HomeMy WebLinkAbout2270 MAIN ST./RTE 6A(BARN.) - Health -.,.
2270 ROUTE 6A, Barnstable
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Commonwealth of Massachusetts °� ��
rn Title 5 Official .Inspection Form
I; Subsurface Sewage. Disposal System Form- Not for Voluntary Assessments r
rQ
u
2270 Main St.
'F.J
Property Address < ,
Neil Ringler p
Owner Owner's Name `
information is
required for every Barnstable Ma. 02630 12-18-20
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.
Imngoutforms A. Inspector Information
filling out forms
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not slim The Inspector Man
use the return Company Name
key.
P.O.Box 784 `
r� Company Address
West Yarmouth Ma. 02673
City/Town State Zip Code
retina 508-364-4398• S114430_
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);.I have personally inspected.the sewage disposal system at the property address
listed above; the information reported below is;true, accurate and complete as of the time of my
inspection and the inspection was performed based on,my.training and experience in the proper function
and maintenance of on-site sewage disposal;systems. After conducting this inspection I have determined
that the system:
® Passes
2. ❑ Conditionally Passes
MICHAEL '.N
3. ❑ Needs Further Evaluation by,the Local Approving Authority- o SEARS
No.SI14430
4. ❑ Fails
TIF���'
p . �q����i(F•S•IN.SPEG�o�`
/finnr►mmu�t����`�
12-18-20
Inspector's Sign re 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 has a design flow of
10,000gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form shouidbe sent to the system owner and copies sent to
the buyer;-if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 j Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�i; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c !% 2270 Main St.
Property Address
Neil Ringlet
Owner Owner's Name
information is Barnstable Ma. 02630 " 12-18-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
1500 gal tank, D Box 2 Dry wells
2) System Conditionally,Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
�v Title 5 Official t•n'spection Form
�i� Subsurface Sewage Disposal System Form ;Not for Voluntary Assessments
............., 2270 Main St.
u
Property Address
Neil Ringler
Owner Owner's Name
information is required for every Barnstable Ma. 02630 12-18-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
Pump Chamber,pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired
❑ 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): -
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require,further evaluation by theBoard of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
r- _ ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2270 Main St.
u� Property Address
Neil Ringler
Owner Owner's Name
information is required for every Barnstable Ma. 02630 12-18-20
_
page. City/Town State Zip Code Date of Inspection
C. Inspection-Summary (cont.)
Cesspool or privy is within 50Rfeet of a-surface water
❑ Cesspool'or privy,is within 50 feet of a bordering vegetated wetland or a salt,marsh
b. 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 aseptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑_The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a'private water supply well**:
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia.nitrogen and nitrate nitrogen is equal
to or`iess than 5 ppm, ,provided,that-,no other failure criteria are triggered. A copy of the analysis must
be attached to.this form.
c. Other: .
4). System Failure Criteria Applicable to All Systems:
You must indicate "Yes or"No"to each of the following for*all'inspections:
Yes. No
4 ® Backup of sewage into facility or system component due to overloaded or
El clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp:doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
�I Subsurface Sewage Disposal System Form.-.Not for Voluntary Assessments_
2270 Main St.
V
Property Address
Neil Ringier
Owner Owner's Name
information is Barnstable Ma. 02630 12-18-20
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) .
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distribution box above outlet invert d`ue 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:
El ® Any portion of the SAS, cesspool or privy is below.high ground water elevation.
El ® 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 water supply
Well.
El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well;
❑ 9 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 2000 gpd-
10,000-gpd
❑ ® 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.
5) 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 CA.
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 Il of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commo nwealth of Massachusetts
�- Title 5 Official In4spection Form
I, Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
2270 Main St.
Property Address
Neil Ringler
Owner Owner's Name
information is
required for every Barnstable Ma. 02630. 4 12-18-20
page. Cityrrown _ State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered-"yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
.should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no'!for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or'Board of Health
❑ Z Were any-of the system components pumped out in the previous two weeks?
t ® ❑ 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)
Z ❑ i 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:
El Z 'Existing`information. For example, a plan at the Board ofHealth.
❑ Z Determined in the field (if any of the failure criteria related to Part C is at issue'
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2270 Main St. -
�� Property Address
Neil Ringler
Owner Owner's Name
information is ��
required for every Barnstable Ma. 02630 12-18-20
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR, 5.203 (for'example: 110 gpd x#of bedrooms): 330:
1
Description: 3
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes' .® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewag 1.e system? (Include laundry system inspection ❑ Yes Z No-
information in`this rebort.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
2019- 7000 gal
Water meter readings, if available (last 2 years usage(gpd)): 2020-1000 gal
Detail:`
H
` 4
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
{ Title 5 Official Inspection Form
J Fi� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2270 Main St.
V
Property Address
Neil Ringler
Owner Owner's Name
information is Barnstable Ma. 02630 12-18-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: -
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. :Pumping Records:
Source of information: 2017
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons -
How was quantity pumped determined?
Reason for,pumping,:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official In`spection . Form
Subsurface Sewage Disposal System Form.- Not for.Voluntary Assessments
2270 Main St.
Property Address
Neil Ringler
Owner Owner's Name -
information is
required for every Barnstable Ma 02630. 1248-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont)
4. 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 nnovative/Alternative*technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection`of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the:DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
11-1-95 #997722
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
23"
Depth below grade: 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.):
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
{ p Title 5 Official Inspection Form
r F�11i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2270 Main St.
Property Address
Neil Ringler
Owner Owner's Name
information is required for every Barnstable Ma. 02630 12-18-20
'
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 13"
p g feet
Material of construction:
® concrete ❑ metal A El fiberglass ❑ polyethylene ❑ other(explain)
1500 gal r
If tank is metal, list ages; r years'
Is age confirmed by a Certificate of Compliance? (attach a copy.of,certificate) ❑ Yes ❑ No
1500
Dimensions:
L
V.
Sludge depth:'
29"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 0
8" .,
Distance from top of scum to top of outlet tee or baffle
18
Distance from bottom of scum to,bottom of outlet tee or baffle
How were dimensions determined? Sludge judge,tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition,-'structural integrity,
liquid levels as related to'outlet invert, evidencecof leakage, etc.): .
1500 gal tank with in and out tees in place both,covers 10" below grade
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�^ Title 5 Official Inspection . Form
�I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2270 Main St.
u� Property Address
Neil Ringler.
Owner Owner's Name
information is Barnstable -Ma.
02630 12-18-20
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet n
Material of construction:
El 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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 per day
t5insp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
f
Commonwealth of Massachusetts
Tile Official -Ins ectiori Form
-
v t � Offica p
II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
2270 Main St.
Property Address
Neil Ringler
Owner Owner's Name
information is
required for every Barnstable Ma. 02630 12-18-20
page. Cityrrown - State Zip Code ? Date of Inspection. ,
D. System Information (cont:)
8. Tight or Holding Tank(conf:)
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
9. Distribution Box'(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0 t
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into o(-out of box, etc.):.
D Box is 16x16 with 1 outlet pipe cover at 28" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2270 Main St: -
u
Property Address
Neil Ringler
Owner Owner's Name
information is required for every Barnstable Ma. . 02630 12-18-20
page. City/Town State Zip Code Date of Inspection
D. S stem Information cont.
y (cont.)
10. Pump Chamber(locate on site plan):
Pumps in'working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑, No*
Comments (note condition of pump.chamber, condition of pumps and appurtenances, etc.):-
}
* If pumps or alarms"are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site.plan, excavation not required):
If SAS not located explain why:
Type
❑ leaching pits number:.
2
® leaching chambers number:
❑ leaching galleries i number.
❑ leaching trenches number, length:
❑ leaching fields - number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
cam, Commonwealth of Massachusetts
Title 5 official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
2270 Main St.
V�
Property Address
Neil Ringler
Owner Owner's Name
information is Barnstable " Ma. 02630 12-18-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cost.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is 2- 500 gal dry wells wells are clean and slight water with no sign of failure
i
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c / 2270 Main St.
u Property Address
Neil Ringler
Owner Owner's Name
information is required for every Barnstable Ma. 02630 12-18-20
page. Cityrrown State Zip Code. Date of Inspection
D. System Information (cont:)
13. Privy (locate on site plan): fi
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding-, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
t Commonwealth of Massachusetts
Title 5- Official Inspection Form
I, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
2270 Main St.
u Property Address
Neil Ringler
Owner Owner's Name
information is
required for every Barnstable Ma. 02630 12-18-20
page. City/Town State Zip Code Date of Inspection
D. System .Information (cont.) l
14. Sketch Of Sewage Disposal System:
Provide a view of the-sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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- No.SI14430
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
• a .
Commonwealth of;Massachusetts
ei Title 5 Official Inspection Form
�I; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
2270 Main St.
Property Address
Neil Ringler
Owner Owner's Name
information is required for every Barnstable Ma. 02630' 12-18-20
page. City/Town State- Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
®, Surface water
® Check cellar -
® Shallow Wells, . ;
15'
Estimated depth to high ground water: 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: 11-1799 '
. 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.d ocu mentation)
❑ Accessed USGS,database-explain:
You must describe how you established the high ground water elevation:
No ground water per plan
Before filingthis Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
\ r
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
2270 Main St. a =
u Property Address
Neil Ringler
Owner Owner's Name
information is Ma. 02630 12-18-20
required for every
Barnstable
page. City/Town P
State Zip Code Date of Inspection
a
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1,-2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® .D System Information:_ ,
For 8: Tight/Holding Tank Pumping contract attached
For 14-Sketch of Sewage Disposal,-.System drawn on.pg. 16 or attached `
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
TOWN OF BARNSTABLE
L` 1ATION Of t I� �� SEWAGE #
VI LLAGE f I}/'�?S � ASSESSOR'S MAP &LOT'2 7 61 3
INSTALLER'S NAME&PHONE NO. 111�te—y S�
SEPTIC TANK CAPACITY IrW
LEACHING FACELITY: (type),4AwLtZeAs (size) ��
NO.OF BEDROOMS
BUILDER OR OWNER fri.
PERMITDATE: IL —/ 2 COMPLLANCE DATE:__/) -13 s
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
v
r rJ
r�
- 0f
/ 0/1
s Fee
No. /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippYication for Miopog 6petem Construction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) Complete System O Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
AssessorMM�p/Pazce D O
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
3 IZ—
Type of Building: Ap�
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(0k'
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S:A:S,;
Description of Soil
Nature of Repairs or Alterations(Answ ,g,rr when applicable) r.-&VA SQ c_ k cj- a
� c,G lrae. cry w� �S
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue b this Boprd of Uealth.
Signed o� ® e Date
Application Approved by Date
Application Disapproved or the following reasons
Permit No. Date Issued
No. I CA •" Fee
THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes
.Pgp C HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
2ppr catton for 0tgpog *pgtem Con!5tructton Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) Complete System ❑Individual Components '
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's M p/Parcel
r� a� P c�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
A t—k c\�e 0O,SZ
11 ,.."A 7 i - /z
Type of Building: '
Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder(
Other Type of Building No.of Persons • ' Showers( ) Cafeteria( )
Other Fixtures
I
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date - Number of sheets Revision Date
- , Title r I n_Z }
Size of Sepffftank _IL . Type of S.A.S.
� `... s. � ,.•,�.�v£-ate,
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) t V.s-A,\\ 1 0-o SQ1 17C_ I-r--^ !C c� &C
e4" 4.Jt des
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system`t
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this Board of Health.
J Signed -\ C? Date
Application Approved by Date
Application Disapproved ior the following reasons
r �
Permit No. .,Date Issuedn
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ' )Repaired( Xpgraded( )
Abandoned( )by \ ce
at (20 1j haMeconstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �" ed
Installer _ __ C .�" Designer
The issuance of this permit shall note construed as a guarantee that the syste will function as designed.
Date 1 Z- -�-3 " Z Inspector
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mt.5poar *pgtem gtructton Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at -Lz-g)
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Constructio must a completed within three years of the date of t
tjDate: Approved byI
TOWN OF BARNSTABLE G,
y LOCATION ��� � �� SEWAGE #
VILLAGE � ��s< ASSESSOR'S MAP &LOT-12 t, 12
INSTALLER'S NAME&PHONE NO. %C&Y L�D/1S
SEPTIC TANK CAPACITY `
LEACHING FACIUN: (type�S �ry�� S (size) J X 1
NO.OF BEDROOMS
BUILDER OR OWNERl
PERMTTDATE: �/ —/ " COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any wells exist. Feet
on site or within 200 feet of leaching facility)
Ir
Edge.of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
1/6/99
a=,�r
NOTICE: This Form Is o Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, ��„` ��5 , hereby certify that the application for disposal works
i
construction permit signed by me dated concerning the
property located at 22?p Ct G X �.�c � , meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
ma.-dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the ma.,dmum adjusted
groundwater.table elevation,
Please complete the following:
/
A) Top of Ground Surface Elevation(using GIS information) S
B) G.W. Elevation +the MAX. High G.W. Adjustment .
i
DIFFERENCE BETWEEN A and B �9
SIGNED : �c.-� DATE: 99
[Sketch proposed plan of system on back].
q:health folder.cen
i t
d
ON
4
68 ci
F
i
L1
1
TOWN OF BARNSTABLE �2 3
LC'CAT
O:tZ
® SEWAGE
VILLAG , 5 �DIG ASSESSOR'S MAP 6z LOT
ll i
INSTALLER'S NAME 6z PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) / ,'% (size)
NO. OF BEDROOMS � PRIVATE WELL OR PUBLIC WATER
BUILDER O OWNER , Ild
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: A19
/
VARIANCE GRANTED: Yes No
Q
i
O O
�P;
I�
yi��
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA6TH ,, , , ,
TOWN OF BARNSTA SL` �` ° �' E
ti
Appliratioo for 11hipasal ork� 'vit r`rirtitsj on
ed
Application is hereby made for a Permit to Construct ( ) or Repair ) an Indivi u ge �i's osal
System at: oa to
2270 Route 6a West Barnstable
................_........_...................................................................... -----------•------------....--------------------------------------._........_......---------..----
Location-Address or Lot No.
...1AId................................. ----...---------•--............................ ...........--..................................................---•--......^------..............--
Owner Address
WJ.P.Macomber..Jr........... ........ ............................ ........ ...
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............_
...............................Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e of Building No, of persons............................ Showers
YP g --------------------------•• P ( )--- 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.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet..._................ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
P' -••-•--•••--•-•-••---•---------••••-•-•---•--•---•---------•-••.....-•--------------------------•----•-..........------•-----•--•--••••-- ------------------
oil
x . Description of SSand............................................................................... --------•--------••-•-•-------------•--•--•--•--•-••----•-----•---.........--•---.-•---
U ............................•-••------......••--------------------•-•-•--•.........•------•••-•------......•----------------•--•------••-••----•-----•-••--•-•-•••--•-•-•••-....---------•••-•--•-..-•--
W
---------------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------•••--------_....
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-----•---------------------------------I-1 J a J-- a l to n l e a cph pit ._..._....
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 Compli ce has g issued by the oar of ealth.
Signed/ /� '%5 --..... 1�J/�./9.1
------------ ---------------- ................
Date
Application Approved By ........................ .. ... ---...
-- ---------------------------------................... ................ —---------'--- ...
Date
Application Disapproved for the following reasons- ------------------------------------------------------------------------=...............................................................
---------------------------------------- ---------------------------------------------------------------- ----- -------------------------------------------------------------------------------------- ---------------------------------------
Permit No. -------- ..:-....�1.. .Ll....................... Issued ---- ------------------------.........................D--ate-te
Date
t
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Allp iratiutt for Disposal Works d �A-qtwLu Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair an Individu� Sewage, Disposal
System at: /
227') Route 6a West Barnstable
••---------------•--•------•----•---•---•---........-•------•------••-•-------•------- -•--•-•--••--••---•-•--........--------•---------•---------•-------------------------••••--.....--
Location-Address or Lot No.
..P.4T...........—............. .... --•---------•-••--------.....•----•--•----_.... -----••---------------.....-----•--------- -•------._._...---._._.._.........---.......--
owner Address
Wa J.P-,Macomber Jr........- ........:............ ......
Installer Address
Q Type of Building Size Lot____________________________Sq. feet
U _-___Ex Expansion Attic I—. Dwelling:' No. of Bedrooms............... ______________________ p ( ) Garbage Grinder ( )
a Other—Type e of Building No. of ersons____________________________ Showers
� yP g -----•---------------------- P ( ) — Cafeteria.(..._).
dOther fixtures ----------------------------------------------------------••---------------------------•-----•----------------••-------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic 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........................................
W
Test Pit No. i................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2.............___minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 ----------------------------------------••-•----•----------•---••-------...-•---•----.....--•-------.........................................................
0 Description of Soil...............................................................................-----------------------------------------------•--------------------------------._...---
x Sand
U
W
---------------------------------- ------------------------------------------------•---------------------...----------------........=...........................................
U Nature of Repairs or Alterations—Answer when
_ ap p _______________________________________________________
..--•----•----•-----••------------•••---1'laoJ.-dalton--_leach pit 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 Complia ce has eep issued by the •oard of health.
Signed l9l
-- --- -- -- .....
`..---. ...- - -.... - ..--
Date
ApplicationApproved By ------------------------ - - ---- ....... ................................. -------- ----------------- ------------------
Dace
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------- ..............
--- ----------
-------------------- ---------------------------------------------- ---------------------------------------------------------------------------- ----------------------------------------
------
Permit No. -------9.f1---`---- .y.... Issued Date
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C�er#tft��tte of C�ontylian.ce
TJHI ,ISylT�Q&Eg�TYJ�'hat the Individual Sewage Disposal System constructed ( ) or Repaired (X )
by...-----------------------------------------------------------------------------------------------'---...--....------------------........---- -------- --- ---...------------....----- ----------------------------------------
Installer
at -------22-77-_Route----..-a....We-S.t_-Barns-table--_--
.................. -- -------- ------- ------- -------------------------------------
has been installed in accordance wir-h the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...... .......... dated ------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A'G.UARANTEE THAT THE
SYSTEM WILL FUNCTION N SATISFACTORY.
DATE. -- ;----------------------------------------------------------- Inspector .............................................•-1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE $
No................ . F EE •- ..............
Disposal Works TDottu#rudiutt Vrrmit
Permission is hereby granted..........J.P.Macomber Jb/
to Construct ( )) or Repair (XX) an Individual Sewage Disposal System
at No....227a.....oute.......a West Barnstable.
Street q
as shown on the application for Disposal Works Construction Permit No._l _.�.V_yDated__________________________________________
.................................. -
Board of health----••-------------••-•--•-•----....__._
DATE.............. -"••- ... ---1,1--------------•------
FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS
C-A-T ION S E W A G E PERMIT NO.
VILLAGE
� a mA /v r P, A1
I N S T A LLER'S NAME i ADDRESS
d U I L 0 E R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �.e�Z: 8�
� g3
O h
C
�.
�" �
t r
� �t
__
No. ............. ..S� ��-:(,l.._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............. /.(lL�L7.....OF.... XsL� ...._._......................_..._..
Applira#ion for Disposal 19orks Tomitrurtion ramit
Application is hereby made for a Permit to Construct ( ' ) or Repair (y- an Individual Sewage Disposal
System at:
.--SP�................................. ................. ...------... .. ......... --------------------
- ocation-Address or Lot No.
Owner
r f. Address
........................... ........) c....... .....J'_Ea2*Y4V�: ............
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other 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.........................................
a
Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water.........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+
ODescription of Soil......................S .t1(X:- .... -----...--------•---------------.-- --.------------•--........----------•---•
V -----------------------------------------------
--------------------------------------
•------------------------------------------------------------
-------------------
----•--•---------------------------
-----------------------•---------------------------------------......------------•-------------------------------••-• ]]---------------------------•••....i-•-------------------------•---•-----------
U Nature of Repairs or Alterations—Answer when applicable._______--..L-__V����___.( ,at.l-.....�1.�______________________
----•-------------------------------------------•-----------------•-----------------•--••---.......-----•--••--------.----------------------------------------------------------------•-------.........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Com H nce has en issued b the board of h
P P � Y �
Signe ..... C'9 �Q �4� y�l>!L -P -� .1- d �
t
ApplicationApproved B . ••. . . -----•..................:...••-----•--•-•-----............•-•.....--•------- . . -- .. . ..---•---
ate
Application Disap ve r t e following reasons:-•-•---•-•--•••••-•-•-•-•--•-•••--•-•---•••--•-----•-•-•----......--•---••••••••-••--••••-•-••-•-•-•------••----
..............:................. •----•--- ----- .............-••-•-•-----•---.....•••-•--•...-••••-•-•-•••••-----•--•-•--••--•---•-••---••-•-•-•-•-••--•-•••••----•••-----•......•-•----•---
/ Date
Permit .....--.--.---e:;�1 -•-------•••-------------- Issued.......................................................
No.................... � Fps.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-------------
.. ..... ..................
Appliration for DispotiFal Works TonIratrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (lam an Individual Sewage Disposal
System at:
f �V kj ff"1✓"'r�- 1 � a
................................. ........................
ocation Address - s x -'�$-pr
.... ..: ,.t .. yt t, .tF ?....1 xr .4_:a}a:.r .� /'x.......................
s e Owner jt Address
a ---, q I-pv' b- k !'4 s� iJ'� f F s l.... f.`........ .....L�-. k f i....F':�..t.S:.�f .........._..---..................................
!...9� r.. ..... ................
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid-capacity............gallons Length................ Width................ Diameter---------------- Depth................
W Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
. x
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY--•--------------•-------------•-•-------------------•-••------.--•----• Date........................................
14 Test Pit No. I................minutes per inch Depth of Test Pit...._............_.. Depth to ground water........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Descriptionof Soil.............................................................--•-•------------•--------------------•--•------....----------------------••------....---•----------------
x
W --•-------------•••-----•----•-------•----•--••----••--••------------------•-•--•-•----•----......................... --------•------•-•----••---...--•--------.....................................
UNature of Repairs or Alterations—Answer when applicable------------------ _ :.¢.. .. '. ... ....... «�...................................
1,.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of ComR4nce has been issued by the board of health.
1
Sign ... ....
r'
Application Approved B ... ---•..��'-�-----------------------------•---•••••--••-----------•--....-•--........ o- ...1 .: .....
Cate
Application Disap ove or t e following reasons--------------------------•----••----------------•-----------------------------------------------------•-•.....--
.......................... .... ......... ..................•----.......-•--•--•----•----------•--.....-•-•--••---•-•-----•----..............................-•-------....---...Date -•--•---•---
Permit ....-•-...........f�. Issued;
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
x.- Tntifirtt#p of ToutpliFanrr
THIS-IS.TOk CERTIFY, That.the Individual Sewage Disposal System constructed ( ) or Repaired (4'�
by y --.-- .......................................................... -•------------
Installer .
has been installed in accordance with the provisions of T r f -State Sanitaryde cr ed in the
application for Disposal Works Construction Permit No................ �-- .......... dated -.C�.. .._._..........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................................ ..................... Inspector---..............- ...................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� /'� ....1.... ..*'..1 i OF.... .. ............................................,d� .. ' � �"ti -
No...... FEE .._ f ✓
Ir
Permission is hereby granted..... ?......_ ram. .. .'
to Construct_( or air i;- n-at Indivrld�}aI Serra a Disposal System
......_..- •-----
treet q
as shown o/thea ca ' n for Disposal Works Construe ' i N ... = �_..._ Dated.._!.... ..............
�rBoard of Health
DATE•-- ...........................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
n--!r A