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HomeMy WebLinkAbout0010 OAKMONT ROAD - Health 10 Oakmont Road Barnstable _n �: A = 349—051 ✓Vt -L i i—v'E Fr—i(—,E GF +Iv FRONT ENEAI1%3FFAIpS i)EPARTi-MENT CAP ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION - Property Address: 10 ® k Owner's Name: Owner's Address lt- -. Date of Inspection: Qz Name of Ins ector: lease print) � �P P P � )����et.�t Company Name: 14A Awk l�.sp�f' s Mailing Address: E) Telephone Number: co — r CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of 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 S(310 CMR 15.000). The system: j Passes Conditionally Passes Needs Further Evaluation by the,Local Approving Authority Fails Inspector's Signature:��� ,l: � Date: 916105 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 ****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 611SP-000 page i Page 2 of I 1 ®FFY[C�1 SPEC—II f�FORM—SOT FOR V O1i UNT ARC'ASSE TNTS SUBSURFACE SEWAGE DISPOSA.'SYSTEM INSPECTION FORM. ET A R CATION(continued) Property Address: 10 04tt(C std Owner: moo. Date of inspection: 9137657 Inspection Summary: Check A,B,C,iD or E J ALWAYS complete all of Section IED A. System Passes: Ti have not found any reformation which indicates that any of the failure criteria described in 31.0 CIviR I5.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below- Comments- B. Systems Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced repaired.The system,upon completion of the replacement or repair,as approved by the Board of He pass. Answer yes,no or not determined(Y,N,ND) the for the following statements.If determined"please explain. The septic tank is metal and over 20 years old*or the septic tank statement r metal or not)is structurally unsound,exhibits substantial infiltration or exhltration or tank failure is' ent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by Board of Health. *A metal septic tank will pass inspection if it is struchuaily sound, t 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 bigli static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled even distribution box.System will pass inspection if(with approval of Board of Health): bro pipes)we zqAaced structim is removed distrriliutim box is fueled or replaced ND explain: _ The system re ed pumping more than 4 times a year due to broken or obstructed pipe(s).The systems will pass inspection if ith approval of the Board of Health): brokers pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I I OFFCI'AL FNSPECTL ION FORM-NOT FOR` OIJUN`TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address;�*14nemt.f Owner: �,,,_4A_ Hate of inspection: S'p-T- I C. ;Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in ord 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 ith 310 CMR 15303(1)(b)that the system is not functioning in a manner which will protect public alth,safety and the environment: T Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vege ed wetland or a salt marsh 2. System will fail unless the Board of Health( d public Water Supplier,if any)determines that the system is functioning in a manner that protects he public health,safety and environment: _ The system has aseptic tank and soil sorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a s ce water supply. — The system has a septic tank an AS and the SAS is within a Zone I of a public water supply. _ The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more Porn a private water supply welly#: ethod used to determine distance *This system passes if well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile or is compounds indicates that the well is free from pollution from that facility-and the presence of ammo a nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are Qered_A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of i l OFFICIAL INSPECT10N FORM-- OT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION EGA PART.A CEltTMCATIGN(continued) Property Address- to Oe-k owwf R Owner: a� Date of Inspection: C$ D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for ail 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 b"below invert or available volume is less than'/3 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within ae 1 of a public well. _,?r Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.]This system passes if the well water analysis, performed at a IDEP certified laboratory,for cafe rm 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 S ppm,provided that no other failure criteria are triggered.A copy of the analysis most 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 CNIR 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 d �e of 10,000 gpd to 15,000 �• - You must indicate either"yes"or"nZ,h" the following: (The following criteria apply to largsystemsddition to the a above) yes no the system is within 400 fe eking water supply the system is within 200 fry to a surface drinking water supply the system is Ioca ed in ative area(Interim Wellhead Protection Area—IWPA)or a mapped Zone lI of a public wit supply well If you have answer/"yes" question in Section E the system is considered a significant threat,or answered "yes"in Section D system has failed'i he owner or operator of any large system considered asignificant threat uor failed under Section D shall upgrade the system in accordance with 310 CNM 15.304.The systecontact the appropriate regional office of the Department- 4 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 10 hro�c yu.�M asp i Owner: �. Date of Inspection: �n� Check if the following have been done.You must indicate"yes"or`4no"as to each of the following: Yes No Q _ Pumping information was provided by the owner,occupant,or.Board of Health Were any of the system components pumped out in the previous two weeks? 14- Has the system received normal flows in the previous two week period? _ Have large volumes of water been introducer)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) L 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? oo _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? d _ Was the facility owner(and occupants if different from owner)provided with information on the proper intenance of subsurface sewage disposal.systems? i he size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310-MR 15.302(3)(b)] 4 5 Page 6 of I l OF ICUL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS N EFENTS SlL'IISIJRRFACF. SEWAGE Da'SPOSAt.SYS'TlrTbi INSPECTION r£II�!'�vi PART C SYSTEM INFORMATION Property Address- tp e Owner: c� Bute of Inspection: 6 FLOW CONDITIONS RESIIDENTIAL Number of bedrooms(design):�_ Number of bedrooms(actual): DESIGN flow based on 310 CNIR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Q Does residence have a garbage grinder(yes or no): IS laundry on a separate sewage system(yes or no):AZ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):JUD Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no)A4L���� Last date of occupancy:� CO&IMERCIAL/INIDUSTRIAL Type of establishment: Resign flow(based on 310 CMR 1 S. ): �pd 134sis of design flow(seatslperso ' gft,etc.): Crease trap present(yes or no): Industrial waste holding tank resent(yes or no):— Non-sanitary waste dis ed to the Title 5 system(yes or no):_ Water meter readings,i vailable: Last date of occupan ,/use: OTHER(desc ' e): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):-60 If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/AIternative technology. Attach a copy of the current operation and maintenance contract(to be ob_tained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of 1 components,date installed if known)and source of information: 1)<��,� 8 _mac t� Were sewage odors detected when arriving at the site(yes or no):_ 6 page 7ofI OFFICIAL INSPE FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSL'"RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 Dede-!v. Owner: Rate of Inspection: 6 BUILDING SEWER(locate on site plan) . Depth below grade: jt76 Materials of construction: cast iron J(40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: X (locate on site plan) d� Depth below grade: Material of construction:jLconcrete,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: &W ei-4/ Sludge depth: _V Distance from top of sludge to bottom of outlet tee or baffle: _. Scum thickness:I v Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: !✓r` How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition.,structural in€egrity,liquid levels as related to outlet invert,evidence of leakage,etc. : J/Jy T N 19�s.-`�Ct .• vv c Q ( GREASE TRAP: (locate on site plan) Depth below grade:— Material of construction: concrete—metal_fiber¢ s_polyethylene other (explain): Dimensions: Scum thickness: Distance from top of scum to top of out tee or baffle: Distance from bottom of scum to bo m of outlet tee or bade: Date of last pumping: Comments(on pumping rec endations,in and outlet tee or battle condition,structural integrity,liquid levels as related to outlet invert, dence of leakage,etc.): 7 Page 6O I1 OFFICIAL INSPECTION N FORM—NOT FOR'VOLUNTARY ASSESSMENTS SUBSUR FACE SEWAGE DISPOSAL SYSTEMTLM INSPECTION FORMM PART C SYSTEM INFORMATION(continued) !6S✓PT4pe3'hJ Address: 0 Owner: t� Bate of Inspection: 5 erg_ TIG-HT or'$LDI,ICIleIti TANK: (tank must be pumped a e of inspectionIocate on site plan Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: Gallo Design Flow: __ g onslday Alarm present(yes or no): Alarm level`. Al working order(yes or no): Date of last pumping: Comments(condition of anon and$oat switches,etc.): DISTRIBUTION BOX: Y (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: e ilro Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): d p PUMP CHAMBER: (locatePumps in working order(yes oAlarms in working order(ye Comments(note conditio of dition of pumps and appurtenances,etc.): - 8 Page 9 of I I 0 INTSFE�lull FORM—NOT FOR vOLIFNTA Y ASSESSi 'S SUBS kFACE SEWAGE' DISPOSAL SV STEM INSPECT ION s 0�II PART C SYSTEM INFORMATION(continued) Property Address: 7Q4L& .4 ff Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): a( (locate on site plan,excavation not required) If SAS not located explain why: .f e T leaching pits,number leaching chambers,number. leaching galleries,number: leaching trenches,number,Iength: Teaching 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.): 714 is CESSPOOLS: (cesspool roust be pumped as p of inspection)(locate on site plan) Number arid configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of constructio . Indication of ground er inflow(yes or no): Comments(note c dition 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 c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 1 V of 1 l OFFICIAL INSPE SION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART i C SYSTEM-INFORMATION(continued) Property Address: ® o4 iw.rt�C ct i Owner: 1 a Date of Inspection: SNETC:H©3F'SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public-water supply enters the building- . 50 6G ,n Page I I of I I OEFICL4, .INSPECTION.FORIM—NOT FOR VOLUNTARY ASSESSMENTS SUBSPACE SEWAGE DISPOSAL,SYSTEM INSPECTION FX ORT .4'I PART G SYSTEM INFORMATION(continued) Property Address: /+ a, Owner:ag c c& Bate of Inspection: 5"14S SITE EXAM Slope e-15 Surface water" Check cellar Shallow wells #Q0 Estimated depth to ground water 21-'�feet Please indicate(check)atl 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 trust describe how e�stab Li shBed p th`e high ground wat r elevatio(So a� LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS 7-- 8 U I L D E R OR OWN ER 0 DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED . .. - � PP _ L�� � Iq6 Cal2n.(t12 � 0�4lINt®n1��NIl4KsTp ' T.4 r I I i � �� '1° �, �8' ` ` 1 .g►�• r •'; __35 fr' Fes$.... _ — MyiHE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _-_,�i®)W.. .......... .....OF... ppl ration for Bigpugtal Workri Tonotrnrtiun ramit ✓Application is hereby made for a Permit to C�nstruct (><) or Repair ( ) an Individual Sewage Disposal System at: �.. t1�K L'.'I.�N . '.®�_s > .... ¢..1..9. ..-- Location-Address or o. ..................................................... ............................................. Owner Address --___ .. ................................•---•--•--•--•--...... .................................................................................................. 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 ersons________________________ Showers a Other—Type g --------•----------'- P ---- ( ) — Cafeteria ( ) dOther fixtures -----------•------------------"----------------....---.•----•-•••------•---•---•--•----•------•--•----•---.._..--•...--•-•----...-•-•-••........-_•--- Design ' ________________________gallons per person per day. Total daily flow_ ,X_ ...........gallons. W n Flow_____________ WSeptic Tank—Liquid capacity1Q09___gallons Length_8_".&".'___ Width_t/'_/©!'.. Diameter________________ Depth_6"8.-"__. x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......1------------ Diameter----6.i___________ Depth below inlet...3•Q........ Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( , ) n aPercolation Test Results Performed by.._. dvtA �_._Xl� !____-.C .Slt`Ciel_�1Y�Zd Date._7`_ .2,.-81______________. Test Pit No. 1...,.q.......minutes per inch Depth of Test Pit...1_Q._'_.__.__. Depth to ground water_1-V_Qrbl_........ (_, Test Pit No. 2.../_O........minutes per inch Depth of Test Pit__).Z.'__________ Depth to ground water M.A,1li_k'.______. 7 O .................. _____________'/ti...____ +..________......_..____....._..8.__..........C....I....__.........__......."._....._.__.._."......____. .if x Description of Soil el f ��_+I,k..._._.l......fJ_.. 3 k1/e�0��o l�tYl__ _S!�(Z sos .j..-------.;--.34--- ' /SAS!...... V -----------•.7�P T../lgl -?'-.........C._.____��-___.__._4.U0a.,&1._4I.?�............ C'__.��A_�avGc _ U Nature of Repairs or Alterations—Answer when applicable. -----------------------------------------------------------------------------------------------------•------•-•--------------•-•---•-•----••••-•----•---•---•-----•----------•----•---•....••-••-•--•-- Agreement: e The undersigned aegesato install the aforedescribed Individual Sewage Disposal System in accordance with . the provisions of 1ITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beep issued by the board of health. Sied......... ••=•--•• ........ -• ......................... ............•-- _._.. Date Application Approved Bv------------------------- - •_ • -•-•--•---- -• --•-• -...._.--`-= :n ? ..5..... Date Application Disapproved for the f ollowi g easons-------------------------------------•--------------------------•------------------------------------------•-•--- ---------------------------------------------•-----••----••...--_-•--••--•--•-•-•.....---•-------•-•._.._......•---•---•-•---•---•---••--••-----------•-•------•-••-----------•------•---•---••-••-•--- Date aPermit No......................................................... Issued-..................................................... Date No................--.....-- Flm$.......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH o...U.........................OF....... .,..-. Aliptiratiou for Bbipaii l Marks Tomitrurtiun Vauti# Application is hereby made for a Permit to Construct (:G)`.,ior Repair ( ) an Individual Sewage Disposal System at: ) - 0,2 �)eR _flC_.. � .>�1 �'�._...90 -�y� / S a=�S �'�� t1if�:��i ,�YLf� ... °° 1-��- .. Location-Address —or Logo. -��r�... ��. .� So.A?._ - --...-----..... • Owner Address a .........................�_I_. A.._.................... ..........._...._.............. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............__3..........................Expansion Attic ( ) Garbage Grinder ( ) '14 Other—T e of Building ____f:._ No. of ersons____________________________ Showers a Other—Type g : No. f p ( ) — Cafeteria ( ) dOther fixtures ----------------•-------•-----••• ----•---•-------•---------•--•--------------•-•••••-•-••---•----••---•----•-•••-••-•-••......---•- W Design Flow_____________�5_.......................gallons per person per day. Total daily flow_3- _/la__=___33D•----_...._gallons. WSeptic Tank—Liquid capacity_10oq__gallons Length_.�6�___ Width_�l_'_A�''_ Diameter________________ Depth_.5���... x Disposal Trench—No_ ____________________ Widths____.__.____._.___ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I............. Diameter_________________ Depth below inlet...3.eQ........ Total leaching area..................sq. ft. Z Other Distribution box (X) Dosing tank ( ) n aPercolation Test Results Performed by---- �w°. �_._{i.tA/......L':1F_?A J__4N�. Date__:!'2 Z.PU_______________ 4 Test Pit No. 1.... O-------minutesperinch Depth of Test Pit...1.2........... Depth to ground water_.&b!x,1 ........ 04 Test Pit No. 2---eO........minutes per inch Depth of Test Pit._lZ_........... Depth to ground water A!AO..C%_____-_- O Description of Soil... Ps t__.��_f r...............®.,.__36 F: ........... Tps...... -----.............'3G......... ------------- x - ---------•----.----- U Nature 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 Sanitary Code— The underst ned further agrees not to place the system in operation until a Certificate of Compliance has been issued by ttllioarlof l ealth. _ ----- ----• ................ .................tee•-__..___. ApplicationApproved By--------------------------- • .... ............ ... •--•------ _•-•......... •--••--• �✓` Date Application Disapproved for the followi F06hi'-f.2�...................................................................................................... �f w Date Permit No:: .- " �'j` Issued... -_ . -•-- •.....----•--•------•-•-•••--- �' f // _ 3 Date . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................... ........ Trrtifira r of fin mpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (x) or Repaired ( ) by..:..._.... w......_.vK�+f F 1 E ---.......`•-•--•-•---••-•------••--•-•-•----... Installer at........................L`� r u C o-i N t = �9__ _Y' �1:_! :�..:.J _.�41 . Izc,o •• ... ...................................................... has been installed in accordance with the provisions of TITLE 5 of The tate Sanitary Code as-described in the application for Disposal Works Construction Permit No........ �___. dated----------- _________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT'BE CONSTRUED AS A GUARANTEE THAT THE .av SYSTEM WILL FUN TION SATISFACTORY. _ � l DATE-•••••-•...._--••-•... .............. Inspector...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Sj ...........................................OF � �,_ 8 ( �<_ No..... . :_.........---_..... 9' ors?o ry r 0h ip711',S al d$ l$ �]Q�tt'$i r hilt lerutt' - Permission is ereby granted........... v_tl V......I .Ef_!_..................................................................................... to Construct ( or Repair ( ) an Individual Sewage Disposal S2o.ZS_R3 tem y� at No........1.0 � -.. �-�✓?-l�t�2 �-h l����1v..1- I�t r�12S f�i�7 if— Street as shown on the application for Disposal Works Construction Permit ___rDated__________________________________________ ' ..................... DATE........ -•��-•------•--------------- ......................... B r of ea h ' FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS... Soil. L o C� 7- 4 T A- 71, 2 D K,ELi.Y E ka e" 11,C7 Z P, L j/-\j F- Ir -7- E F-L-;i v/ too c>LoA' Z-A 10 0 L) Ir 7 pt Im, T SN p 4 �<o TO 01v IS^C Aw. 20/0 Lw ARICA ONE ON Foo oF f:nr,4isH GRAVE 2.t or rSA 4rw4e Me ImersAVICOJE, c (I AA —Z* C.0461c P�A I q AOU CaVER 'TV P4, ST pqgVeNT rINS4P F90AA -PA 1 1.,. t k- w F re Mukh S19041&mi pi tart it A&�AAAA"IkL 6to 40 rtt )4 Y4 FOor -2 sc) k LtAc-,W -7 2 /6 7 4,/-Q T A4ZO 5 — AL W LO 7 , C-11y GALLON 4'Nuri -7 2,Z Ic TANK i� ,12-r T pipe (WATSiaH )i )r4V"T 3 0 7LO 2-01m ikJ YST F,M C)E TA I L, �b FA M L..�f' y ON 1�-) p G'c I r i r,AT 10 N A" OF -4 1-4- 5ep"rl C, 5,YSTE.'m cor-je>Tpuc-i Ot I '� / I,--, A r -7�4 E MASS.4� ALL C.0NF0_R/v\ TO sm i2\J1jZ0NAAF-P4TAL a0PF, -r1TLS y- ri-0 vj IZ r*'V 1 C-7 I-D 7- 1--7 7 4� Tt-46 OW" 27. 4M 150AIZO Of 4eAL�-ri-4 ij QA1 AL 1 -5 91ri e- TA,,,�14, D i-�irsz i OLJ-ri i le "1*11 Re Q '0. Lr,-AC44 . CA,PA C,I T'/ —330— 'L + AN L-FAC-1-41h4a PIT -rO G, 40- 9D GONC42eTf' :z 20000 951 A -'IN 0N 10 LOA D I IV CA NOFMqs4 Jim- ID 12 tJ FWA L-0 >Z�—m 04- ---mmewo-ft" No 3 • APA PEZ5,14AN LOA91"4a L14�i�0 MONAHA A 31 IST A - L TO s AS'S T' OF 17F.Et?E;. SEP. 1 1 ig `3 0-t.1 Z L k C C C.) O'tJ T'i 0 V'1 T- T' ENGINEERING aRm DESIGNING SURVEYING C INC. HfEP4,TA At2 Ek-11" AMZ�OVA L- 4ORT DENNIS, MASS 3ou 2831