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HomeMy WebLinkAbout0030 HARRIS MEADOW LANE - Health 30 HARRIS MEADOW LANE, BARNSTBL A= a r z G e a n F v o � t COMMONWEALTH OF MASSACHUSETTS f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: a Owners Name: "- //s6- Owner's Address: l ' Date of Inspection: ai7066 Name of Inspector: plea a rint) �r �rk)b • .' f �a 00 A Company Name r r Mailing Address: _ e -_ Telephone Number: - �•.=,,; 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 i. Conditionally Passes . Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature:'- }Da. : The system inspector shall submit a copy of this inspection report to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report,to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ;A ""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 v Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:,36 &-��P,Cl ljr M A Owner: Date of In pection: ii/�S%U Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D A. ystem 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. 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 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- 2 `) ;Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARTA CERTIFICATION(continued) Property Address: Owner Date of 1 "peclfion: 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 aseptic 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 n . 3 Page 4 of 11 OFFICIAL INSPECTION FORM:NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:cc LAW �zo Owner: Date of I pection: ZI / D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow 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. t0 Any portion of a cesspool or privy is within a Zone 1 of a public well. y portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds .indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a 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 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST . Property Address` s Owner: r Date of I spection: 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 week's? • ✓— 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, locaied on site,?' , Were the septic tank manholes uncovered,•opened,and the interior of the tank inspected for the condition of the baffles.or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems The size and location of the.Soil Absorption System (SAS)on the site has been determined based on: Yes no a Existing information.For example,a plan at the Board of Health. lO _ 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)] a r 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IppNF,,ORMATION Property Address: Owner: Date of In pection: /4/d 5—/U0 FLOW CONDITIONS RESIDENTIAL' Number of bedrooms(design):—Vi . Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): . Number of current residents Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no [if yes separate:inspection required] Laundry system inspected(yes or nok�� Seasonal use: (yes or no Water meter readings,if a�ilable(last 2 years usage(gpd)): Sump pump(yes or no): (, Last date of occupancy: COMMERCIAL/INDUSTRIAL/,)jik, -- Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Was system system pumped as part of the inspecti (yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TY"F 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): proximate age of 1 components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no) — 6 -Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � �_ � � � • Owner: Date of I Pipection: /" /y 0 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: M Comments(on condition of joints,venting,evidence of leakage;etc:): SEPTIC TANK: (locate on site plan) r Depth below grade: A ' Material of construction:_concrete_metal fiberglass_polyethylene —other(explain) _ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):•^ (attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: f, Scum thickness: y �/ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to botto f outlet teete_e®or baffle: How were dimensions determined: �`m`r� Gtc1t1 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc.): 14 GREASE TRAP• _ ocate on site plan) u �J 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.):. Page 8of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:,0 Owner: Date of In pection: // /.'1"1U_,_, TIGHT or HOLDING TANIG 4 (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: �(ifresent must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution t o ou ual,any evidence of solids carryover,any evidence of kage into or out pf bog,etc r PUMP CHAMBE`;/)6L-�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 Page 9 of 11 f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INFORMATION(continued) Property Address: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not.required) If SAS not located explain why: E Type ching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,-condition of vegetation, etc.): CESSPOOLS;,/, (cesspool must be pumped as part of inspection)(locate on site plan Number and configuration: Depth—top of liquid to inlet invert: r Depth of solids layer: Depth of scum layer: a Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY ocate 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.): x 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addres Owner: _ r. Dated I spection: 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 su ly enters the buildingAm o I T 10 f Page 11 of l I OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM_ INFORMATION(continued) Property Address: C - I,t Owner: Date of Inspection: 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: You must describe how you established the high ground water elevation- f a* i 11 i - -- C011�I0\�'�&aLTH OF MASSr1CI-JUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF Vl';-"/ DEPARTMENT OF EWDZONMFNTAI, PROTECTI ONF WINTER FTRF.FT. 110', 1T� �1A 0210 ,(;l 1512•S:;Un n c r Hof 4,��>9�9. y• • ARGEO PAUL CELLUCC•I r, DAN'ID B Sln'�� Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �// yJ� CERTIFICATION Property Address: 3Q MCa17'7,( /'(ek)C" '•�" -r I 1 ame of Owner --litcl. ftz 0—— J Address of Owner:__ �� S� [gfC(�pYO lijfA Date of Inspection: Name of Inspector:(Please Print)__c 6__L ,Wlt?'� 1 am s DEP otwd.aYsi��FidISPF�oFR� •340 of Title 5(310 CMR 15.000) , Company Name!+ Mailing Address: --.! . — --- Telephone Number: NE DF W R E ORD M A��Dpp74E_ CERTIFICATION STATEMENT S6$-7361 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: Passes , _ Conditionally Passes , _ Needs Further Evaluation By the Local Approving Authority q Fails 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 thirty (30) days a: 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 ow,e: shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tire system owner and copies sent to the buyer, if applicable, and the approving authority. ' NOTES AND COMMENTS This inspection' report -is NOT a Guarantee or Warranty for any satisfactory continuing orjuture performance of the onsite .sewage system. . revised 9/2/98r Page; orit n P Vnr,rd nr Rc(10 d PaprJ 1 x r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'roperty Address: 30 Jwner: TL "LCt, x Date of Inspecti INSPECTION SUMMARY: /Check A, B, C, or D: e A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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, up 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(2O) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound', shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. 5 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). 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 " revised 9/2/98, Page 2ofII f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued_) Property Address: Owner: 37it ma.-- Date of Inspection:9/ate t . / /1 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEMM 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 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 AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system (SAS)and the SAS is.within 100 feet of a surface water sup,-,, c, 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 systerti 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 9/2/98 Page 3 of 11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,(continued) Property Address: Owner: �K Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described 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 Yes No Backup of sewage into facility or system'component due to an overloaded orclogged 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. 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 isless 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: 1 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: _ 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 upgrade the system,in accordance with 310 CMR 15.304(2). IPlease consult the local rerori& office of the Department for further information. r . revised 9i 2/98 lllagc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,B CHECKLIST 'roperty Add re s: [� a�' " "" Owner: Date of Ins tibn: f� 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. x _ As built plans have been obtained and examined. Note if they are not available with NrA'. � � W/ 0��f , /� exf/_, b �e 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 bak, or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Q The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information. For example, 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)] _ The facility owner (and occupants,if differeru from owner) were provided with information on the proper maintenaa"-of /1_ SubSurface Disposal Systems. , + •s revised 9/2/98 pj�c5of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ' 'roperty Add ss: 3d WaY7 "f / t Owner: Date of Ins on: FLOW CONDITIONS RESIDENTIAL: Design flow: YSM g.p.d.lbedroon-. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow__ Number of current residents: a Garbage grinder(yes or no): Laundry (separate system) ( es or no):170; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no):J10 n i9 , 1 000�R / G1r}_9j /�a/ zV Water meter readings, if available (last two year's usage (gpd) L A. /Il 7 `7 l/�" Sump Pump (yes or no): no t Last date of occupancy: juyw— COMMERCIAL/INDUSTRIAL- Type of establishment: Design flow: gpd ( Based on 15.203) Basis of design flow 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: / / e Y�Cln � 'mil a! CL G System pumped as part of inspection: (yes or no)—JID If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date.operation and maintenance contract Tight Tank Copy of DEP Approval n Other APPROXIMATE AGE of all components, date installed(if known)Eand source of information: /e Lit Sewage odors detected when arriving at the site: (yes or no) jj6 , revised 9/2/98 Page 6(if Il SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 3 / �/]0 /�av xj / , iwnef: . Date of Inspec-pon: a i 9 BUILDING SEWER: / (Locate on site plan) Depth below grade:/ Material of construction:_cast iron�40 PVC_other (explain) Distance fro rivate water supply well or suction line JJ Q ( C - Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grader Material of construction:concrete_metal_Fiberglass._Polyethylene—other(explain) F If tank is metal, list age_ Is age confirmed by Certificate of Compliance-- (Yes/No) Dimensions: S� x/(' Sludge depth: toe Distance from top of sludge to bottom of outlet tee or baffle:-.2'?-- Scum thickness:_ r Distance from top of scum to top of outlet tee or baffle: yl o -rvy — Distance from bottom of scum to bottom of utlet tee r_ble:NCJ How dimensions were determined: 'omments: _ ' ecommendation for pumping, conditio of in�let and outlet yes or baffles, depth of liquid level in relation to outlet invert, structural rntegiii,. evidence of leakage, etc.) �4PL_(J►'hVh rcM/tom_(' _+.__.. ._ GREASE TRAP: , (locate on site plan) Depth below grade:_ Material of construction: _concrete_metal Fiberglass _Polyethylene_other(explain) r "` 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 integr.V evidence of leakage, etc.) revised 9/2/98 Page 7of11 F - , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C ``/� �/� �� ,,/ SYSTEM INFORMATION (continued) 'roperty Address: 30 f7a,,rY V � ,,1,-C_Or►'11 Owner: 4 ntac, Date of In pectibn: 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 a Alarm present _ 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 (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evi ence of solids carryover, evidence of leaka a into or out of box, etc.) bf PUMP CHAMBER:_ s (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.) — I revised 9/2/98 PaFc8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION='(continued)' 'roperty Add s: 2) lICtT».(n rnQ�C�r Owner: Y ' Date of Inspecti q/�� � • SOIL ABSORPTION/SYSTEM(SAS): (locate on site plan, if possible; exc�allvation not required, location may be approximated by non-intrusive methods) If not located, explain: Type' leaching pits, number: leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ - Alternative system: ' Name of Technology: ` Comments: (note condition of soil, signs of hydraulic failure, level f ponding, damp soil, c ndition of ve et�tion, etc.) a Q/12 CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. )epth 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.) ' 1 revised 9/2/9 Page 9ofI1 f ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION (continued) 'roperty Address: /r pC✓l�I�l r I �l t '. .. )weer: ] lC _ Date of In pecgbn: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house)' t - 1b 0 t JG revised 9/2/98 Page 10 of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) , roperty�Address: 36 lle, ,f Owner: '{? �J Date of Inspe -on: NRCS Report name Soil Type Typical depth to groundwater _ USGS Date website visited Observation Wells checked Groundwater depth: Shallow _ Moderate _ Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater*! Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions s ,Q Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) D (1 r S So cr�ov� GA- j revised 9/2/98 Pag(- Ilurll f S-/83 Copy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property 3D r�lAh'/�'%S /rl�/�ovGv�d� /�i9/jlVcSfi5161E �. Owner's name Date of Inspection PART A CHECKLIST S�Cp �'Pe Check if the following have been done: 6 19 �4� 9.- N _Pumping information was requested of the owner, occupan , ndd o Health. CU None of the system components have been pumped for at least S s 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. dF 5ys�Er7 AIiAjG.gc;zfi The facility or dwelling was inspected for signs of sewage back-up. The site was inspected for signs of breakout: All system components, excluding the SAS , have been located on the /site. y 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 SAS on the site has been determined based on existing information or approximated by non-intrusive methods. _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. XL f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents YZ�F5 garbage. grinder, yes or no laundry connected to system, yes or no IV6 seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: IVIA Last date of occupancy OCC up/� - GENERAL INFORMATION Pumping records and s urce of information: - 6USc� `/.4 S fiy �i4C,i}/1/7" �S%�C,� �'2��SfieyCT�/Oy► N System pumped as part of inspection, yes or no if yes, volume pumped 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information• /q9 02 1W Sewage odors detected when arriving at the site, yes or no g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: Y - (locate on site plan) depth below grader material of construction: __L_concrete metal FRP of her(explain) dimensions• S X S—�jC fQ 6 « 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 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, recommendations for repairs, etc. ) 1710y DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments : (note if level and distribution is equal , s carryover, evidence of leakage into or out of box, recommendation sfor drepairs, etc. ) PUMP CHAMBER:_,/ - (locate on site plan) Pumps in working order, yes or no Commen s: (note ndition of pump chamber, condit on of pumps and appurtenances, recomme ations for maintenance or repai , etc. ) at 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (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 and number _ leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (locate on site plan): number an configuration depth-top f liquid to inlet invert depth of so ids layer depth of scu layer dimensions o cesspool materials of c nstruction indication of g oundwater inflow (cesspoo must be pumped as part of inspecti ) Comments: (note condition of so' l, signs of hydraulic failure, leve of ponding, condition of vegetatio recommendations for maintenance o repairs,etc. ) ' PRIVY: (locate on ite plan) materials of onstruction dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, evel .of ponding, condition of vegetatio recommendations for maintenance or repairs,.etc. ) .. : .,• 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' �RR�91��rfir� w�c� !'16tsaR �xr oxnrr,� I 0 r D � --i3'- 1 D-BoSc t a.eW PrT A 6ol LE�c�1 P T & 2 DEPTH TO GROUNDWATER depth to groundwater method of determination or approximation: 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? Discharge or ponding of effluent to the surface of the ground or , surface waters? Static liquid level in the distribution box above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 day flow? Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface,water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? XV within 50 feet of a private water supply well? y 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 analy= for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. r Address of property 3 o y�6RiS ^F15idow G,g,�r C5.�eV574 Owner ' s name J7rct-�, kineAIS Date of Lnspe—btion 0t130 jqS 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Mtkop,(Y Company Name �p 69V(Kr/A01GvfA� Sri Company Address Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Check ave not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector ' s Signature Date I- Original to system owner Copies to: /��/�suSfi�,��� /�4C ��• Buyer (if applicable) Approving authority �`ZNOFggq ANTHONY c 0 BOSWORTH y �gT110 RS INSPE�QQ OWN OF BARNSTABLE LOCATION.® A fllr Gw A;. SEWAGE # ^ VILLAGE 13 hl )F 6 ASSESSOR'S MAP Cz LOT INSTALLER'S NAME & PHONE NO: Or, 6 u () S y;a-=-`'7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) '� (size) C 3 iSro�-t NO. OF BEDROOMS- "J PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER -TAC k /`1ARR l9 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: / ® 161y VARIANCE GRANTED: Yes No M 1 S-\1 a � 60 70� _ Z-79 THE COMMONWEALTH OF MASSACHUSETTS 1 BOAR® OF HEALTH TOWN OF BARNSTABLE ApplirFa#ion for UiipnsFal Workii Tonstrnrtion farAff - l Application is hereby made for a Permit to Construct (k) or Repair ( } an Individual Sewa Disposa System at* rr .. . �7A� . GEC .........•............... • — ......................................................... Location Address or Lot No. ---......-•— .....:• _ .---•-----•--•.•• - .............................................. er ` Address .......................•••---- . Installer Address UType of Building Size Lot. 49�'....___._Sq. f t ,--, Dwelling—No. of Bedrooms.____'__________________________________Expansion Attic ( (� Garbage Grinder ( � 'w Other—T e of Building ............. No. of persons.._._____._...._._...__._... Showers — Cafeteria A4Other fixtures ............................................=----------•-•-••---•----•-----•----•••-------......•---•------•-- - W Design Flo fixtures ............:...........gallons per person per day. Total daily flow.._..._•._. 0_......._....__._._..gallons. WSeptic Tank—Liquid capacity115W.._gallons Length.lQ"2 ____ Width_q-E5..... Diameter__- _.._. Depths5.!Tca__..... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area............ ....sq. ft. 3 Seepage Pit No.....L............ Diameter.....�Z.......... Depth below inlet........(Ca........ Total leaching area..53�_.__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) l' '-' Percolation Test Results Performed by...___. k _.l�l G_.'h.Y�-_____________________ Date..... '__�z'_..�...._._.___.... Test Pit No. 1....._3.......minutes per inch Depth of Test Pit-____4.�.__......... Depth to ground water..6o FAkcoumi-¢_E7 (s, Test Pit No. 2..............minutes per inch Depth of Test Pit_____j.......... Depth to ground water.�?T__ !��q? !TWJG=0 O Description of Soil........ i4 �2.s. ....- U -----••---•-------•----••----------•-•••-••••.......•-•••-•-----------------------•--•----••••-•-•-------•-•--•--•---••----•-•----.-•••-------_.....----••------------•••...._..-•---•••-•------------- 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 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 .. . . . . . ------- '----`f �� " f�' .-.. Dat ApplicationApproved By ---------0V V. , -----------------------_--- .......................................... ----- Date Application Disapproved for the following reasons: ----------------------------------------------------------------------------------------- ---------------------------------- ------------------- --------------------------------------------------- .-- ---- --...------------------ .......--------------- ---------- ------.----- --.............................- ------- ........-----==---------- �jDaw Permit No. ----------.-/ ---------------------------- Issued ------------------ Dace 79 Fmay... ...... �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l/ TOWN OF BARNSTABLE i Appliration for Disposal Works Tonotrnrtiun jhrmit Application is hereby made for a Permit to Construct (Y\) or Repair ( ) an Individual Sewage Disposal' System at.�itz:i?- s AD LAK.\ � Paz�s s3c_ c� �----------- _......... ------------------•----- •-----......------...----------- -------. -------------*------------ - ---- ---- ------- ---- ------------- Location-Address --•.•------.--•-------------------------or.. Lot No. ... 1=. ...................•--•----_.._.._...._......_..._._._..._ ._._..........------......---...------...........-- ner g Address a ` ....................... ----- ---••------------------•------------------- ---•---------------�-%......... .------Il -,emu~ �o Installer Address UType of Building Size Lot_ 3 --------Sq. feet Dwelling—No. of Bedr Garbage Grinder (Wo)ooms_____.__________________________________Expansion Attic ( � aOther�—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ----------------------------------------------=--- W Design Flow..........-•- 2_5.........................gallons per person per day. Total daily flow------------- 4.0....................gallons. WSeptic Tank—Liquid.ca.pacity)5 gallons Length_l-Ea'_9_>_.. Width.c4nb--___ Diameter---------- Depths::G."_r Disposal Trench—No..................... Width,.-._______.___•_--- Total Length.................... Total leaching area....................sq. ft. - Seepage Pit No...... ------------ Diameter-----lZ---------- Depth below inlet.........(s;...__._ Total leaching area...�>.3_Li_...sq. ft. Z Other,Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed . . ..................... Date.....?!._4 :. A..._.-.._._.... Test Pit No. I......3.......minutes per inch Depth of Test Pit.....1�_.._.__.. Depth to ground water_ tom Ee t.ety xe2 67 Li, Test Pit No. 2......3.......minutes per inch Depth of Test Pit-----_1.4.......... Depth to ground water..�a5t-agk4TG�_GD 94 Tu--� p� Lo w` S�t35o!-c .:Y�' ..4A1+1 _.� `2-.9_L�µ`(.._q_;IS.�-ty?raVG.4 . 0 Lo wt Sv Descnptton of Soil........... �-7=-----0_ (------•--�`--•-$--- �so�c,-�--�-5---_`_�__;_��7;---� V --------•-•--•-•--•-----••-••--------•------••----•----------•---------------•---•-••••-•...---•-••-•---••--•--•---•----•-----•------•------.... W- UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees toyinstall the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the'State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health.. �a p� Signed ........-- _---------- `-------- ....�---------------..........------------------ Date Application Approved By .....-` -.. ...... _a$ ................._.-.-----..-..-.......................----.....-._....-.......-.......- Date Application Disapproved for the following reasons- ....................................................---------------------------------------------------------------------------------- Date PermitNo- ------------- -`.. ............................ Issued ---------------------------------------------------. --------- Date THE COMMONWEALTH OF MASSACHUSETTS 0 BOARD OF HEALTH �./ TOWN OF BARNSTABLE &r#ifiratP af Compliance THIS IS XO CE TIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) Installer at ----------------------------------------------....................................---- ----- ...........--------....------- ---- ------ ------....----.............--.... h.as been installed in accordance with.the provisions of TITLE 5 o The State Environmental Code as described in rh�eapplication for�DisposalWorksl�Cons ruc ion.Permit No. .....-- �` S'... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARAfNTEEJTHAT THE SYSTEM WILL FUNCTIIO�OrrN SATT�� .milISFACTORY. /0 Gt/Irt _ DATE...........................................1 ...-------............................................ Inspector ..../ ....................... --------------------.-............. THE COMMONWEALTH OF MASSACHUSETTS �l BOARD OF HEALTH �� , J_9 TOWN OF BARNSTABLE /G No.............•......... FEE...........CJ Disposal Works Tonstrnrtiou permit Permission is hereby granted............................................................................................................................................. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System LatNo w E S`�R .. .............• -- C -••--•-••-••......•---.............. Street j .. as shown on the application for Disposal Works Construction Permit No...................... Dated..____.,�__A 6�--+.........._...... _ ................................. : = -------4 .....---•-- DATE .......... .......................... Board of Health FORM 3850E HOBBS&WARREN.INC..PUBLISHERS SX/ZE 7`�r/ 0 r,4 a K.TER , SULLIVAN . rso. 2r33 k'Q v. Z7 9lL y %'Zc,)i-/ M //`,( X .cat = 4¢0 c:5,A U�{'rf;L. P/I` � 5 E-. c'' i'0Oc 6'-9 L /z -5- v4k OF X RicHanD CS`� S .SCE TCjI {:ter - .; 0-1 /N r' , • e t n G✓h G-2ivc a�w 7-ER lr;> TF-31'fi�D�-E .2•�2.9 1 \ •PC.G 24'C�3 fL�S�4���.�.._.r•. '_`.___ �77 q0 < ti i t�7oF�\: J.7j u�o..+,��G, �....•.�._ B'�•t�' 7u��,vA'r..1 :J+1c,���.GCT/�c'STQ '� �1 �I fiYO-6 1-7 oc GG<: /,yy. 80X iNl/. GL A , jf7//[3 M1e C o E _ _. K. F,rt, .o T.a.vie• �4TO ��Z�• •� ,.�IV Y, +/IV✓• Y 'I�rL •• 'J (d� ys.to =',S� ' fb � .3 �--•C� 3{---- . LoCQ�/asp L�h'.��:t ',•r, m... ¢Z.ls /Vo P11A77Z y 47"TyE'FovnV u " B.4X7�,2 �• iC/j�E /.vC. 4.t�1,�.fE•Tl��G� .e�4lJ/.�EN1�Nr".S'd.� Ti�/� .E'.EGisr�.ec=l.�.�rvo .Sl/,e,iE ~ .• .S��N yffit/O TyE o.cF.S.�� fi�E.2EdN S.��UG�ypT Fes.` US.E-p VEE r + OF ER S 1 SULLIVAN IVo. 29733 I N TH. SS ¢ f _�( '" � � .H• ,--- ,;_,7;/l fit- � � �c ' 7 SLQd ,Seo � HARD a AXTER No.2404a / /cwtv ' I\ tN • �� ..• G4y3 , 1. •� Z. L`l 9 • � e :- O s:,, n r i f V , 9 t- ; rq . I . } _t 1 ... ��d✓ y J Sr6.rE AV / E Y' j- F- � t' e No. -------------- Fee-------------- - BOARD OF HEALTH TOWN OF BARNSTABLE Zipplitation-*rIftl Con5tructionpermit Application is hereby made for a permit tp Construct ( .�'j Alter ( n), or Re air ( ,)an individual Well at: -------- -- —---- — ------ — —— — P Location — Address /""�______ Assessors Ma and Parcel r A/�� /oJ Gi---a--�--d_--T Owne QA n t - -'—D-ll—t-----/'—ti-G�/JOw�10c•J �J Installer — Driller Address Type of Building Dwelling--------------------------------------------------------- Other - Type of Building ---- No. of Persons------------------------------___-_ Typeof Well--!r y---------- ------------------------------------------------- Capacity--------------------------------------- -_--_ -- --, Purpose of Well--/-LZ�` k,T°v`='- __� -- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificatq of Compliance has been issued by the Board of Health. Signed- ----— -------------------------- date Application PP on Approved By — --- --- ---- , - - _..... date i„ Application Disapproved for the following reasons:----------------_----------__:.__________________________��__ --------------------- (, date Permit No. --- /- �' -`�- — - - - - Issued---------------- -~ �a� --> BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of Compliance . THIS LS TO,C 2F,,Y, Th he Individual Well Constructed ( ); Altered ( ) or Repaired� 3 � _ -='----� ---- © ®;� C _ _S�"- o---------- jInstaller has been installed in accordance with the provisions of the Town of Barnstable Board of Health P_riivvate Well Protection Regulation as described in the application for Well Construction Permit No. V. ilg!-Afated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT-BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL TUNCTION SATISFACTORY. DATE--------------------- - ------------ ------ Inspector---------------------------------------------- -- —— --_ No.k - -�-'--- -7Q Fee BOARD OF HEALTH TOWN OF BARNSTABLE A.ppritationi orlDeYY Cootrurtionpermit Application'is hereby made for a permit t Construct ( Alter ( ), or Re air ( )an individual Well at: - ° _1l�,ti , S /4 Ca b _-L PC ---- f - _ _�) � -------------------------------- Lj -- - Location — Address Assessors/Map and Parcel M/• �G//rS /lcii� Meo���J L*J ST �l� Mc• — —� — — — ---------------------------------------- ------------------------------------------------------------------------------------------------- Owner Address -0A •s<<~�a(�w� � Q/1—l`—'� ,i C —_— 3 ----- 1tu.�c,r . ��ax T�GO -------------------- - --------------------- - } - ------------------------------------------------------- Installer — Driller /— Address 1 O o7 G y f Type of Building Dwelling----------------------------------------------------------- Other - Type of Building------------------------------------ No. of Persons--------------------------------------------------------- Type of Well-��4 —— --— ----- - -- -- Capacity---------------------------------------------— - - - - - Purpose of Wel 7;�:� Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificat of Compliance has been issued by the Board of Health. jo Signed- == - --------------------------------------- ----?l-f r-f°�---------------- date Application Approved By---- - date Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------—---------------- ------------------ / date Permit No.—°�` =�-r- - ---------------- Issued--------------.�-y 1 �j-----~--; -��- - date BOARD OF HEALTH TOWN OF BARNSTABLE -Zertlfltate Of Compliance fr THIS IS TO �CRTIFY, Th��}}/he Individual Wnell Constructed"1Altered ( ) or Repaiiredy _ c. u � �✓_ 3/ lYoc,�_Do,---41 !---o ZoY��o_ �4-S^ 0V 6��{ rInstaller 5'Q a//r S �� UI c..i -------- has been installed in accordance with the provisions of the Town of Barnstable BoJarr�d►of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -ated-'--�--�� D --- 1�-'- � THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE----------------------------------------------------------------------------------- Inspector--------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Very (Con5trurtion J)ertmt No. -------- - Fee---------------- Permission is hereby granted- -=Je 0 "°-`�--�^' --/ �J rl/° � c ------------------- -------------------------------- to Construct (M, Alter ( ), or Repair ( ) an Individual Well at: No. 32-------t/u� s — '— G__c jc? — ---`----'-----------------------------------------------------------------------------=---------------------------------------- Street as shown on the application for a Well Construction Permit Dated ----- --- ------------------------- — _ -- Board of Health DATE-------- -��