse r 4.,L ft 3t f ® aq` �.,�`p b 6■p rl 50 . SCAL / DART /! 71 I CERTIFY THAT THE PROPOSED & � EGlS't RE REGISI'�RED T¢ : @®.�3Z a� I�UILOING SHOWN ON THIS PLAN { _; tax C91�-I1. ` �fiIaAN ll{ F �r, xp �yY M CO.NFORIsS TO THE ZONING ' 1.�+1�IS so 4.ieE I�7f['.��� T .. �ti r �} ^� N4{NEEf� r ` a R Y t „ irel OF-BARNS.TABLE � ��f �[js !^IaYA►;NN I ►, hA`�►SS`µ ; �' YIE��� ."®F. A E REQ. LAND S'Ui3VEY0R ��.� 's"•�""4 r1x'j"i s` 3 r'* .+T_ E��,,•W,hv`�� �,i '� t3�4 t`+'� �ir+`,, R _.^�u1„- E °s�*'�y` �g Hi""`;�'4.JK •z T ,e. a�" .�. - r°v {r���.'4ir,N�� f;������ .�s' t' �� x�`��?t•�'d. �y�i€ '��?,�r��. �J ",.^a�°.�:.`'x�'S :.� ...��.t�' na'SY,..t M' .,e+Y.�"„..�.�.�°:�� �%�.rg+:-.iR� ..�.:-7i�sr��;�•Zx,�i,'Y r ��.!,i.e".�,�'.°`'�»'.,..fi_�' "+'' ` `�'' '�� _ 20 FT. MIN• !VOTE !� EITHER 7-NESEP?!G TAoY OR 40 LzAC.I,rIMG D1r ARE /yOR& 7-NA.IV /2"SOLON/ SNALl ME ,&A?0&6dg7- T-o CONCRETE P/TCM h'EAVy C^ST ICON COVER BE,USA® - o-. CDYE/�S t�r�.4oE cc) ��/� CLEAN S�4N® LIVOID Level- VIA.' r: LAYER JIB CsA4 • d + • " - � a . 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Fps... ..�.....�..- i4MI VED dqigned leConserva nDepa rt1A11 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiun for Diri.pnia1 Hlurk,s Tunitrurt"tun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: _ :, __. ....�.....---••---•_•_•.. ...... ....��. ....... ......•- ..... f... /� y�cahon-:1�9dress t or Lot No. O -ner Address a . � �s�Jo� , .r/t'llfS---•----------------------- Installer Address Q Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms...........`..........................._.Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons..-.------------------------ Showers ( ) — Cafeteria ( ) Q' Other fixtures .....••••....-•--------------- . . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length--......... .... Width-------------... Diameter................ Depth................ Disposal Trench--No. .................... Width.................... 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----------------------------------- aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 1-4 G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....-••••••...............•--------•----•---•••-••-••••••-•--••-•••...•-•_•-•-•••-_----•_----....---......................................................... 0 Description of Soil........................................................................................................................................................................ V .....-•.....................••••••-•••-•-••-•-----••....••-••••••••••••••-••_•••••-••-•-••-••••-•--•-•-•-•-•--•-----•-••-•--••-••-•-•-•-•--•......•-•-----•---•••••-•............---•-................... W ---- -------------- ----------------------------------- ----------------------------••••-•---•••------•---------------------------••-----••------•••••••••-•••---••••-•-••............-•--•--•-...... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ................... 3T ........ ------ - >_t/T ir'7- ...... 1�' �7 I.....�/= . Ttf�1!j......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environ I Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h s been i e he board of health. Due Si n-d ....... ..�.. \J V t Application Approved By ............. ...�`�...s....., r_ .................... ..-D1..3..--. .� ve Application Disapproved for the following reasons: ....................................... .................................................. ......................................... ............................ . . . ............................. - - . ................................ . . ...................................... ........................................ �.. --V7� Ihre PermitNo. .... ...................... Issued .................................................................... Dare r'y'""'L9..-.v:�,:�..*�ti+f� ...;.,1,n.•�;.jailer+.,,ySu�r:� S�'+atit#9�=:�!«`'6'�-,st�dY't{'+-va'�,�F.]��r.+`"^:�.-GyJirL..+�..:f:,J7�i�s..s'•Js..o+�n,+.�...'i6�.''��y',:.^�'f:..L•,.ed�'.:yy„ttit.,�.c..a.✓-..1'.`...»:°'..c..,.,,,r,�:'H v. ....�iC:Mt:�R�441�,�4 No....Y.3.^._y.77 ........... .... ' THE COMMONWEALTH OF MASSACHUSETTS 9 BOARD OF HEALTH 13 OF BARNSTABLE V Appliration for Diriposal Eurks Tonstrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ... lad �. L �.a.t.... 1 - ... {-• ....... •• - . cation•- -Ayidress a or Lot No. W oy�ner Address � Installer Address d 'Type of Building Size Lot............................Sq. feet U a 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............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length-----_.............. Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ 0 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ OG •---•---------------------------------------------------••-•-•-•----...---------•--..................---..........-----•---••---...................---•....-- ODescription of Soil........................................................................................................................................................................ x (- ------------------------------------------- --------------- UW •-••------------------------------------•-•-----............__.......---•----------•-----------•--•------••-- •-----•--------•----•--�------- Nature of Repairs or Alterations—_Answer when applicable.............................�_..._��-'j...._...._................._...................... •.................. ......1Nfi.l rTeXT"nR5.......t Z'2_I......2Fj..jo.�-...._ TQst/ . 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 .(1...".. -_ 1................. .................................:...... ������ Dace Application Approved By ................ .1..- -� � ..........I ..........f..-./...tea..-.��.Zj C\� ....< �.............................. Dace Application Disapproved for the following reasons: ........................:................................................ ... ................................................... .............. ... ................... ..................................... ............................. ........................................................ ........................................ PermitNo. ...... ..:...��..... ................................ Issued ...................---.............................................. Dare y+ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ter#tf ra e of Tomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( !�) by ................A,Qy�0"V.e..... --------------------------..........Insri.. llc•r .............. ...... ...__..... ........... ........._................................. --- ............ at ................ ....... R--------------IV.....V aA.Y.32-. z8-L1E............ ........... ................................... - 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 -------............_.............._.------.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEA�AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- ...f7­07. 9.3....................._...................................... Inspector .......... .. . ........................_.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Disposal Works C onstrurtion "rrmit Permission is hereby granted------........tc6�`j----------^S 1 ��/ ``---------_- --•---•--------------------.---..---_.-_---.-----•------•-•--- to Construct ( ) or Repair (0 an IndividuM Sewage Dispose pISystem R� , atNo................ r'•-•-- r'e"t.--•-- ----- ............ - <- /!------------------------ ------- .......................... Street as shown on the application for Disposal Works Construction Permi�No.��_�7�__ Dated........................................... `l, Board of Health -------------------- ......................................... l DATE C� -� --. -------•------ / FORM 36508 HOBBS A WARREN.INC..PUBLISHERS