Loading...
HomeMy WebLinkAbout0073 AUGUSTA NATIONAL DR - Health 73Augusta National Drive , ♦ ', Commonwealth of Massachusetts Title 5 official Inspection, Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every Barnstable MA 02630 08Y2111.1 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.. Important:When A. General Information filling out forms /7�n on the computer, use only the tab 1. Inspector.. key to move your cursor-do not Michael Kellett use the return Name of inspector key. Aardvark Environmental Inspections Company Name P.O.BOX 896 Company.Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address„and that thd, information reported below is true,accurate and complete as of the time of the inspection.The-ispecticn was performed based on my training andr experience in the proper function and maintenance of.6,n 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 ❑ Fails Y; ❑ Needs Further Evaluation b the Local Approving Authority y pP 9 `/ E&U 080/11 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. �AC� ` V I V t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Dis sal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Fume information is required for every Barnstable MA 02630 08/21/11 page. Citylrown 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 Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑' N ❑ ND(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every Barnstable MA 02630 08/21/11 page. Cityrrown state Zip Code Date of inspection B. Certification (cont.) B) System Conditionally Passes(cunt.): ❑ 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 leveled or replaced ❑ Y ❑ N` ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced. ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board.of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the:system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of'Massachusetts Title 5 Official Inspection Form. s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 73 Augusta National Drive Property Address Ken Freiner Owner Owner's flame information is Barnstable MA 02630 08/21/11 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the'Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50,feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is Tess than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component.due to overloaded of 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 %day flow t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owns Name information is required for every Barnstable MA 02630 08/21/11 page. City?own 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: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public.well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered'.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1'0,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria erast 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 El ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped.Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered `yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every Barnstable MA 02630 08f21111' page, City(rown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping,information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were:the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the'-baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existingr information.For example,a plan at the Board of Health. ® ❑ Determined in the field (f 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): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 1.5.203(for example:110 gpd x#of bedrooms): 330 t5ins•11/10 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 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every Barnstable MA 02630 080111 page. City(rown state Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[f yes separate inspection required] Z' Yes ❑ No Laundry system inspected? ® Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 07/11, 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 Titre 5 system? ❑ Yes ❑ No Water meter readings,if available: t5i na:I VI T fa 5 Official Sublaul W.-gaga^ap=i System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every Barnstable MA 02630 08/21/11 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 ® 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) (f yes,attach previous inspection records,if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form. "s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's flame information is required for every Bamstable MA 02630 08;°L1/11 page. City/Town State Zip Code Date of inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 08/06/81 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 2' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.), Septic Tank(locate on site plan): - Depth below grade: 2.4 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 4" t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's{dame information is Barnstable 02630 08/21/11 required for every page. CityrTown state Zip Code Date of..Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last.pumping: Date rft 5'Offic a{4aspection ft Suhsurtace Savags Vy'wtm=Paga'C at 117 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's flame information is Barnstable 02630 08/21111 required for every page. Cit)erown 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 ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons parlay Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is Barnstable MA 02630 08/2171.1 required for every page. City/Town State Zip Code Date of Inspection D. System information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box, etc,): no box present 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.): Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located,explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is Barnstable MA 02630 08f21/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits: number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length ❑ leaching fields number,-dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil',condition of vegetation,etc.): This system has a 6'x6'precast pit surrounded by two feet of stone.There was no liquid present with a stainline 39"up from the bottom. 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's{dame information is required for every Bamstable MA 02630 08/21/11 page. City/Town State Zip Code. Date of Inspection D. System Information (cunt.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every gamstable MA 02630 08/2.1'/11 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system,including ties to at least two,permanent reference landmarks or benchmarks.Locate all wells within 1001 feet.Locate where public water supply enters the building.Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately � ea- foal ��� 0 30 a 13 t5ins-11110 Title5.Qfficial Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form, s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °r 73 Augusta National.Drive Property Address Ken Freiner Owner Owner's fume information is Barnstable MA 02630 08/21/11 required for every 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: 30.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ® Observed site (abutting 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: USGS maps show an elevation of over 30.0!feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Me Official inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Augusta National Drive Property Address Ken Freiner Owner Owner's Name information is required for every Barnstable MA 02630 08/21/11 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C,D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Tice 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS z W EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION p oW TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION �Z Property Address: 73 Augusta National Drive Assessor's Map:355 Parcel: 007 Cummaquid,MA Owner's Name: Estate of Lois A White Owner's Address: C/O Cape Cod Five Trust&i Asset Management P.O.BOX 20 Orleans,MA 02653 Attention: Stuart Nickerson Date of Inspection: November 5,2008 Name of Inspector: (please print) Richard Judd(SI9584) Company Name: Richard Judd,R.S. g° Mailing Address: P.O.BOX 1315zz ` Harwich,MA 02645 Telephone Number: 508-896-9316 CERTIFICATION STATEMENT ; I certify that I have personally inspected the sewage disposal system at this address and that the in for ation reported ` below is true,accurate and complete as of the time of the inspection.The inspection was performed ba sed on my training and experience in the proper function and maintenance of on site sewage disposal systems. I g m a DEPD �`r- approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: rn X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: November 5, 2008 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&,.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:PASSES The subsurface sewage disposal system was observed to be standard and operational at the time of the field inspection. The existing 1000-gallon septic tank did not require routine maintenance pumping at the time of the inspection. ****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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is,imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed F distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ' ND explain: Titles f Tncnanfinn P-' A/1 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 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: T41. 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] NO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Title S Tnonartinn Fnrm(./1�/7!1!1!1 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X Has the system received normal flows in the previous two week period? — _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? X _ Was the site inspected for signs of break out X _ Were all system components,including the SAS,located on site? X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum _ X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no X _ Existing information.For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Tula G,Tnona�tinr�Fnrm ail�nnnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(Permit): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330. 549.5 gpd provided Number of current residents: 0 Does residence have a garbage grinder(yes or no):NO Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):NO Water meter readings, if available(last 2 years usage(gpd)): 07=58,06=79(gpd/avg/yar). Sump pump(yes or no):NO Last date of occupancy:July 2008 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): -Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Per Health Department:no records on file 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 X Septic tank, *distribution box,soil absorption system(* system does not contain a distribution box) Single cesspool _Overflow cesspool _Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed(if known)and source of information: Per Barnstable Health Department:Disposal Works Permit 81 430 date of compliance 8/6/81 Were sewage odors detected when arriving at the site(yes or no):NO T41.�,Tnor�nrtinn Fnrn,�/1 G/7Ml1 6 I Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 BUILDING SEWER(locate on site plan) Depth below grade: Waste line exits below walkout cellar slab. Waste line is 36"below Vrade. Materials of construction:_cast iron X 40 PVC other(explain): Distance from private water supply well or suction line:town water service line is> 10' from waste line Comments(on condition of joints,venting,evidence of leakage,etc.): There were no observed signs of backup or leakage within the walkout cellar at the time of the inspection. SEPTIC TANK: 1000-Gallon (H-10)(locate on site plan) Depth below grade:top of tank&outlet cover:24" Inlet cover: 10"below grade. Material of construction: X concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 8.5' lone by 4.8' wide by 4 0' flow line Sludge depth: <1" Distance from top of sludge to bottom of PVC outlet tee: 32" Scum thickness:0"(not formed). Distance from top of scum to top of PVC outlet tee: 7" Distance from bottom of scum to bottom of PVC outlet tee: 14" How were dimensions determined:ground probe,measure stick and measure tape 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 liquid level was observed at the 4"PVC exit line Pipe invert The inlet portion of the tank contains a pie cast inlet tee.There were no observed suns of backup breakout leakage or hydraulic failure within or above the tank at the time of inspection. The septic tank did not require routine maintenance pumping_ GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): T;flA S 17--Aii 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Title S Tno— tinn T:nrm ui VIM() 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number:(1)6'X 6' with 2 0' of sidewall stone leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): Surface to 18"diameter cover:21". Surface to top of it: 34". Surface to floor of it: 114". The leaching it did not contain any standing liquid. Sidewall stain indicators were measured at 36"to 39"above the floor of the leaching pit. There were no observed signs of backup breakout or hydraulic failure within or above the SAS at the time of the field inspection CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIM': (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.): Tit1. G Tncr�nrtinn Fnrm Oil ci,)nnn 9 Page 10 of l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 73 Augusta National Drive Cummayuid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 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. LOCATION A B DEPTH SEPTIC TANK IN 26.0' 28.0' 10" SEPTIC TANK OUT 32.1' 33.1' 24" LOCATION Y Z DEPTH LEACHING PIT 30.4' 13 2' 21" PAT 1p \ POOL 7= I 'WOOD q fDE:C11 NO,: 73 AUC-.USTA NATIOKfAL PK i 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: 73 Augusta National Drive Cummaquid,MA Owner: Estate of Lois A White Date of Inspection: November 5,2008 SITE EXAM Slope 3 TO 8% Surface water >100, Check cellar DRY WALKOUT Shallow wells DRY AUGER AT 6.0'BELOW LEACHING PIT FLOOR Estimated depth to ground water is>4.0' feet below the SAS floor. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-1f checked,date of design plan reviewed: Observed site(abutting property/observation hole within 1.50 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) X Accessed USGS database-explain:USGS contour map&Barnstable ground water contour map You must describe how you established the high ground water elevation: The estimated depth to ground water is based on the use of the USGS Quadrangle(To nr_ographical)map the Town of Barnstable GIS contour mapping and the.Town of Barnstable ground water contour map Approximate USGS surface elevation at SAS: EL 58.0 Approximate SAS floor elevation(-9 5') EL 48.5 Minus ground water contour elevation: EL 20.0 Estimated depth to eround water below SAS floor: 28 5' 6;x Id k - s 0 Tula S licrar+inn G'nrrn �/l V�l1M 11 CAT ® �10/ A G E P E R IT NO. j -�13�� VI-LLAGE INST )A LLER'SS' NA FAE a AID0RESs 6UIL0EIII OR ® NER DATE PER)ffl!p IT ISSUE ® DATE C 0 M P L I A N C E ISSUED _ 161$1 1 M lj� i r j Map Page 1 of 1 Town of Barnstable Geographic Information System Parcel Viewer Custom Ma Abutters Map Size Zoom Out l P ® In m_ JPG Turn map layers on/off by � selecting check boxes beloN - t ? U Town Boundaries Ati ` \ $ I ` v(1 Road Names 3 Voter Precincts " z X 57.4113 f ° i I yy AfX Map&Parcel Nur 42.38 N 4aFYI Parcels 4 ` f f r !X 63.5r7 .c .84 X X `I f 56.6b £sx [� FEMA Q3 Flood Z, ,. f ashx AE(100 yr flo AO 100 Xi 3 ( yr flc 63.42 ,X5876, VE (100 yr flo ;< 5D 3S X500 (500 yr E . ,1 ' Q Neighboring Towi {x �1 t; '" i f r- W [j Water 97 F e t 6t.s7 ❑ Streams . i X X W 66 1 ^ . � '�" ❑ Jetties Set Scale 1° =;97 I Aerial Photos I MAP DISCLAIMER Copyright 2005-2008 Town of Barnstable,MA All rights reserved.Send questions or comments to GIS Bar'nstabieMA v1.2.3083[Production] r S - 20 http://Www.town.bamstable.ma.us/arcims/appgeoapp/map.aspx?propertyID=355007&map... 10/6/2008 _ _�_ ��-e ( f-- � S ✓ �, 'r � e � TR OY WILLIAMS SEPTIC INSPECTIONS qD q �Fc� p U Certified by MA Department of Environmental Protection NOr 3 1300 B 19 Hummel Drive y�� o P tqe� ly~r South Deru}�s, MA'02660 COMMONWEALTH OF MASSACHUSETTS �► EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS py DEPARTMENT OF ENVIRONMENTAL PROTECTIONo ONE WINTER STREET, BOSTON, MA 02108 617.292-5500 WILLIAM F.WELD TRUDY CORE Govemor Secretan• ARGEO PAUL CELLUCCI DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A CERTIFICATION 73 4� �S �u Na fin. 4 C� y d Property Address: f �r- Address of Owner: . Date of Inspection: 145 /1 /�(7 Troy Will 1 1 1 d m S (If different) Name of Inspector: Y 7 �5�s fQ Nc.. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title S(310 CMR 1S.000) j 19 �j� Company Name: Troy Will iams Septic I.nsaections yJ � 114 Mailing Address: 19 Hummel Drive. South Dpnnis MA . 02660 Telephone Number: (5 0 8) 3 8 5-13 0 0 O � G r 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: i/ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: y ,1L. Date: 0 d A f y 7 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] SYSTEM PASSES: V/ I have 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] 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. Indicate 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 aacked, structurally unsound, shows substantial infiltration or exfiltration,or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced wfth 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: httpJAvww.magnet.state.ma.uVdep f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 3 4u /V c- Owner: A ; Date of Inspection: A , 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) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: n///"q 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: 73 14,E f s N l Ito- Owner: S �, Date of Inspection: D] SYSTEM FAILS: You must 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 Backup of sewage into facility or system component due to an 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 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] LARGE SYSTEM FAILS: /J 119 You must 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 owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. 1 (revised 04/25/97) Page 3 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 3 �� S Owner: Date of Inspection: -7 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. _ 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. 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)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 7 3 '�9vY a Owner: ��" S Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:_3 3 y g.p.d.Poedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes or no):— [S Laundry connected to system (yes or no): ye S Seasonal use (yes or no): '�G S c // Water meter readings, if available (last two (2) year usage (gpd): / S �`�U 5 4 �/o i, S S S� 7�u� y 4 All s Sump Pump (yes or no):__6�o Last date of occupancy: p; , COMMERCIAUINDUSTRIAL: NJ/a Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or-no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if.available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: f t`uSY_- QJati✓ae- &A q$f/( u1-a, C- oWh�✓ System pumped as part o�ection: (yes or no)�/o If yes, volume pumped: gallons Reason for pumping: TYPE QF SYSTEM Septic tank4ii9tributiepi be 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: / c 'A Sewage odors detected when arriving at the site: (yes or no) /V 0 (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION (continued) Property Address: 7 3 1q, Owner:, S �� Date o Inspection: BUILDING SEWER: / (Locate on site plan) N Depth below grade: Material of construction: _cast iron _40 PVC_other (explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: _k/concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 6 O o S I/e," Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:a Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6 �� Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) C6F•�r� �- t f ok v t cam. /1 U i t d c 71—✓ c- �2,r w J va.. 6 C r GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Pago 6 of 10 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 ,3 /y✓ s /VC- Al vh Owner: Date of Inspection: TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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 level: Alarm in working order_Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:,V/,g (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) !' c coo ✓Jt c.� a� �s - �v. / -f- �-c. A v.., :mac �v�...� PUMP CHAMBER: A`l, (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 3 IqJ 9 JS A/C---)i Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_z (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: 61-c X 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 of hydraul' failure, level of onding, condition of vegetation, etc.) c c,, CESSPOOLS: (locate on site platy 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(cesspool must be pumped as part of inspection) 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.) (revimad 04/25/97) Page ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 93 �{uy '�S �z� ✓�/�-�7�"��--� Owner: S 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) 3 � lu 3 02 7 ! 3 a It / J G (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION (continued) Property Address: ?3 Owner: �p-5 oti Date of Inspection: Depth to Groundwater Feet adjusted high groundwater level 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.) V/ 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 your own words how you established the High Groundwater Elevation. Must be completed) / (,..+ ; a t/i r �+�. l CA 7 r�.d l o-7e G Nn ; r, . o 1 s /3b /?b/H, o /t�. L .�'t L.J CA S vl / h '�1, i S h C,�!—O.0 {r (revised 04/25/97) Page 10 of 10 a L0 CAT 0 _ EWA C E PER IT NO. 3c, VILLAGE INSTA LLER' 00AISE 6 @DRESS ' J I BUILDER OR OWNER X',' ary/ 3 DATE PER T ISSY D DAT E COMPLIANCE ISSUED gZ611 -Po o L � - ��A 2 N .� .� A d FEs..... .. ............._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ..........7~_ ..............OF.....��4d�ly/.2�.�..---.............................----........... Allp iration for Uispas al Vurkg Cnnnitrn ion rumit _✓ Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --•--•-------------••----.............-------••---•-•----•--------........•---•-............------ o tion-Address tion-Addressor Lot No. � - a .. /•E'• ,nerr Address ........................... /. ............................. ......•........... -••--- � -•---..........--- Installer Address Type of Building Size Lot............................Sq. feet Dwelling-No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) '1 Other—T e 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........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit......--............ Depth to ground water...--................... (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil......................l`..1r!?.._�y_...__.. --------•-•--------------•---•------------------------•----------------------------------------------•----------- x W .................................................................................................................... ....................... T. VNature of Repairs or Alterations Anew en applicable.------1,!_at✓ .........�es! !`+ _�O!-.f...".,rs6�!Q- ... ........................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T:'l,i4. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has n i ued by the board of Dealth. Signed•--- ............................. ... ................... Da Application Approved By....... Da Application Disapproved for the following reasons-----------------------------------------------•-------•------•----------------•-----------.....------------•--- --••----------•--•---------------------••-------•-------------------•---•------•-............•-----•-----..... Date PermitNo......................................................... Issued.------------------------------..........----.......... ., Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... .�..............OF...... .!f"1 , r.. ..-.. ApplirFa#inn for Disposal Works Tuns rnrtion frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � +,'j—, j ................_...... +L tion-Ad re or Lot No. ....................... r ?......-�, , + ► � . ................................ her Address a ........................... r�'.-.. !v....... ---•----..............!/e4_ft�..k......, --------.....--------.....--- Instal:er Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___.....................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type T e of Building No. of persons ................... Showers YP g ---------------------------- P ( ) — Cafeteria ( ) W Other fixtures ------------------------------------•-•••••... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ 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......................................... i a 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........................ P4 ---------- •••- D Description of Soil..............•-•••• Ff...` __..._...___. ---•................•-----------------------------•------•----...-------------------•---••••••----••......•-----•••. x V U Nature of Repairs r Alterations An w en applicable_.._._ +�f.....__._ t±�4 s«► f..�........ ' a _ ..•••...-/�'...1!1-- r'--` s .-• t . ....-•----------------- ------ - --------------------------- -•--:_.. ..---...----------........-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTI 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance h edbh boar d of ealth. ----Signe -- ....... • - --- ....................... Application Approved BY . ............ Date Application Disapproved for.:the following reasons:-----•--------•--•------•-------•--•---------------------------------------------------------•--•-•••----------- ---•--•-••••-----•-•--••-----•-•-----•••••••--•••---•--•-••.......-••---•--•--•••--..._..----•-•...._.....--••••---•••••••••••---•••-----••-••--••••---•--------••-•-•••-•••-••••---••••••---••••••------ Date PermitNo--_------------------...............................- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........✓...o?.A.v.Y`:.............OF.... ......................................... (9rdifiratr of Tomplionrr THIS TO CERTIFY Tha ythe Individual Sewage Disposal System constructed ( ) or Repaired ('�) by.............. ....... W_-•-----....._.._.........._�1..................................................... ............................................ at-•••-•-•-•-.......- •-- - ------------------.................................... has been installed in accordance with the provisions of `� -T 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No__ ./._%�� .................. dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL HOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 0 DATE........................................... 6 .................. Inspector................. .....4.L---------------•-----....._................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF—HEALTH /...... ..... `^............OF...... - 5�:............................. FEE.__ ............. f Dispn Works Tono#rnr#ion rani# Permission is ereby,granted•. •. _�id ..... '.! ------------------------------------------------------------ to Construct �or Repair � n _ SC, Disp sal Syst j Street as shown on the application for Disposal Works Construction Permit No............. ...... Da*d.......................................... ' -° -------•••---------•-------------- DATE................ ".� Boa of ealth FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS l No..---...G..... ... Fps............................ THE COMMONWEALTH OF MASSACHUSETTS ��. BOARD OF HEALTH .................. ....... .........OF..............................-----...................................................... Appliration for 43iiposttl Works Tonstrurtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at � 7�j uS�G G1a IV -�..---- ..�J---G�`�.............�--��...__. ----- ----•• ---------- --.-----•------ -------- -- atio dre or t No. .. ' Ow r ddress a ... . -•----......-•----------•-----------. Installer t r Address UType of Building Size Lot.._5 ------_____Sq. feet �-, Dwelling—No. of Bedrooms-_--•--_5•---_---•--•_•_______________Expansion Attic ( ) Garbage Grinder aOther—Type of Building __________________________•- No. of persons-------h................. Showers ( ) — Cafeteria ( ) P4 Other fixtures ...................................................... -- W Design Flow......... ......................gallons per person per day. Total daily flow......— .and'.........____.._____.gallons. WSeptic Tank—Liquid capacity/ft-O.gallons Length---f0....... Width._S�---- Diameter-________- Depth_______________ x Disposal Trench—No. .................... Width.................... Total Length...........t------- Total leaching area....................sq. ft. .. Diameter....... ......3 Seepage Pit No.. ,Q�'g._ �O ___- Depth below inlet--g........... Total leaching area__________________sq'ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................................................................... Date------------------------------------------ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--------------____--.-.. (q Test Pit No. 2................minutes per inch Depth of Test Pit......... ....------ Depth to ground water-________-______----_-_. O Description of Soil............................... U -••-•-----------------•--••-•----------•-------------•--••-•------------. -_-------------- --- •. ---------------------------------------------------------=-------------------------- W r U Nature of Repairs or Alterations—Answer when applicable------------------------------------- -----------------------------•------- ===--.......--•---•--------•--. ----------------------_ -- ------------------------------------- Agreement The undersigned,agrees tot install the aforedescribed Individual Sewage Disposal System in.accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance h e, _i e the board of.health. Slgne -` ---- ........................... ................... 5 •-------------------------- Date ApplicationApproved. BY----------- ---------••--..................................................... --==----------------------------------- Date Application Disapproved for the following reasons:---------- ..........-.......................................................................................... ..................................-•--- -•-----•----•---•-•-------•••-•------------•••••-----------••••--•----•------••---------•----••---------•--•-•------••----••----•---- b _ � ..... ----- Date PermitNo.......................................................... r, Issued.. - 1 Date No.......................... Finc.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ---------------------OF............................. Appliration for J:Riiposal Works Tomar Uidion Prrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sys ----------­-----­- ------- - ------------- ............................................ 7, t No. .... .. . ............................... ........ ....................................... Add ............ ................................................ ........................... ................................. Installer Address 30e-o—---------------------- Type of Building' Size Lot............ ---------------S U 9(1*t Dwelling—No. of Bedrooms............................................Expans&n Attic Garbage Grinder Other—Type,, ilding ............................ No. of persons........._._................ Shower, Cafeteria Other fixtures ... ............................. ------------------- ........ -73 2a4 A— /0 ........... ------------------------------------ ail" Design Flow____. 'gallons per person per day. Total wily ow.. ------------­------7-------------- ...............................---------gallons. 9 Septic Tank—L�' ` pacify__'__........gallo& Length................ WiJdLh_ -.e---------- Diameter---------------- Depth---------------- Disposal Trench—No..................... Width.................._. Total Length---- ----------- Total leaching area------------------_sq. f t. Seepage Pit No...................... Diameter.................... Depth below inlet......_............. Total leaching area------------------sq. f t. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Pi Te�s I it.......�?........... Depth to ground water......._.._..........--. rx-4 Test Pit No. 2................minute �ch p �_Of .......... Depth to ground water____________________. . P4 .................. ------- . . . .............. ................................................................. 0 Description of Soil----------------------- --------------------------------------------------- ----------------------------------- U .................................................................................------------------------------------------------------------------------------------------------------------------- .....................................................................................................................................­--------------------------------------------------...... ------ U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------:-------------- ---------------------------- .......................................................................................................-------------------------------------------------------- ------------------------------------- Agreement: The undersigned agrees to install the - redesc d Individual Sewage Disposal System in accordance with the provisions of Article XI of the State S itar he undersigned further agrees not to place the system in operation until a Certificate of Compliance h e its 6-k6a'?ftf-health. Signed--. ..................................................................................... ................................ Date ApplicationApproved By.................................................................................................. ........................................ Date Application Disapproved for the following reasons:................................................................................................................ ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued.------------------------------------ ................ "bate'." -THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF................................................................................ fit Q11rdifiratr of Tomptiana THIS IS -CERTIFY,-CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by----------------- ................................... ....................................................................................... In adler at.......I..... ... ............. ... .. ........ -------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions o Article XI 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 CONSTRUED AS A GUAR& TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ---- ........................ DATE------ ........... Inspector.-, ... ....... ----- ....................../--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ................................................................. .........../.!�p ....OF......./6!� No. FEE.-,.;;— ..................... 1--f urtion Vrrmit Permissionis hereby granted............................................................................................................................................. to Construct ) an N or Repa4i 4 1 j AS j*�t�, r- 3 %ytge Dispo*Apstim at No 711 ------------ -- CA Street as shown on the application for Disposal Works Construction Permit No___________7 te --------- ------- d/Z A ------------- ........................................A ---------------------_- -------_----- DATE.......... 161 -7 Board of Health .. ................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS