HomeMy WebLinkAbout0063 CEDRIC ROAD - Health 63 CEDRIC ROAD;CENTERVILLE _
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No. 42101/3 ORA
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COMMONWEALTH OF MASSACHUSETTS
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EXECUTIVE OFFICE OF ENVIRONMENTAL AF +� S
DEPARTMENT OF ENVIRONMENTAL PRO TI�iA 9 j9 '
/
ONE WINTER STREET. BOSTON. NIA 02108 617-29?•�j00 '� �y `9�
w'ILLIAhf F.WELD L ` RUDY CORE
Governor
Secretan
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION 17
Property Address: (13 C� L RO
DRrAD;CEn �?rE2vJtC14_7
Address of Owner:
Date of Inspection: 'o I r S 196 (If different)
Name of Inspector: f�\Cn(,E (,£TErJD2�
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: N%coL.6 L, (r£TE+)pP_E , PF •
Mailing Address: WtI,Y,Ut�t AVEn1t1Ei Ct)i1£II�.SWANSEA� O���
Telephone Number: StofA-!g 3-�4p4S
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site seNvage disposal systems. The system:
_V Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ F ' s
Inspector's Signature: Date:
The System Inspector shall submit a copy 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 report to the appropriate regional office of the Department of Environmental Protection. 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] SYZI
TEM PASSES:
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: l '�� 'C ti k 9_*oL err kV 66('D A . 7f f n)
e0i�A le 6j"-) 'I �6E�6 #-C- NQ b4AJ(of4 F I L r C c g d S E. cif= L.o In/
vJA�f_k- g6L.E,
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 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
OEP on the World Wide Web: http:ltwww.magnet.state.ma.usldep
��'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
�5 C�b�2t_C- 9-c, D, CE,v +Property Address: �.-R�/� l..l..�i�
Owner: P,()"ItORST
Date of Inspection: 10 11 51 C)8
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
pipe(s) 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 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:
I
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 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 supply 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 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 ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: (03 C>^ R�G 2a4 , C ErJ'i E 2 v I LLB
Owner: A Rov RFM 3-tDR VT- ^I I
Date of Inspection: 1 p 15\9b
D] SYSTEM FAILS:
You must 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.
N� Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _
V Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
�11R Any portion of a cesspool or privy is within a Zone I of a public well.
IV� 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:
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 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: (:as�C„E�Rt
Owner: SI+A(ZON) R44Mk16,R9 -' f A JZ 1
Date of Inspection: 10 It 5 9 A
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.
_ As built plans have been obtained and examined. Note if 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.
✓ _ 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.
_ Existing information. Ex. Plan at B.O.H.
_ 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))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ""� 2t G a
Owner: S0-At? n1 tV`tv11 �`t- &qA)B
Date of Inspection: ID I S 1 9�
FLOW CONDITIONS
RESIDENTIAL:
Design flow: I 10 g.p.d./bedroom for S:A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no): F$
Laundry connected to system (yes or no):V
Seasonal use (yes or no): I Q
Water meter readings, if available (last two (2) year usage (gpd): 88,00061U,
Sump Pump (yes or no):Ala
Last date of occupancy:CjRff^�rl
COMMERCIAUI N D USTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)
Industrial Waste Holding Ta present: (yes or no)_
Non-sanitary waste disch ged to the Title 5 system: (yes or no)_
Water meter readiny available:
Last da/- ,up
ancy:
OTHE )
Last daancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
\AA)APL-/ 199 S t AJ h( sT z-- 9
System pumped as part of inspection: (yes or no)
--&Q
If yes, volume pumped: gallons
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)
VA Technology etc. Copy of up to date contract?
Other St^Pfit C_ �K 1.�f ? / �' (fit 5 �f►4 C+1 tjto P►tS
PP� GE of all components, date installed (if known) and source of information:
2 I AJ 19
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
" SYSTEM INFORMATION (continued)
Property Address: (03 C��R�t✓ '(ZD' � C&A)TSkV w�
Owner: %4A1Z01%J P(PM14WZS't- GA JZI
Date of Inspection: 10 115
BUILDING SEWER:
(Locate on site plan)
rr
Depth below grade: owisw( )
Material of construction: _cast iron ✓40 PVC _other (explain)
Distance from Private water supply well or suction line NA
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on site plan)
t
Depth below grade:z--(rOP OF Tq41r-�
Material of construction: vEoncrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:4 (Itj +,DE� f���Tl`!ty` f - 1 � I a t (r'e. 6o4-oAA Or- I-,q4l<To oUl'+�T rNVEkt>
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle:"-
'cum thickness: Fc to 1614
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:lt) f,EUD M 6A d426rv(
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.) IMA 5 L — CU��EnJ'f'
A L NS F► OA) COR L&N'9' 116 11 Q
rNA F fft66 IN A V ON U6661-)
"Jt 5 I N N
GREASE TRAP:__
(locate on site pl:n)
Depth below gra:.le:
Material of const uction: _concrete al _Fiberglass _Polyethylene _other(explain)
Dimensions:_
Scum thickness:_
Distance from top of scum top of outlet tee or baffle:
Distance from bottom cum to bottom of outlet tee or baffle:
Date of last pumpin .
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: ce RIC, �I), cl—C/'j7-Ep—
Owner: 51 4(ZOA3 QQ/N Hog'�--- (Bg42::1
Date of Inspection: I DI)51 98
TIGHT OR HOLDING TANK: ;etal
k/must pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gal ns
Design flow: allons/day
Alarm level: Alarm in working order_Yes; _ No
Date of previous pu ping:
Comments:
(condition of inl t tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet inve
Comments:
(note if level and distribution 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 chamb , condition of pumps and appurtenances, etc.)
(revised 04/25/97) page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Cbr (Rt C_ RUA I'> , C.f—( tCR V1 t.t-"E
Owner: S+IARanI P�QrM HOR9T — PY-)N-16 t
Date of Inspection: 1 6 1 I S 1 98
SOIL ABSORPTION SYSTEM (SAS):z
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive 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 Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
CESSPOOLS: _
(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 (cesspool must be pump d as part of inspection)
Comments:
(note condition of soil, signs of ydraulic 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 hyd re, level of ponding, condition of vegetation, etc.)
(revised 04/15/97) Page a of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Cie— P't r✓ I�j 10 p � C�����1/1 U4
Owner: S�kAt2o+`1 2�Mttv2ST— l31�N21
Date of Inspection: O 151c�
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)
� r-
�� 'rl s
c -
(revised 04/25/97) Page.9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (OS C. tz A Ce-41*.op,VI LSE
Owner: \qAM *QA t�Z.)
Date of Inspection: t CM S 1 -)8
Depth to Groundwater >JO Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V 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
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be comple.ed)
�— C 1►� SPIT G, 12,5 C—KC)M 6�A1J�
tro P
cal
(revimed 04/25/97) ?age 10 of 10
r _ y,
No... 7d FIms.�...20.oo
/............... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town........... .....oF.........Barn t table
Appliratinn for Disposal Works Tonstrnrtlun .erntif
Application is hereby made for a-Permit to Construct ( ) or Repair4X) an Individual Sewage Disposal
System at:
63 •Cedric Road Centerville
................ ----...---------•-•-•--•-•-•-------•-------.......--•---•-----------------.........---.........••-
Ramhorst Location-Address or Lot No.
Owner Address
w J.P.Macomber Jr.
--------------------•-••------•------------------------------
Installer Address
Type of Building 3 Size Lot............................Sq. feet
�-, Dwelling_—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---.---.---................. Showers ( ) — Cafeteria ( )
Otherfixtures --------------------- ---------•----•-----------•---...------------------......--------- ----••-------•••------•-••-•••............-•--••......-•--
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......-------_--..-.---.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.-----.............. Depth to ground water........................
9 •------------------------- ----------•-----------------.--------------------.--.---•----•---------..----------•----------------.---------------------
0 Description of Soil........................................
x -Sandt &...GTave ------------------------------------------------------------------------------------------
x = , npI
U Nature of epairs or Alterati ns—Answer when applicable.--....:........................................................................................
--------------- -----•-------------------•---------------------------------••---••-•...........•••••-•-•-•-•-••--••--•-----•-•------•-••----•--•-•--••-•---••----•-••••-••-•-••-•---•-••-------.....••--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ilTLi� 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 e 77board of hea h.
Signed 1.:.. % !' - 11121/89.:._
Date
Application Approved BY --•C J ..... � �-"j ...........:..
Date
Application Disapproved for the following reasons:................................................................................................................
--•-•••••-••-•-•---•--•-•--•--•-••-••-•-•••••----•-••----•--••-•-•••----••...•-------•••--•---••---••-•------•---••--•••-••---••---•------•-----••••----•------•-------••-----•-----••--•-•-•---•-••----
g Date
PermitNo....... .......7o........................ Issued.......................................................
Date
No. 1-...7.6.` Fps........ ............ ...
'
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD OF HEALTH
Town - ar�r.ti:a�1
............. .....OF..................,.....................
Appliratilin for Disposal Works Tonstrurtuatt Frrutit
Application is hereby made for a Permit to Construct ( ) or Repairx(1 y an Individual Sewage Disposal
System at:
G�jr! ,coact CI.:iIteY: .-.:101
Location-Address or Lot No.
......................-.......................................................................... --••-----•--......-_. ._ .....
owner Address
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling No. of Bedrooms........... ...............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
P., Other fixtures .----•------•----•-•----•---•-•...... •-•------------------------
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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
..a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---_------_--•-----____.
f1, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....._------_-_----____.
a' .............•.........................................................................................................................................
......
0 Description of Soil.........................................:.:.. = -== ^•:.:= y---------------------•-----•-•••------•-• ..............................................
W
------ - --- y.............---- --- .................M, lyl Nature of Repairs or Alterations—Answer when applicable.............................................................................................
---•---•••••••--••••--•---•••---•........----•-•----•---••----••-••.......-••--•-•-••••.....-•-••-----•-•-••-•-•---------------•------••••••--•••---•••--•-•-•••-•••••••••-••--••-•---••--•--.......----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued byy�the board of health.
Signed _.:... = -•-- -••--•-• -•••-•...-••....•--• •-••--. ---•••---•----••-......
Application Approved By-•---•--•-• --- ••--• t`',�` ...........................
Date
�/` ..
......................................
Application Disapproved for the following reasons:............................. ----•---------•-----------------•--------------------------•......--._...---......
-•--------------•----------------•----------.:.....-•.------.........------•---•-------...........------------•-------•--••-----------•-------•---•-------------------••••---•-•-------•--•-••---•_....
Date
PermitNo.... {,e-.-1,.._:.._1. .. .. Issued-------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
` ' ?.................I.....OF........Ppr is U ::1e
....... .............................................................
ffffifiratr of Tompliatta : y�
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-•-•-•..I:.E=.='a C!n- ='F''-,T.r.•-------------•--...........-----•------------ --------................-----....--...----------------•-.............------........--.•......--
n
Installer
c „e cf.r Road Cent ar f.i 1�r
has been installed in accordance with the provisions of I-P 7il.;i'' r of T�e State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._._.'.._C_.___-___._._0�l.__.. dated-......................__________._._._.._.._..
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION
SATISFACTORY.
DATE..... ° ................................ Inspector' s' . . r ,i ,'' ''r�'G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No...... ! FEE........................
Permissiog.is hereby granted..`- ...............................P.Macomber Jr.
•----. •-•-•--•---•------••----•--•-••---•--••-••......----••-••••-.......
to Construct (�1•) r Rep r Lan r34, ua -wage Disposal System
at No.••-•-• (_..................................3.C; i® t� G�t L-:` .
......................••----•--.........-,........---.......---------•------•----------•---•--------------•-----------------------..............
Street 70
as shown on the application for Disposal Works Construction Permit No.... .............. ated_._....___._____..___.______._._.__.__....
...............................
Board of Health
DATE..................... ..........................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
TOWN OF BARNSTABLE
LOCATION (�`�'► r �r,yd SEWAGE # �
VILLAGE-�'�r V�,� ASSESSOR'S MAP & LOT/ L
INSTALLER'S NAME & PHONE NO. bed . C
SEPTIC TANK CAPAC � 4
LEACHING FACILITY- type) �� (size) �
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER � 7
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ���
VARIANCE GRANTED: Yes No
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