HomeMy WebLinkAbout0036 BRIDGET'S PATH - Health 36 Bridgets Path, Centerville
UPC 12543 '
No. 53LOR k`�sT.coNS�J�a
HASTINGS, MN
COMMONWEALTH OF MASSACHUSETTS Q3
_ EXECUTIVE OFFICE OF ENVIRONMENTALAFFA q� � �o
DEPARTMENT OF ENVIRONMENTAL PROTE IO'�* O
G �
ONE WINTER STREET. BOSTON. NIA 02108 617-3.93.5:00 9��Dy(9199 led
W'ILL1AN'F V1'ELD
0XE
Govemc. Ti Secretar,
ARGEO PAUL CELLUCCI D.AVID B STRU L:
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions
PART A
//�� �^ CERTIFICATION
Property Address: l�h. Address of Owner: (`�-�� '�- --�` C_V\,,�L
Date of Inspection: o���2S�t'4-- (If different) 5r(-0 j M-IOA, -
Name of Inspector: _ p •Td�tt 0" b ,G I O
1 am a DEP approved syste ins ctor pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:
Mailing Address: O 964y
Telephone Number: t!5oV f tc
CERTIFICATION STATEMENT
I tend� that I have personia'N inspected the se�%aee disposal system a! this address and that the information reponed belo.% is true, accurate
and complete as of the time of inspec-oo The inspection v,as performed based on my training and experience to the proper function and
maintenance of on-site se"age disposa systems. The system
X Passes
Condinonaii� Passes
_ Need Funhe• Evaluar n he local Approving Authonh
Fa.,s
Inspector's Signature• Date:
The Svsterr Inspector shal' submr a copy of this inspection reoor, to the Approving.Authoriry within thirh, (30! days of completing this
inspection. If the system is a shared system or hay a design flo.% of 10,000 gpd or greater. the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Emironmental Protection.. The original should be sent to the system owner
and copies sent to the buyer, if applicable. and the approving authorin.
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 ONAR., 15.303.
Any failure criteria not evaluated are indicated below.
COM ENTS:
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.
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 exfiltrat)on, 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.
(revcaad 04/25/97) Page 1 of 10
DEP on the Wond Woe Wea hrx rnvww magnet state ma.usloec
ell.r00 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
f���. CERTIFICATION (continued)
( Property Address:
�r Owner: t�..pp'(_ �
-ADate oftlnlspection�'�"`
�"►_` BI SYSTEM CONDITIONALLY PASSES tcontinu-d
`'�• ,Ql I Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) 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 replaces
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 protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
., WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or pri\ti is within 50 feet of a surface water
Cesspool or pri" .is .%ithin 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
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.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supniv well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water t supply well uniess a well water analysis for coliform bacteria and volatile organic compounds indicates that
s pp , y
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 PP m. Method used to determine distance (approximation not valid).
3) OTHER
(zeviied 04.'25/57) Page 2 of 10
� v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:.3c gy.,`4
sef-S ;�
Owner: �_ l VA:21-(,-C1C1V
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "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 bans
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.
Sta;ic liouid level in the distribution boa 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 flov,.
Required pumping more than 4 times in the last year NOT due to clogged or obstructeo pipe s
Nurnber of times pumped _.
Any portion o'the Soil Absorption Svstem, cesspool or privy is below the high groundwater eieyanon
Am por•:on of a cesspool or priv} is within 100 feet of a surface water suppiv or tributan to a surface water supply.
Am portion of a cesspool or priv is \,%rthin a Zone I of a public well.
Ar.,. po^ion e-a cesspool or pro.-v is within 50 feet of a private water supply well
Any po^,or o`a cesspool or pnvy is less than 100 feet but greater than 50 feet from a private \,%•ater suppiv well with no
acceo;abie water qualm anaiys+s If the well has been analyzed to be acceptable. attach cope of well water analysis for
coltiorm ba(neria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
You must indicate either "Yes' o, "No" as to each of the following.
The following crire,ia app!� to large systems in addition to the criteria above:
The system serves a facilm 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 Svstem 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.prograrn
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/57) page 3 of 10
v •
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Properv. Address: ,� ���'Cj- QkS z L.. _ CQ mil-- ,
Owner: - Cl2*A_4f�K r
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 pan of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facdi-, or dweliing %%as inspected for signs o'sewage back-up.
The system does not receive non-sanitan• or industrial waste flow.
The site %%as inspected for signs of breakout.
All s\stern corponents, excludine the Sou .Aosorption System, have been located on the site.
_ The septic tank manholes mere uncovered, opened. and the interior of the septic tank was inspected for condition of
baffies or tees, materia: o- 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 o%%ne• Banc occupants. if difieren; trom owneri were provided with information on the proper maintenance of
Sub-Suriace Disposal System.
Exist!ne information. Ex. Plan at B.O.H.
Determined in the field :r an,. of the failure criteria related to Pan C is at issue, approximation of distance is
unacceptable 115.302:31:b`?
(revised 04/25/97) Page 4 of 10
I • A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9✓4 d��"'s
Owner: k—e- L-/Li`?`/�-�
Date of Inspection:
sl �-
BUILDING SEWER: y
(Locate on site plan) Wc)
Depth below grade:
Material of construction: _cast iron _40 PVC _other (explain`
Distance from private water supple well or suction h-t
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc..)
SEPTIC TANK: i( (b
(locate on site plan
tl
Depth below grade
Material of construction concre:e _meta _Fiberglas: _Polyethvlene _othertexplain
If tani ;s metal. Iis: age _ I; age con,rmec b\ Ce�d;cate of Compuance _(Yes"�o
Dimensions 1QXjCg1Vk
Sludge depth b" 3 y
Disiance from top o: siudge to bo;o*� or outie: tee or ba`�e _4
Scum thickness: A " _
u
Distance from top or scum to toc o'outlet tee or ba^^ie Q1�
Distance from bottom o'scum to bor.o•n o+ outlet tee er bar:,e 14_
Now dimensions mere determ;nec ILIA L/n .
Comments
trecommendation for pumping. condition of ;niet and outlet tees or baffles. depth of liquid level in reiauon to outlet in ertt, Structural
integrity, evidence of leakage. etc.! V
GREASE TRAP:_w
(locate on site plan:
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 0let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
;ntegrity, evidence of leakage, etc.:
(ray-sad 04/25:97) Page 6 of 10 '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.ti1
PART C
SYSTEM INFORMATION
Property Address: 36 13t1,1Cj(r-Cki
Owner: C ,
Date of Inspectioy
n:
FLOW CONDITIONS
RESIDENTIAL:
Design fio\,% aO , o.d.!bedroom for S.A.S
Number of bedrooms
Number o'current residents Q
Garbage g,; der (yes or no.,: OQ
Laundry cor•-ected to system (yes or no!
Seasonal use (yes or no-rNV
Water meter readings, if available (last two i2: year usage tgpd): IJ C7
Sump Pump (yes or no):
Last date o*'occupant, 90VWV 4,- -cl; V-XtA�
COMMERCIAL'INDL'STRIAL:
Type of establishme-it.
Design fio%% Qahonsda\
Grease trap present. ryes or no_
Industria! \taste Holding Tani: oresent: -ves or no
'son-sanitan haste discnargea to the Tate 5 systern Ives or no_
\'later meter readings, if a-,a,labie
Las:Pate o: o clpzi--c-,
OTHER: .De�cribe
Last date of occuoanc,
GENERAL INFORMATION
PUMPING RECORDS and source of informatior
System pumped as par, of inspection: tees or no:_
If ves, volume pumped eallons
Reason for pumping
TYF SYSTEM
Septic tank/distribution boxisoil absorption system
Single cesspool
Overflow cesspool
Prtvy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: '�:- r' �C)
Sewage odors detected when arriving at the site. (yes or no)�1v
(revised 04/25/91) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: y_
Date of Inspection: �f
TIGHT OR HOLDING TANK: :'Tank must be pumped prior to, or at time, of inspections
(locate on site plan.
Depth below grade
Material of construction _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flo". galions`da.
Alarm level Alarm in ).%orking order _ Yes, No
Date of previous pumping
Comments:
(condition of inlet tee. condition, o' alarm and float switches. etc.)
DISTRIBUTION BOX:
(locate on site pia-•
Depth of iio.u!d lee aoove outie: in,e,. 0A11 2AW-WW
Comments:
(note if level and distr- ution is au evidence of solids carryover, evi ence of leakage into or out of box—etc.)
s3�`►aiY —'Q �G� i�e� f�Zl �2 Ws F y I110�ut off- c. 4
PUMP CHAMBER:LV
(locate on site plar.
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.)
(raviaed 04/25/5') Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�^ SYSTEM INFORMATION (continued)
Property Address:
Owner: / l . Gk&u���
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS)
(locate on site plan, if possible; exca,auon not required, but may be approximated by non-intrusive methods',
If not determined to be present, explain:
Type:
leaching pits, number.
leaching chambers, num
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dirnensio.n.s.
overflow cesspool, number
Alternative system
Name of Technology
Comments:
t4 condition of soli, signs of hydraulic failure, level of pon g,c on a
vegetation,
CESSPOOLS: _
(locate on site play
Number and configura:,on
Depth-top of liquid to inlet Inver,
Depth of solids layer:
Depth of scum laver.
Dimensions of cesspoo!
Materials of construction.
Indication of groundwate-
inflow tcesspooi must De pumpeC as par, of inspection.,
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.)
(revised 04/25/97) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IN-FORMATION
-(continued)
Propert% Address: 3.c
Owner: �^ �A-�(�r•C
Date of Inspection:
o �Z 7
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)
i'
. 1
35
(zn•iaa4- 04'25!5?; Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ ,/%, SYSTEM INFORMATION (continued)
Property Address:rj b Per• �
Owner: C /Vr IC-7
Date of Inspection:
3L--
IL `
Depth to Groundwater 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
Cnec'K with Iota! Board o! realm
Chec'K FEMA MaDs
Check pumping records
Check local excavators. installers
Use LSCS Da-a
Describe in voj, ow,. %+oros ro%% you established the High Groundwater Eievation. (Must be completed;
CK l e. I L'G�� ��Co�►�— C( RT g ' 31 C." lei L,._J
(ray.aad 04'25'5-, Page 10 0! 10
LOCATION `-� -SEWAGE PERMIT NO.
,lam i a 7e- 7 7 Z ,
VILLA
IN.STA LLER' NAME & ADDRESS
B U I*L D R OR 0
DATE PERMIT ISSUED
DATE : COMPLIANCE ISSUED
L- -
a�r
i �
.�
No.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA TH
.
,� Iirtt#ion for Diopooal Works Tontrnrtion pamit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at: /
...load e ��.. �.............../?.� 112Z oe� P /Ile- IV4S-S�........................... .... .......... ........................................... Y..
on Address ^7J >
.........., �fR� f� �' �/7 l�C'..V f 6.r Nl.....Q vs
� I/( Owner - v - dd ess
W -..--_T--_�..�S. .... ..........
............................ .- -•-• --.. _ ......--- .._....5...-----..........--•--•--^----......:...
Installer Address �
Type of Building Size Lot. EJ..�:.470Z....Sq. feet.
Dwelling—No. of Bedrooms............................................Expansion Attic (Yo Garbage Grinder ry
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
aOther fixtures ----------------_----------------•-----------------.--....•--•----••-•----•---•••-•----.....---"-•--•-"
d gallons per erson per day. Total it flow__________ ___ . gallons.
W Design Flow------------`�---••------•------------g P P �,P , X --------•--•------•--------- o
* Septic Tank—Liquid capacity�P allons Lengthy i..� . Width_._�__......_ Diameter________________ Depth__ ......
W Disposal Trench—No. .................... Width•...._............. Total Length.............__.__- Total leaching area....................sq. ft. '
x
Seepage Pit No------Z........... Diameter.... Depth below inlet...4............ Total leaching area..®.�._.sq. ft.
Z Other Distribution box (�) Dosing tar}-
'~ Percolation Test Results Performed b ..__ :....a.. ._.__ _ .?�• _..... Date..._ ®Vf V
Y 7 ,`�a Test Pit No. 1....0......minutes per inch Depth of Test it.......4........ Depth to ground water�-Y.�.__�l
Test Pit No. 2................minutes per inch Depth of lest Pit..................... Depth to ground water........................
}
O v '.�. / ce�/d per/s+ G� /J Y�j_ lrL -- � n'
Description of Soil f �H't._.._
V ---••---------------------------------
-------------
-----------
•------
.-----------
- ------------ --•-•---•---------------•--------•-------------------•--------------------
--••---•-•"----
W ------- .•.--------------------------------------------------------------------------------" ........ ----------------....•••-----"------••----•---••---......---------•••--•-
VNature 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'IT?.l• 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issu d board of health.
SI.
i �l ----
-----------
Si
---
/ Date
Application Approved BY-----. ---- ---•--------- G�'�/ ��-•� 7_'_Z -
D ate
Application Disapproved for the following reasons:....................................................................... ........................................
--•...............................•-•--------•--••-------------------------------........---•-------•"--•-•--------••"--•- •--------•-----•-• --•------•-----------•---•--•-•-•-------...........
Date
Permit No...•.__..._.....•.._.... -• Issued.. l -
Date
N ........ Fxs...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD
''1....�.. , OF HEA T
OF .............. ..�
.�?....
• pphrtt#iun for Dispoii al Winks Tonstrurtiun ramit
Application is hereby made for a Permit to Construct Zor Repair ( ) an Individual Sewage Disposal
System at: ` e S n Ile
�'/..V............................�--� .........-------•--- -•---..._... ........•----•••--••---............•-- ... ._...... _
--ion-Address / ��• Lot No n` /
r {� e 7'i o2 oZ �h v.. ....- l�S /07-i / /'A
jOwner v ddress
W ..... ..... ---•--•••-•---•--•--•....................•-•-••••••••-•---•. ` ... .._....._!. ......••-
Installer Address ,p���
Type of Building Size Lot/.-& .� ....S fee
Dwelling—No. of Bedrooms........ Attic � )� �` Garbage Grinder
04 Other—T e of Building No. of persons____________________________ Shower`s — Cafeteria
ad Other fixtures •-
x
W Design Flow.._.._.____.%J. ___________________gallons per person per day: Total il�y flow._/.__.___��-__ ...................
WSeptic Tank—Liquid capacity/P�gallons Length&'?_C____ Width__ _.____.__ Diameter________________ Depth_f�-•.__.....
x Disposal Trench—No._._..___ Width . Total Length.___..._.___y______ Total leaching area....................sq. ft.
._
Seepage Pit No �..-____.__.. Diameter___.......__.___ Deptl below inlet___t�............:'Total leaching area_4 D.f._.sq. ft.
Z Other Distribution box (� ) Dosing _
'-' Percolation Test Results Performed b .___ .......�.....
Q Date....
a Y - p�
a Test Pit No. 1....�-------minutes per inch Depth of Test Pit......_�'�__......... Depth to ground water/__y_o___ ...�..__.
Test Pit No. 2......_.........minutes per inch Depth of Test Pit.................... Depth to ground water........................
i = , .. . .........
0 Description of Soil__�____� cr�' `'"' �'� � __.__..___ �'
----------•-•-------- -- ---t..._..
U ---••••-----•--•-•------•-••-••••-•••-•--•-•--••••-••--...-•-•-----•-•--•--••---•••••--•--•-••••-•-•-••-•--•-•-•-•-•••-•--•-•-•---•••••-----
W ---•---•-•-•-•--------------------•--------••---------•--•--------- ------------•-•----••--•-••----••-•--•-•••-•---•------------•••-•--•-•---•-••---••---•-••--••--•••-••-•-••-•--••-•--•-..._...--
UNature 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 TITI-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate 6f Compliance has- eeri is a board of health. l 7
............... !�"`q__ate��
Application Approved B
Date
Application Disapproved for the following reasons:--...
....-------•-•--•----••---•-•-•-•-••-•-•--•...•--•---•••••-•-••---••••--•••-••-••••.._ -•-••----...
.__.....•••.......--•---•---...••--•-•••••--•••••--••-•-••--•-----•••-•-•==•-•••---------•------•-•...•--•••--•-••••----•-•---•--•--•••••••••---••-••---•-•---••-••------•-=----------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS -
BOARD O HEALTH
Q'' �...........OF.... l._...............................................
C�rr#ifirtt�le of f�um��ittnrr HP ITH I TO RTIFY, That the Individual Sewage Disposal System constructed (�Or Repaired ( )
bY•-- . •••. ---_.. ....................
----•-
� ler ;
at -• -----------------------•------.._..._..-•--•••-••---•--
has een installed in accordance with the provisions of TIT > of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__.__�_____ _'�-__.___ dated...//-- _t-___Z_7`__7i* ._!_....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................••-•----•-----.......------...-••-...-•••-...----•-••---• Inspector....................................................................................
4 THE COMMONWEALTH OF MASSACHUSETTS <*-
i '
1BOARD F H.EALTH
f
?..........OF.....A........... . . .................................................
No._...;.. ._..... FEE... .5..._:.........
ab5poll
ur - 1Tvnstr iun "permit
Permission eb anted ---.......................
Y �Z.� s'
to Constr ct or Repai " an In idu S ADjo*s ".yst
} z � c
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HYANNIS, MASS. 02601
REGISTERED ENGINEER ® LAND SURVEYOR
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