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Home My WebLink About0008 BAYBERRY LANE - Health 8 BAYBERRY LANE, CENTERVILLE A = 190 063 4 Snem Illl ® y� �. NOP..?��R �src ' HASTINGS,MN `ram COMMONWEALTH OF MASSACHUSETTS ff j EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS >(� DEPARTMENT OF ENVIRONMENTAL PRO �CNT �� i � ONE tiI\TER STREET. BOSTON_ N1A 02108 617-29?•>", yC�. ,V,�D Yam, \1ILL1:1Ai F ss ELD AY 4 1998 T Ci),CO\f Governor .M Sec reLan ®� o�EATNOFSADEPj LE D. FD>f3. STRUHS tiARGEO PAUL CELLLICCI i Lt-Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION f M 1 Commissioner PART A +1J CERTIFICATION 8 V Property Address: 9 Qayberry L,n. � Cr/►�rY+��' Address of Owner: Date of Inspection: +/2S-198 (If different) Name of Inspector: R%eh 2,,,) 4BAr 1P I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: fill l�iw Sw tfc �p c D. Mailing Address: 7 -01'78 Telephone Number: 2 S-5"-0417 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at th;s address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and; maintenance of on-site sewage disposal systems The system �/Passes _ Conditionally Passes _ Needs Further Evaluation B� the Local Approving Authority _ Fads / ]{ Inspector's Signature: `t"'�"Cl�^' Date: Ii+O'/ The System Inspector shall submit a cope of this inspection report to the Approving Authority within thirty (30) days of completing this inspection If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the repon to the appropriate regional office of the Department of Environmental Prote-cuon. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World wide Web hap uwww magnet.state ma us/dep ZJ Printed on Recycled Paper / �L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: C, 8e/btt— Date of Inspection: ¢/Z3'/9$ B) SYSTEM CONDITIONALLY PASSES (continued' _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipetsr or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass Inspection if (with approval of the Board of Health) broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system.is failing to protef,.t the public health. safety and the environment 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH T AND SAFETY AND THE ENVIRONMENT: SYSTEM NMENT:OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEAL _ 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. IC WATER SUPPLIER, IF 2) SYSTEM WILL FAIL UNLESS BOARD ti{p,NONEREALTH (AND THAT PROTECTS LTHE PUBLIC HEALTH AND SAFOETY ANDDETERMINES THAT THE THE SYSTEM IS FU ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. _ n system and the SAS is within a Zone I of a public water supPvY well.The system has a septic tank and soil absorptio the SAS is within 50 feet of a private water _ The system has a septic tank and soil absorption system and ore from a m The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or or private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonianitrogen and nitrate nitrogen is equal to or (approximation less than 5 ppm. Method used to determine distance �_ not valid). 3) OTHER r " Page 2 of 10 (revised 04/25/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR;I�A PART A CERTIFICATION (continued) Property Address: Qo'Ybc� �• Owner: C. gQanp�}- Date of Inspection: ¢/u'/98 DJ SYSTEM FAILS: You m t indicate ei: .er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day floe`-. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: 1 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04125/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: gr71berry Ifi' Owner: C. Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No &___ _ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N/A_ As built plans have been obtained and examined. Note it they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. 111A The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. VA _ Existing information.-Ex. Plan at B.O.H. j�(/�_ Determined in the field (if any of the failure criteria related to Part,C is at issue, approximation of distance is unacceptable) (15.302(3)(b)J (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION Property Address: $ bayberry I-A- Owner: C, 16640('1' Date of Inspection: 412s196 FLOW CONDITIONS RESIDENTIAL: Design flow 110 g p d.`bedroom for S.A.S Number of bedrooms -_ Number of current residents If Garbage grinder (yes or no, Laundry connected to system (yes or no):VA Seasonal use (yes or no; No Water meter readings, if available das( two (2) year usage lgpd! Sump Pump (yes or no) NO Last date of occupancy Now COM.MERCIAUINDUSTRIAL Type of establishment —� Design flok% gallons'da� Grease trap present. Ives or no;_ Industrial Waste Holding Tank present Ives or no, Non-sanitary waste discharged to the Title 5 system (yes or not_ _ Water meter readings. if available Last dat of occupancy OTHER: ;Describe, Last date of occupancy GENERAL INFORMATION PUMPING RECORDS and source of iniorma(ion System pumped as part of inspection. Ives or nor 146 /A, in1a►—eNs•S1V-"� If yes, volume pumped gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribuuon box/soil absorption system Single cesspool _Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: onka&,eun Sewage odors detected when arriving at the site: (yes or no) 1`FO (reviaed,04/25/97) Page 5 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 62yberry Ln- Owner: Cc Benoit Date of Inspection: 4—l2s-1�18 BUILDING SEWER: (Locate on site plan: Depth below grade 2- material of construction cast iron _ 40 PVC _ other (explain; 3e, Pvc Distance from private water supply well or suction line Diameter 4" Comments. (condition of joints. venting, evidence of leakage, etc.) R11OO c SEPTIC TANK: (locate on site plant Depth below- grade Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/Not Dimensions. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle. Scum thickness Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle How dimensions were determined Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) GREASE TRAP:7-7 (locate on site plain: Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: $ q-7 berrr , Owner: C, 19en.0I- Date of Inspection: q-larl" TIGHT OR HOLDING TANK:1 /A (Tank must be pumped prior to. or at time, of inspection) (locate on site plan) 7— Depth below grade Material of construction. _concrete _metal Fiberglass _Polyethylene —other(explain) n) Dimensions: Capacity: gallons Design flow: gallons/dad Alarm level: Alarm in working order l es; _ No Date of previous pumping Comments (condition of inlet tee. condition of alarm and float switches, etc.) - DISTRIBUTION BOX:��' (locate on site plan) Depth of liquid level above outlet invert: Comments (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (reviaed 04/25/97) Page 7 of 10 c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 B3rb erry l.Ai Owner: C. SeACIt Date of Inspection: 4—�25/98 SOIL ABSORPTION SYSTEM (SAS): Ar (locate on site plan, if possible. excavation not required, but may be approximated by non intruswe methods. If not determined to be present, explain. Type: leaching pits, number_ leaching chambers, number_ leaching galleries, number: leaching trenches, number,length. leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technologv: Comments (note condition of soil, signs of hvdrauhc failure, level of ponding, condition of vegetation, etc i CESSPOOLS: _✓ (locate on site plan) Number and configuration. —see D dr/ Depth-top of liquid to inlet invert A,4c,av 7' Depth of solids layer: O Depth of scum layer: O Dimensions of cesspool: ' / -er8 4Z -� Materials of construction:_ Rreeist Indication of groundwater: Nonr inflow (cesspool must be pumped as part of inspect,on)_ Only t 3t Wzrer —nQ e��DpA Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 5o;ds OW, A0 *y of any 1�2i lore ,— o re fens nit&J'= elh_ 3` � 41 PRIVY: /4 (locate o 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.) (revieed 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: r3 Fay berry I-n. Owner: C, $enoi f Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) f9'�ra» Prep, lire ask Al -308' 01- 34' p B Az- s2' 82- zd ' BAY MZgy 'UN, (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8 0 IF a1beri-r 4.11), Owner: C, Benz l"i- Date of Inspection: 4IZj'/9g Depth to Groundwater tL30 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers L- Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) q,.?d,! t E/P✓. G,-a gtc+und wa ta` loer m-2ps Clr•v, 30 t (revised 04/25/97) Page 10 of 10 M ..5 QQ........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Towl.............OF................. bye.---........------......---------------------- ApplirFation for Disposal Works Tonstrnr#ion thrutit Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal stem at: 8 bersar_..Ln.,...Cent rillre, 1�1A....a2632---------- .................-..................................--o........................................... Location-Address or Lot No. Ch roles..Bellai-t--------------------------------•--•----•--.....--------------------.: ..8..-Blueherxy..J a-,•--I+ente=i.11e,--N1A.....026.32... Owner Address A &-.3 QeaspQa1._3exYi0a..............:.................................... ..128..BishAps.-Tej=aiae.,...Hwannis,-.iviA....02601... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............3.............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons..........3 ............. Showers ( ) — Cafeteria ( ) a' Other fixtures .. d . ------.•-------•---•-•--------••--- 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........................................ � 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..--....---.........---- ----------------------------------•---•-------------------------------------•-------.............---.......................................................... 0 Description of Soil.............................Sand.........................................................................I �., -----••••-••---•---•---••--------•----------------------••-----••--------------•-•----------;••-----------•-----•-•-•----------•----•------•-------•---------------.....................------•-•---•. W ---•••-----------------------•--•----•-•--•--•-•-----------•-•---•••--•-••-••--•••••••-----•---•-•------•-------••---•----------•------•-•-•----•---•---------••-•------•--•--•--•-••-•--.............. VNature of Repairs or Alterations—Answer when applicable.-----.i.n&ta _1atLon...Qf..a..1,.0Q0.-ga1Lon..pra-cast S t Q ae..pa0keL-]aacb--pit-- ...Qxeraow--)- .................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT L4 5 of the State Sanitary Code ' The undersi d further agr s not to place the system in operation until a Certificate of Compliance h e 'iss ed by t f health. -- Date Application Approved By.....-- ---- --••.?.. . ..... . . ... -- ......................... ...............9 -V8Q-------- Date Application Disapproved for the following reasons: ........................................ --•------••........:..............•----...............------•--------------------•-------..............-----------------•----------------•-----------------------------•-----••-----•--•-••••----•-•... Date PermitNo.-_80=........................................ Issued................ VaQ...................... Date v SEWAGE W A E PERMIT NO. LO CATION . G &-U-Z0641� _ - VILIAGE I N S T A LLER'S NAME i ADDRESS R U I L D E R OR OWN R DATE PERMIT ISSUED 0 -r- E-,} DATE COMPLIANCE ISSUED/-. � �-� r � � � ,�.s r ,. , l- � l� �� _ �c�� o� No.80-.. g.... ......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............T.o�............OF..................13.411 table----------..._....----••------....---......-- , pphraiion for UiopooFal Works Tonotrurtion Vernfit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: $ $ u13 ....02632.......... ....................................................--------•---•-------....-•---......•••------•- Location-Address or Lot No. Be Charles nloit .............................................................. &..27.u,eberry..Ln., C�nt,arville, - � 2 .... ... Owner Address a A &_.B..Ces_ spool--Service................................................... ..12$..Bishops.Tarrca,...4annis,-__MA....02fDI.- Installer Address QType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.............3............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons----------3............... Showers — Cafeteria Q' Other fixtures ...................................................... Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter___-___..___.-_. Depth................ xDisposal 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---------------------......................................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_--__--______._._.----.. f% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----•------------------------------•-----------............................................................................................................. 0 Description of Soil............................. and-•------------------------•-•------------------------------------------------------------------•--------•---•-••---------------- x W -•-----•••------------------•----•-•----•-•-•-•••---------------•-••-----••-•--•-•---•--------•---------•--•---••-•----------------••--•------------••--•••-----•-•••------••----•------•--••-•---•----- ,V Nature of Repairs or Alterations—Answer when applicable.-____installation-__d---4---1,00Q•_g4,1011-gran St stone packed leach.Pit .......--••---- ••-------------------•---•---. ------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT,TLE 5 of the State Sanitary Code—The undersigned further agre,6 snot to place the system in operation until a Certificate of Compliance has been issued by th board,of health. Application Approved BY - � f --••------• �/D �80_.._._.. 4 Date Application Disapproved for the following reasons_____________________________________________•-_--------_------...._..____....._................................. •-------------•------•-------------------••-------------------•--•--------..•.__..•..._......---------------•----------•-----•----••-----•---••-------•---•----------.....---•----------•--•------------ Date Permit No_80................................................ Issued---------•----? 8�80 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................Town O F........................Barnstable ... .................................... Tnrtif iratr of TonapliFanrr T li&S�S ssCE T ol 2ry That th IncL[id Se a e Dis osa1 S-stem construct d ( ) or Repaired (X) by -------- ... ••-•--••--poi----------------- ' leLti B:shops. e�rac�, Hyaiis, MA 02�01 at......................................................................................................................Blueberry Ln., Centerville, MA___ 02612iler----.Charles Benoit has been installed in accordance with the provisions of TI-6 j o, lie State Sanitary 9Cgdb�g described in the application for Disposal Works Construction Permit No......................................... dated....._/_-__.--_..______.___._____._._.____._._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUE AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. 1( 0780 DATE................•---•---••-----...--•----•----•-•--•-••--•••--......._..--•_•_.. Inspector----� -- - ---- .. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town.............O F...........Barnstable 80-—jf fd ............................... $ 5.00 No......................... FEE........................ Disposal Vorkii Tonoirudiori unfit A & B ,;Cesspool Service Permission is hereby granted ----------•----- -----•---------•--------------- to Con uct ( 1 or Re air X) an I d vidu ei& Disposal S stem I13 eblrry L�i., eMerv�l�e, MA �L�32 - Ch�les Benoit atNo.. --•- - ----- - ---------------------------------------------------•.•----•••---------------•••••-•-•-•---•-•--...-••--•---•••------------•-•--•--.................. Street as shown on 2y�""'Ione applic for Disposal Works Constructti n-��-Permit No..................... Dated.......4.$�80...............:.. ar of f Health DATE ----- -------------•--•-.... 1 FORM 1255 HOBBS & WARREN, INC., PUBLISHERS