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HomeMy WebLinkAbout0002 PALOMINO DRIVE - Health 2 Palomino llrive Barnstable .. A =1 316 086 n F S Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is gamsable MA 02630 07/12/10 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information •' on the computer, use only the tab 1. Inspector: C key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections my Company Name P.O. Box 896 Company Address East Dennis MA 02641 Citylrown State Zip Code 508-385-7608 SI 3742 Telephone Number License Number B. Certification f I certify that-I'have personally inspected the sewage disposal system at this address and Miit t information reported below is true, accurate and complete as of the time of the inspection=i5hepectio was performed based on my training and experience in the proper function and maintenah&of8n site sewage disposal systems. I am a DEP approved system inspector pursuant to SectiopA5.340 of Title 5(310 CMR 15.000).The system: ry 0D 9 n ® Passes ❑ Conditionally Passes ❑ Fails 3 ❑ Needs further Evaluation by the Local Approving Authority w 1 M 07/15/10 inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of,Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving.authority: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 'CommonweaNh of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every Barnsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.), Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank'is replaced with a complying septic tank as approved by the Board of Health: "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is Barnsable MA 02630 07/12/10 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): The system required pumping more than 4 times a year due to broken or obstructedpipe(s). The ❑ Y q P P� 9 Y system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Commonwealth of Massachusetts luTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every Barnsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has 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 private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis; performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded 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.%day flow r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments y 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is gamsable MA 02630 07/12/10 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or : tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.' 2 Palimino Drive Property Address Marie Anderson Owner Owners Name information is required for every Barnsable MA 02630 07/12/10 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant, or Board of Health ❑ ® Were any of.the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been.introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for'signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 440 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every garnsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 04/10 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft:, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every garnsable MA 02630 07/12/10 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ®' Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is Barnsable MA 02630 07/12/10 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 07/19/96 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.6 feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1.0 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: 2" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every garnsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to'bottom of outlet tee or baffle 29„ Scum thickness - 2" 6'# Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. - Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every garnsable MA 02630 07/12/10 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments yt 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is Bamsable MA 02630 07/12/10 required for every _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The box was level and tight with no sign of carryover. 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.): I Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 4 Commonwealth of Massachusetts VUTitle 5 Official Inspection Form IW. 14 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive ' Property Address Marie Anderson Owner Owner's Name information is required for every garnsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits y number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions. ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):. This system has two 6'x6' precast pits surrounded by two feet of stone.The pits were dry. There was no sign of ponding or failure in the stones. 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 Commonwealth of Massachusetts LW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Marie Anderson Owner Owner's Name information is required for every gamsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Commonwealth of Massachusetts IFTale 5 Official Inspection Fora ftbm Face Sewage Disposal System For -Not for Voluntary Assessments 2 Pa6mino Drive Property Address Marie Anderson Owner Owner's Name } inibmud revery Bamsable _. MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection D. System Information (coat.) 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 q5 �S Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form Not for Voluntary Assessments 2 Palimino Drive Property Address Mane Anderson Owner Owner's Name information is Bamsable - MA 02630 07/12/10 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ` ❑ Shallow wells 20.2 Estimated depth to high ground water: feet feet , Please indicate all methods used to determine the high ground water elevation: ❑ -.Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: P ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS niaps show an elevation of over 20.0 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 2 Palimino Drive Property Address Mane Anderson , Owner Owner's Name information is required for every Barnsable MA 02630 07/12/10 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist y ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on.page 15 or attached in separate file f i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION 0P n. PARCE1. ' ®� LOT TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 2 Palomino Drive Barnstable RECEIVED Owner's Name: George & Dianne Blair Owner's Address: JUN 2 3 2004 Date of Inspection: — d✓� TOWN OF BARNST.ABLE Name of Inspector:(please print) W i 11 i am E_ .Robinson Sr. HEALTH DEPT. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 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 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails / Inspector's Signature: � L Dute: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth or. t DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000. gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies:Sent to the buyer,if applicable,and the approving authority. Notes and Comments •`••This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 F OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued)- Property Address: 2 Palamino Drive Barnstable Owner: George & Dianne Blair Date of Inspection: 4 —/f--O 1-1 Inspection Summary: Check A,B,C,D or E/.ALWAYS complete all of Section D A. Sys( M Passes: l` 1 nave not found an information which indicates that an of the failure criteria y y ntena 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 reps d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expla' . e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existin tank is replaced with a complying septic tank as approved by the Board of Health. •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ing that the tank is less than 20 years old is available. ND xpla'm: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or o ded pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with appAnval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a lain: The system required pumping more than 4 times a year due-to broken or obstitxted pipe(s).The system will pass ir spcction if(with approval of the Board of Health): broken pipe(s)are replaced obsWctiun isnmoved ND ex ain: Page I of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 Palamino Drive Barnstable Owner: Georcfe &. Dianne Blair Date of Inspection: 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 fa ing 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 functionin in a manner which will protect public health safety Y g p p 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 sy tem 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 I 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 front a rivate water supply well•• Method used to determine distance -L'This system passes if the well water analysis,performed at a DEP certified laboratory,for colifort» cteria and volatile organic compounds indicates that the well is free from pollution from that facility and &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. they: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 2 Palamino Drive Barnstable Owner: George & Dianne Blair Date of Inspection: _O D. S2 tem Failure Criteria applicable to all systems: You m st indicate"yes"or"no"to each of the following for all inspections: Yes N 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'/,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 I00,feet of a surface water supply or tributary to a surface water supply. _ Any portion of.a cesspool or.privy is within a Zone 1 of a.public well. .Any portion of a cesspool or privy is within 50 feet of a private water supply well._ _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 f et from a private uatrr 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.1 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 b considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gpd• You in st indicate either"yes"or"no"to each of the following: (TIte fo owing criteria apply to large systems in addition to the criteria above) yes no e system is within 400 feet of a surface drinking water supply 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—1WPA)or a mapped Zo 11 of a public water supply well If you have ans Bred"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 fatted.The owner or operator of arty large system considered a significant threat nder Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The syste owner should contact the appropriate regional office of the Department. 4 I Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 2 Palamino Drive Barnstable Owner:Georcre & Dianne Blair Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ZPumping information was provided by the owner,occupant,or Board of Health Y Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? _ Have large volumes of water been introduced to the system recently or as part of this inspection?,. ✓ — Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? _t/_ 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 _ Existing information.For example,a plan at the Board of Health. _4_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance. is unacceptable)[310 CIAR 15.302(3)(b)) 5 Page 6 of l l NOT FOR— OFFICIAL INSPECTION FORM _ VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 2 Palamino Drive Barnstable Owner:George & Dianne Blair Date of Inspection: 4-1 r-O L-1 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):.L/Number of bedrooms(actual): 3,1-/ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): Number of current residents: Does residence have a garbage der(yes or no):LI,U Is laundry on a separate sewage system(yes or no):%� [if yes separate inspection required] Laundry system inspected(yes or no):&�e) Seasonal use:(yes or no):_4e., e) Water meter readings,if available(last 2 years usage(gpd)): 7/0 3 to 6/0 4 69, 000 Sump pump(yes or no):/-& 7 0 2 to 6 0 3 70, 000 Last date of occupancy: G n/fg—o f COMMERCIAJed USTRIAL Type of establish Design flow(bas310 CMR 15.203): pd Basis of design fleats/persons/sgft,etc.): Grease trap press or no):industrial waste g tank present(yes or no):Non-sanitary wacharged to the Title 5 system(yes or no):Water meter reaif available: Last date of occ /use: OTHER(descri GENERAL INFORMATION Pumping Records Source of information: !!!A—A Was system pumped as padof the inspection(yes or no): C✓ If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE 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): Approximate age of all components,date installed(if jwown)and source of information: J � 4 1�01� Were sewage odors detected when arriving at the site(yes or no): , 6 Page 7 of I 1 - OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 Palamino. Drive Barnstable Owncr:Geor re & Dianne Blair Dale of Inspection: ®� BUILDING S dxvER(locate on site plan) Depth below gra e: Materials of con truction:_cast iron _40 PVC_other(explain): Distance from p ivate water supply well or suction line: Comments(on ondition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓(locate on site plan) ) Depth below grade: I 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: _ e,. A ,(o Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: t 't Scum thickness: (3 — I Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottomgo[outlet tee or baffle How were dimensions determined:.C3 '�:�. Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): p J_ GREASE TRAP:_(locate n site plan) Depth below grade:_ Material of construction:_co crete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum 0 op of out tee or baffle: Distance from bottom of scu to bottom.of outlet tee or baffle: Date of last pumping: Comments(on pumping rec nunendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,ev ence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:2 Palamino Drive BarnGt-ab1 P Owner: _en-r c% R Dianne Blair Date of Inspection: TIGHT or HOLDIN 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: allons/day Alarm present(yes or n Alarm level: larm in working order(yes or no): Date of last pumping: Comments(condition o alarm and float switches,etc.): DISTRIBUTION • �' BOX: /(ifprcscnt must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate o site plan) Pumps in working order(yes or n Alarms in working order(yes or o): Comments(note condition of mp chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 T• OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 Palamino Drive Barnstable Owner: George & Dianne Blair Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): i/(locate on site plan,excavation'not required) If SAS not located explain why: Type eaching pits,number:_01— leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: esspool must be pumped as part of inspection)(locate on site plan) Number and configurat on: Depth—top of liquid t inlet invert: t Depth of solids layer: Depth of scum layer: Dimensions of cesspo Materials of constructi n: Indication of groundw ter inflow(yes or no): Comments(note con tion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site Ian) L Materials of construction: Dimensions: Depth of solids: Comments(note condition of s il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 Palamino Drive Barnstable Owner:George & ,Dianne Blair Date of Inspection: o SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. �47 l 3y c� Z1S 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2 Palamino Drive Barnstable Owner.George & Dianne Blair Date:of Inspection: G—1 O L-( 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 ISO 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: 11 TOWN OF BARNSI ABLE b f LGCA�70N . 1� aP�0f,.14-- SEWAGE # 33 6 VI!.LAGS 13A ���. ASSESSOR'S MAP & LOTJ/ O9 INSTALLER'S NAME&PHONE NO. �1t�v=� K(sSLLJG ���—o q V�i/ SEP'f1C TANK CAPACITY /O o® G,4 L SCE1Tlc, �i ..J ✓ ��[1�T'��� LEACHING FACILITY: (type) T��Py4501 (size) d0® C.,L NO.OF BEDROOMS BUILDER OR OWNER 9 &=^,Q C r,� -PERMTTDATE: 171 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 on site or within 200 feet of leaching facility) WA Feet Edge of Wetland and Leaching Facility(If any wetlands exist 'I within 300 feet of leaching facility) Feet Furnished by .,$' Z ,,v Vol 0 o aTo Ato .y C 'T-o /coo Cs'r ®®Q cc,o Lo T V4,2 L,O>CATI0N / . SEWAGE PERMIT NO. ,,;, P I VLLLAGE INSTA LLER'S NAME & ADDRESS r c COT, s 7' 7 7 S"— w B URDE R 0R_,QWN.ER J c /4 DATE PERMIT. ISSUED DATE COMPLIANCE ISSUED I 6D4-6 l L No. r . ., J Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pp iration for ZigpooY *pttem Con.5trurtton Vertu Application is hereby made for a Permit to Construct( )or Repair(V�an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. 6 aZ a 7 2(�ALo�r.J a A��vE �� oR y� 61.E/,Q, 846 fa Ul a Installers Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �Rj,9� G• 1Ss1WG g / 9�%a,��) B�oO k �d w F-sr r� Type of Building: Dwelling No. of Bedrooms Garbage Grinder(uJd Other Type of Building o No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1,10 gallons per day. Calculated daily flow 330 gallons. Plan Date a Number of sheets Revision Date Title Description of Soil Nature of Repairs or Alterations(Answer when applicable) v o0 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of It . Signed Date Vh Application Approved by Application Disapproved for theVollowiny reasons Permit No. Date Issued No 3 Fee Veo THE'COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWNI,OF BARNSTABLE., MASSACHUSETTS 2pplication for �iqiol 6pelem C6*5trurfion 3 tt Perm' Application is hereby made for a Permit to Construct or Repair(�an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. GCOA �C�- Installer:s Name,Address,and Tel.No. 179 VO y y y Designer's Name,Address and Tel.No. C, 1 W 94o o/c, WC-7ST Type of'Building: Dwelling No.of Bedrooms Garbage Grinder(4c)) Other Type of Building. Wo,-) F— No.of Persons -3 -Showers( Cafeteria( Other Fixtures Design Flow 1/ 0 gallons per day. Calculated daily flow 3 3 C) gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature.of Repairs Alterations(Answer when applicable)--T,4.57-4 it SrF 0,00 =J 5r-4 &e.4 '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 peration until a Certifi- cate of Compliance has been issued by this Board of Nalt Signed I XAA_L 7, A A_A&�V Date Application Approved by Application Disapproved for the4olnlowin reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed or repaired/replaced on by for as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 31-.Z36-dated Use of this system is conditioned on compliance with the provisions orth below: No. Fee 469 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwiqoal *p5tem Con.5truction Vermit Permission is hereby granted to V, '15S/ .)Cz to construct repair an On-site Sewage System located at 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. All construction must be completed within two years of the date below. Date: Approved by ':� �:<;K�::�:x�i► � 'tea' '� �'' — : 'ssa`v �r,_.cno`.vat�c�a9 a..cn.v�: a--7.1rr^f, ; 1 _f;r,9 rl ;�'�'✓'p �,�;�1�;��� �/1'�/1'oa ,�N-z OAC .i�'Ya9orrrvoJ 1„ 4 >. " i f ti'i�si`S )`•� �/Y1 /YO Q•7-4 d- 7 Se / "d'7d /YO !v/�/Gf +;'r.�eF ,tla ) atit :16 �/YiQ7/nB Sp"-4 1di'i'1 iC�/1�aio �Cgm�w'�z9N' ram' 4"121 Jo �lt.�a/ ,�:� %ivo 1�.� � "{°4M wI�S / �/• ✓ � T/ • Y /®�/+��yl/ /�'� / �,�rq /��y�,.) —/yqp�.®...0.'_.] I s L_7�), r=AV.tVus��4,s✓f8�'" + Pfr<�rl�r }�t ' i tI S �a'r. S c i , ;,-•i � +, tk F? ''h��ysY rs li:��`�1��'t , , :;`r ;.i�`�.:;` C�8 —L`'��� _ .. �:,.. •,,, {: t ;I ♦♦ 4 1 � f V t. ,r r 4. I O ' L7/ ,i No......................... ... .................. THE COMMONWEALTH"OF MASS.ACWjjSETTS 0 t BOARD OF "HEALTH .� a Applir4 ion -fur Jigpugal Murky Tanstrurtion Pumil Application is hereby'made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal 8Z n �a Lof at- n-Address / J or Lot N o• /. �r dr s "^ W Installer Address• U.: Type of Building Size Lot____________________ S q. feet Dwelling—No. of Bedrooms----- Expansion Attic ( -_) Garbage Grinder•( ) a4 Other—Type of Building _____________`-____________ No. of persons----------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------------------------ W Design Flow---------a.$070.____________________gallons per person per day. Total daily flow.......... --- _ 49----_-__.____gallons. WSeptic "I�cmk—Liquid capacitd0-gallons Length________________ Width___..._,_.._-_._ Diameter_..-__.-_.__.._ Depth-________-.-... x Disposal Trench—No.____________________ Width_____________ _ tal Length------------_----- Total leaching area.............-.-----Sq. ft. Seepage Pit No.........../------- Diameter__ _ thJbelow inlet____________________ Total leaching area----- --------- ft. z Other Distribution box ( ) Dosing tank ( ) .a a ,t� � WV4;t,j' t .I Percolation Test Results Performed by .- � -n_._ *_? �..___ _.__..___ Date._ -------- ------- -------- a Test Pit No. 1................minutes per inch Depth of-Test Pit_- _---------- Depth to ground water-.______:_____-__-_. L14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__-_-_______________---- F� R A^ O Description of V � . _ ---� - a - f-- , � � mi y= wy j s k _ , VNature of Repairs or Alterations—Answer lien applicable_-_. -_ - !`#..,. `____-_ _____ `----e `r" j ____________________c___.__.____._...�._t___ -------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescrilied Individual Sewage Disposal System in accordance with the provisions of Article 1I of the State Sanitary —The u rsign hercgrees not to place the system in operation until a Certificate of Compliance has b en is by th bar of ht .Sig 777--- --- ------ - --------- ----•----••------.__---_._._..._ Date Application Approved By--- -------f ... ...7 : Date - _ Application Disapproved for the following reasons:----_------------ - ------------------------------------------------------------------------------- ---•---•-••---------------•----------------------._...-------............'=-=--------------------•-••---•••••----•---•-----------•--•-•------••---- ------------------------------------------------- Date PermitNo......................................................... Jssued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALT OF......... R...... Z o iration -for Diq viial orko Tonotr trtion rrtnit Application is I ereby'made for a Permit to Construct ( , ) or Repair ( ) an Individual Sewage Disposal Syst at: 5 , } D ` Lo at n Address or Lot N ,J' S ner dre s W (�/��}/{ ,. + f •�^- �_ ... `r'CS+�F•+r-• J V --- - ..^_i C °v.__lt�-_:t: __� YV[Y.._..-. -F'--3--•- :� ^, f Installer Address ! d . Type of Building ,. Size•Lot...:........................Sq. feet Dwelling No. of Bedrooms ..,.t ____Ex Expansion Attic Garbage Grinder,a g— P (. ) g ( ) pi Other—Type of Building \'o ;_of persons.- ______ _________ Showers ( ) — Cafeteria ( ) 0.i Other fixtures - - ` ` ---- ... -- ----- - --- - ----- --•--------------------------- {. W Design Flow.......... gallons per person per day. Total daily flow_______ ___ _ ___�-. _._.._.._._gallons. z Septic T,-nk—Liquid capaci �t�>✓gallons . Length________________ �ti�idfh.......... Diameter---------.------ Depth.._.__.__._.... W x• Disposal Trench—No-____________________ widtli_ -_ _ tal,,Length-------------------- Total leaching area--.-____--_-.____sq. ft, t Seepage Pit No.........._/_:____ Diameter___ ____________ _ th�beI" i let___________________. Total eachin trey___ _----. ._sq. it Z I. .Other Distribution box ( ) Dosin n"� ) + ., R � 'Percolation Test Results Performed by ___ _._....____ Date.: ------- ------ ,`�a Test Pit No;i_______________minutes per inch epth of Test t ___ .. Depth to around water------------------------- Test�, ; Pit No 2 : ,___-::-ruinutes per-inch Depth of Test Pit Dept to ground�'water------------------- - -- --- A O Description of S Il "" ' Ad _ ° + 'fir - --------------- -- -------- ------ ------ ----- -- ------- ------------------ U Nature of Repairs or Alterations—Answ n applicab .._ .; ___--- ...: ........: . --- -` --- _ ---------------------------------------- Agreement: .t* ti + y � � 'The undersrgned agrees' toy install the aforedescribed Individual,_55_ag IDisposal System iii accordance with the provtsions of Ar>ic1eT of fiheiS a( ,'Sam ary`Code= The uii rsigned fu 1'ierrttgrees,.nof to place the system in t operation-until.a Certificate of Compliance has been is u by th b.K 'of h , tli. a7fit' ig _ ___ ------------------------------- Date`4 A Vication.APProved BY'�" - '" 7 ------- Date Application D.isappro`v'ed,for the following reasons: ------------------------ _. ________________________________ w , n f i .. da Date Permit No. = I sued. y Date THE COMMONWEALTH OF MASSACHUSETTS r ,r - BOARD. F 'HEALTH ..........O F. ` � ' �rrtif ir�tle :of f�n�m�li�tnrr_ �� _ � �• �'. w, ........................ TH IS T CIF ICY,, v, the.--Ftrdi id---rS w"age DisposalSMem cottstructed or Repaired ( ) by "''` -- ; • Inst1 er - ---- -•--11- - - - -- ---- ---- hasrheen installed in accordance with the provisions of : e NI of The State Sanitary Code as described in the application for Disposal Works Construction Permit,No... lZ►d___._,_ .__.t dated ._._ : `'7. ................... THE-ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE'=THAT.THE t '.SYSTEM WILL FUNCTION SATISFACYbIZY. / , tJ • . p DATE. ��+ .1 G 9t � Inspector �O ..................... __••---- THE COMMONWEALTH`OF MASSACHUSETTS �, I _ " ' _ rr,.-•Y-:.an,Y BOARD. O?F, H:EALT }�.1..: •'. t.. ._ 1 _ . . No------------------------- -FEE__,.. == - �i��o�ttt ork,� C�on�tr�trtiott �rriattt �� Permission is hereby granted......................................... --------------------------------------------------- __---•--------------------------•--•: to Constru ( or Repair aan Individual Sew ' Disposal ,Sem ~ at No.� L.� C J E•�y..i Street as shown on the application for Disposal Works Constructi/n -,.rrn t No. t2__ Dated_._a,.-_. ./ y �� Board of Health DATE...J."_.ter_: 77------------------------------------------------ a �, FORM 1255 HOBBS & WARREN, INC.. 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