HomeMy WebLinkAbout0094 BEECHWOOD ROAD - Health 94 BEECHWOOD RD., CENTERVILLE
A= UPC 12534
No.2-153LOR
HASTINGS,UN
d
a ' � COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
95�
a s�.
039
TITLE S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM MENTS
PART AT
CERTIFICATION `y
9�Property Address:
Owners Name: w s/� oo N �
..�
Owners Address:
Date of Inspection: ✓✓� �.3a 1� '-
Name of Inspector: lease ip�rint)Co Pan Name:
�C!�
Mailing Address: o ox
Telephone Number: /yl
CERTIFICATION STATEAZENT
I certify that 1 have personally inspected the sewage below is true,accurate and complete as of the time disposal system at this address and that the'
Win$and experience in the tmx of the ' information reported
Proper function and hOn' inspection was performed based on my
Approved system inspector pursuant to Seed ��ance of on site sewage disposal systems I am a DEP
40 of Title 3(310 CMR 13.000). The system;
Passes
Conditionally passes
Needs
Further Evaluation by the Local Approving Authority
Inspector's Signature;
--_ Date: 9 d s 0 5
The system inspector shall submit a copy of this DEP)within 30 days of completing this inspection report to the Approving Authori
gpd or greater,the inspection.If the system is a shared system or has i deli ty(Board of Health or
DEP. inspector and the system owner shall submit the report to the a r g°flow of 10,000
The original should be.sent to the system owner PP°pate regional office of the
authority, and copies sent to the buyer,if applicable,
PP ,and the approving
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions
time.This inspection does not address how the system will perform in the future
conditions of use. itions of use at that
under the same or different
Title 5 Inspection Form 6/15/2000
page 1
Page 2 of 11
OFMC7AL INSPECTION FORM_NOT FOR V
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION SSESSMENTS
PART A FORM
Property Address:
CERTIFICATION(continued)
9� /-
t��C�L✓00� �c1
Owner: p
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/AL�yS complete all of Section D
AS asses:
I have not found any intbrmation which indicates that an of the f '
15.303 or in 310 CINIt 15.304 exist Any mum Y ailnre cri
ribedteria not evaluated are indicated below. in 310
scrI
Comments: C11sR
7B• S m Conditionally Passes.
One or more system components as de
scnbe� the
repaired.The system,upon completion of the 'Conditional Pass"section need to be
replaced or
replacement or repair,as approved by the Board of Health,will
Answer
Pass,
Yes,no or not determined(Y,N,ND)in the
for the fexplain. ollowing statements.If"not determined"please
The reps tank is metal and over 20 years old*or the
unsound,exhibits substantial infiltration or exfiltration or Septic tank(whew metal or not)is structurally
existing tank i replaced with a co lsept tank failure is im> �t S y
•A metal septic tank will pass Inspection f it i approved by the Board of Health, pass u�on if the
indicating that the tank is less than 20 Y sound,not leaking and if a Certificate of Compliance
ND explain;
Observation of sews -
obstructed pipes)or due to b or break out or high static water level in the
approval of Board of Health): 'settled or uneven distribution box.S will Paw inspection box due to broken or
System�Pass inspection if(with
broken PiPes)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain: i
The system required pumping more
Pass inspection if(with 4 than approve of the Board of 4 times
a Year due to broken or obstructed i
P Pe(s).The system will
broken pipes)are replaced
obstruction ,Is removed
ND explain:
Titla Q i»a►wntin»Fnrn,b/1�MIUV1
2
Page 3 of 11
OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY
" S�SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS
PART A
CERTIFICATION(continued)
Property Address: l R�
Owner: / 00 " ,�✓/ e
Date of Inspection: -Z_f OS-
.•C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further e
is failing to protect public health,safetyor the environme�,valuation by the Board of Health in order to determine if the system
1• System will pass unless Board of Health determines in accordance with 310 Cm 15
system is not functioning in a manner which will protect public health,safety and the 03Wr��nt the
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 tail unless the Board of Health(an Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
d
The system has a septic tank and soil absorption system
surface water supply or tributary to a surface ( ) the SAS is within 100 f water supply, eet of a
— The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
The system has a septic
tank and SAS and t supply.._,_ he SAS is within 50 feet of a P nvate water
— The system has a PP1Y well.
private water supply well**.
tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
ell++.Method used to determine distance
**This system passes if the well water analysis,perf
bacteria and volatile organic co o�at a-DF.P certified labors
mpounds"indicates that the well is free from tort,for coliforni-
the presence of ammonia nitrogen and nitrate nitrogen is pollution from that facility and
failure criteria are triggered.A copy of the analysis �to or less than 5
Y must be attached to this form provided that no other
3. Other:
Tifln � ina^nrfinn Fnrrp F/��/7nM
. ' Page 4 of 11
OFFICIAL, INSPECTION FORM—NOT FOR SUBSURFACE SEWAGE DISPOS VOLUNTARY ASSESSMENTS
AL SYSTEM INSPECTION I'
PART A FORM
CERTIFICATION(continued)
Property Address: 9 A
G e. eLv
Owner: 0
Date ofIspecon: 02✓
D. 0�
System Failure Criteria appUcable to all systems:
You must indicate-yes-or"no"to each of the following for All•inspections:
Yes No
./ ackup of sewage into facility or system co
Discharge or ponding of effluent s the s anent due to overloaded or clogged SAS or cesspool
Stegged SAS or cesspoolsurface of the ground or surface waters
tatic liquid level m the distribution box a due to as overloaded or
001 above outlet invert due to an overloaded or clogged SAS or
_�•,t�uld depth in cesspool is less than 6"below invert or available volume is less than
s p���than 4 times in the last year NXd a to clogged or obstructedday
flow
:./ Y Portion of the P#*s)•Number
y portion of cesspool SASS cesspool or privy is below high ground water elevation.
�Supply. spool or privy is within 100 feet of a surface water supply or tabu
— Y portion of a cesspool
�'to a surface
_�Y Portia of a cesspool s� Or Privy rs within a Zone 1 of a public well.
y Portion of a cesspool or privy is within 50 feet of a
esspool or Privy is less than 100 feet but
greyvate water supply well.
supply well with no acceptable water quality analysis,MIS systema�t�' feet from a private water
performed at a DEP certined laboratory,for coltform bacteria and volatile o
Peres U the well water analysts,
Indicates that the well is tree from Pon
from that facWty and the presence of
nitrogen and nitrate nitrogen is equal to or less than S rSaoie eponi ands
�'e triggered.A co PPm,Provided that no other tirll ammonia
copy of the analysis mast be attached this form.] ire criteria
�./ (Yes/No)The system MIS.I have de
described in 310 C11Rt 15.303 therefore that one or more of the above failure criteria exist as Health to determine what ,therefore the system fails.The system owner should contact
will be necessary to correct the failure, the Board of
E. Large Systems:
To be considered a large system the system must serve a facility with a design gn now of 10,000
You must indicate either"yes"or"no" gpd to 15,000
(The following criteria apply large systems each of the following;
8 Ystems in addition to the criteria above)
yes
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tabu
tary to a surface drinkingwater supply
-- _ e system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)o
Zone R of a public water supply well
r a mapped
If you have answered"yes"to an
"Yes"in Section D above the large system has Section o�;o o,'s considered a sr
significant threat under Section E or failed under Secton D l;n,ficant threat,or answered
15.304. Pastor of any large system considered a
The system owner should contact the appropriate regional office oftheD�m m accordance with 310 CM
Department.
Ti+ln rno^nnfinn grin.,AK11 CMAAA
A
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: -A G./oo
Owner: i'o0.1 Og ro 3a'
Date of Inspection: of 5
Check if the follo have been done.You must indicate' es"or"no"as to each of the following:
Yes o
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?
_ v Have large volumes of water been introduced to the system recently or as part of this inspection?
/ Wen as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwel
ling 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 dimensions,depth of liquid, for the condition
of the baffles or tees,material of construction,
fluid,depth of sludge and depth of scum?
Was the facility
maintenance of subsurface sewage disposalsystems different from owner)provided with information on the proper
The size and Iocation of the Soff Absorption System(SAS)on the site has been determined based on:
Yes n�
sting 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(3)(b)]
Tifln.9 TnanoiHi�n Fnrrn 4/1 C/"AAA 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S
E
PART C
SYSTEM INFORMATION
Property Address: 9'r( �e4
Owner: wo ems, �.
Date of Inspection: ,Z
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 3 3�
Number of current residents: .--- ! x#of bedrooms):
Does residence have a garbage grinder(yes or ) /(-V
Is Laundry
y system
operate sewage system
(yes or no : separate inspection
inspected(yes or no):NV
Seasonal use: ) — (�y� required]
(yes or no):/moo
Water meter readings,if available(last 2 years usage
Sump Pump(yes or no): /lam (gpd)):
Last date of occupancy: G u r�w
COMMERCL4L'1NDUST'RIAL
Type of establishment:
Design now(based on 310 CMR 15.203):
Basis of design flow(seats/persons/ evd
P Present sgil;etc.
Grease trap (yes or no):_ )'
Industrial waste holding tank present(yes or no):—
Non-sanitary waste discharged to the Title 5 system(yes or no):—
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
Pumping Records GENERAL INFORMATION
Source of information: /f/'p
Was System �`�"`' s
If yes,vol Pied as part of the inspection(yes or no): � ��'rS — � w
Reason for pumped:P�Pg: termmed7
gallons--How was quantity pumped de — "
_
77:1 SYSTEM
�/ePtic tank,distribution box,soil absorption system
—Single cesspool
Overflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous
_InnovahvdAltemative technology.Attach a c inspection records,if any)
obtained from system owner) copy of the current operation and maintenance contract(to be
—Tight tank _Attach a copy of the DEP approval
—Other(describe):
APProximate age of all components,date installed(if known
l9 80 and s0%;5�ce ]information:
Were sewage odors detected when arriving at the site(yes or no):
Title i rncnoi.tinn 17nrm A/I cmmn
• Page 7 of 11
. OFFICIAL INSPECTION FORM—NO
T FOR SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOMENTS
FORM
PART C
Q�1 SYSTEM INFORMATION(continued)
Property Address: /'T ,f>ee C Gj�,,00� �`✓
Owner: o1✓
Date of Inspection• ,2S p
BUILDJNG SEWER(locate on site plan)
Depth below grade; 01S
Materials of construction:— ast iron _-�40 pyC—other e Distance from private water supply well or suction line: ( �)•
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Z(locate on site plan)
Depth below grade• /�
Material ofconstruction• ✓ _ �
_,concrete
—other(explain) —fiberglass_..polyethylene
If tank is metal list age:— Is age confirmed by a Certificate of Co
certificate) mpliance(yes or no):_(attach a
Dimensions: � x �� copy of
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffie: o�7 /
Scum thickness: '� _
Distance from top of scum to top of outlet tee or baffle: S`l
Distance from bottom of scum to botto
How were dimensions determined: o of outlet tee or baffle; G
Comments(on pumpingreco 2 " c
as rel tied to outlet iav mmendations,inlet anti o et tee or baffle conditio
e ence of l�gep etc.): n,structural integrity,liquid levels
{I)Pe e C
O ON spy 20 �N G7N�
r
GREASE TRAP:Zgate on site plan) - - -
Depth below grade:_
Material of construction:_concrete_metal—fiberglass __polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of sc o top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or bafli—�;—_Date of last pumping;
Comments(on pumping recommendations inlet and outlet tee or baffle condition,structural��
as related to outlet invert,evidence of leakage,etc.): grity,liquid levels
Ti}Is i T-0—t;- V,—m F/1 cnnnn
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
MENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM S
PART C
�J SYSTEM INFORMATION(continued)
Property Address: / 14a2 c 4cvoo j ,�2j
Owner: /�oe �
Date of Inspection: of 05
TIGHT or HOLDING TANK:�V(tank It be
Pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal
—fiberglass_polyethylene oiher(explain):
Dimensions:
Capacity:_ gallons
Design Flow: gallons/day
Alarm present(yea or no):
Alarm level: Alarm in working order
Date of last pumping: (Yes or no);
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: if present must be opened)(locate on sit
e plan)
Depth of liquid level above outlet invert; !,4 0/✓�► L-
Comments ge into
(note if box is level and distnb a to outlets equal,any evidence of solids carryover,any evidence of
leakage intout x,etc.).
PUMP CHAMBER: �y (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.):
----------------
Title Q Tnonmhinn C......L/1 lMAnn Q
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Q SYSTEM INFORMATION(continued)
Property Address: / &--e 4 woo� pQG/
&J ! e,
Owner; 00 o Date of 9 aS os
SOIL ABSORPTION SYSTEM(SAS);
(locate on site plan,excavation not required)
If SAS not located explain why:
T /
YPe y
eachmg pirt,.number:
leaching chambers,number;
leaching galleries,number.
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
innovativeJalternative system Type/name of technology:
Commen (note condition of soil,signs of hydraulic failure,level ofponding
etc.): ,damp soil,condition of vegetation,
�� J•S ,s7't'Rne� �� ii �^
/v ✓/ hs 07C
p his GG Cq �,
CESSPOOLS; (cesspool must
be Pumped as part of inspectionKl o iEe plan)
Number and configuration: -
Depth-top of liquid to inlet
Depth of solids layer. ;� o 0
Depth of scum layer. ��1 p o o a
• t
Dimensions of cesspool• `�k J <0 o O
Materials of cons truction:- ` I--- - -- - -_ --- -- ----- -� p-o 0 0- it
-- - Indication of-
groundwater inflow(yes or no): --Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition ofsoil,signs ofhydraulic failure,level ofponding,condition of vegetation,etc.):
Titan rncnnr}�nn r.'n....L/7GMnnn o
' � 1
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: i�e G
n yv/ --4
Owner: Pao✓' -Z
Date of Inspection: A p
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.
14
Y TV_ ' _{
. j 0 LI/i ( DQ�
- / 4-1 f a►4 t o /-.c rrrovti CJ
it
� J
3L
Title G inerni Finn Fn►m 4/19nAAA 10
• Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
E
PART C
SYSTEM INFORMATION(continued)
Property Address: - 14.-
OV4
Owner: 0 c9✓ r� Odd
Date of Inspecdon: 9 ot,S 03
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated �11l
depth to ground water `7c� feet
Please indicate(check)all methods used to det
ermine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design Plan reviewed:
g property/observation hole within 1 S0 feet of SAS
ked with local Board of Health �o t
Checked with local Coexcavators,installers- attach wp
Accessed USGS database-explain; ( documentation)
----------------
You must d cri how you established the hig groundwater el do ;
ev o k/
tv, u
OG
r
0 ,pA0
(900,0
0 3d.9
(A,/6-
Tit.i fn°^nnti�n>:nrrr.!./1 i/'fAM
11
�c
L 0 CATION SEWAGE PVMIT NO.
VILLAGE
INSTA LLjER'�S-^ NAME i ADDRESS
3 U I L D E R OR 9WN ER
?f. !f;-/bus-
DATE PERMIT IS UEO
DATE COMPLIANCE ISSUED 73d -�
I
22
9
No.42&.-.L1J9 Fps ......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.j
T .....OF........... ....w,,,w,S7��/...e.4
AliptirFation'.for Uhipati ai Worka Toustrnstinn rantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 47
........•....... l' —.^:(� ............ ..................................w................�
cation-Address or o. e
.r.,-—-------------------------- ----- l...........................
(� Owner ess.
.......... �Zi ...jisl/htl.................................................... ....... .......................
Installer Address
d Type of Building Size Lot.. .&V..........Sq. feet
U Dwelling—No. of Bedrooms........l./71 ...............Expansion Attic ( ) Garbage Grinder (a®)
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Ga Other fixtures ----------------------------- .
W Design Flow.................................43::7gallons per person per day: Total daily flow.....................3,74...........gallons.
WSeptic Tank—Liquid capacity_4.oM..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No._,//.o=-------- Piameter.................... Depth below inlet.................... Total leaching area..rr'�,&-V...sq. ft.
Z Other Distribution box ( Ll Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
04 Test Pit No. 1-------A-----minutes per inch Depth of Test Pit------ Depth to ground water......................."
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-__-______-___--_..___-
a4 ......................................./ =
Description of Soil...lZ__i�_.._P.Y#----�--'--../&AI&At...��✓ �:�------ �ia✓ �x�.!�!�._..
W
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 TLNU 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued
�by/the board of health.
Signedk. jle. __LY/l.F/�crr ..��c!�:.�(/ry--�1-�� � �� r�f
/ 9
Date
Application Approved --------------------------------------- �, .Z0,44...
Date
pplication Disapproved for the following reasons________________________________________________________________________________________
-----------------------------------------------------------------------------------------------------------------------------•-------•--------•-----•--••-----•--•-----•--------...-------••-••--------
Date
Permit No.................•--------------------------------------- Issued-....�:...��'��
....................
Date
FES..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ ..............OF....................................... ......--------
Appliration for BiipwiFal Hlorkii Tontrurtion rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................................................................................................. .......................................................... sC .....-----'-•-•--
Location-Address or Lot No.
......................_............................................-............................. -•'-...•••------------•'-'.._._._.........-'---•-•............•----.__..._.....................---
Owner Address
W
Installer Address
Q Type of Building Size Lot.......... .................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder (NO)
a'4 Other—T e of Building No. of persons............................ Showers
Other—Type g ---------------------------- P ( ) — Cafeteria ( )
dOther fixtures ------------------------------------•----•---'•----....••-•---'------------•-'•-------------------------•--•----•--••----.....---••------••-•--•---_..
W Design Flow............................................gallons per person per day. Total daily flow--------_.............._....................gallons.
9 Septic Tank—Liquid capacity............gallons Length-------_------- Width----____-_-__-- Diameter---------------- Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----_------------- iameter-._.-----_-.--______ Depth below inlet.................... Total leaching area._2,A_.V...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------------------------
fr Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_._-_-------___--___-_-.
a -----------------------..............................................--......................................................................................
0 Description of Soil............................................................................................................................................................•--.r:.
x
U -----•--------------'-----'--•----•-•--------------•---•••---•---•--'•-•--'------•------•.......---------------...----....------------•----...-••---'---'-'...--------------•-•--''-'----••'-•-•-••---
W
-------------- --------------------------------------------------------•-•-----•------'-----------------------------------------------------------------'--•--------------•----------•"-•--'•......-
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 TITLi• 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... •=..............................
Date
Application Approved By-- - irrs,t ✓ •.,,,1 � "c /Or's.0---
�ate
Application Disapproved for the following reasons:-------•-•------------------•-•--------...._........---•----•----'----------•-----...-------••-•-•.............
..................................................'•---••'---•---•'•.......----••-•••---_._.....•'••--•--•••'•-•--••••••--'-'-••-----------------•'--•----------------•------_....._..------------'-'--
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....�. ................OF..... .. �� �..,,,,�,�1rNe......................................
Trrtifiratr of Tomplittnrr ,
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed fl ) or Repaired ( )
by..........-•-4�-,��..•w �144.................................
installer
has been installed in accordance with the provisions of TIT rR 5 of The State 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
SYSTEM WILL FUNCTION SATISFACTORY.
••�� L�! 7
DATE........ ............................................................... Inspector..........�--••-•••-- �'-1.........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0^►,.•.x....................OF....... ,* .............................. "�
FEE...✓---
i ooaal nrk T—Wnstrnrtion rrmi
Permission is hereby granted......G ., ---...W��A�L-4411..-•--•---....-----•----•'................................................................
to Construct (yor Repair ( an Individual Sewage Disposal System
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Street
as shown on the application for Disposal Works Construction Permit No.... ..._. )Dated..........................................
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Boar of eal
DATE...........-----•-----•••••-•-•--•••--••'-•'•-•--•-----•-••......•--'-•------'-
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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