HomeMy WebLinkAbout0015 CRANBERRY LANE - Health 15 Cranberry Lane
A = 226 - 111
Centerville
5 M E AD®
No.2.153LOR
UPC 12534
smead.com • Made in USA
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can Commonwealth of Massachusetts
Executive Office of Environmental Affairs
— Department of
eta
Environmental Protection
William F. Weld
Goy mor
Trudy Coxe cc
Secretory,EOEA
David B. Struhs 350 MAIN ST, W.'YARMOUTH
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
5 CERTIFICATION
MAP# Z1 .Z� ` `. , '"
PAR#
PRO ERTY ADDRESS: -3-r Cranberry Lane, Craigville Bruce Bowen
DATE OF INSPECTION: June 20, 1997 4605 Bayne Court
NAME OF INSPECTOR James D. Sears Rockville, MD 20853
COMPANY NAME, ADDRESS AND TELEPHONE NUMBER:
A& B CANCO, 350 MAIN STREET, WEST YARMOUTH, MA 02673 (508)775-2800
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 sewage disposal systems. The
system:
PASSES
CONDITIONALLY PASSES
ex NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AOTHORITY,
FAI LS F
Inspector's Signature: Date: June 26, 1997
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, or C
A] SYSTEM PASSES:
N/A 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.
B] SYSTEM CONDITIONALLY PASSES:
N/A One or more system components need to be replaced or repaired. The system, upon completion of the
replacement or repair, passes inspection.
Indicate yes, no', or not determined (Y, N, or NO). Describe basis of determination-in-all instances. If
not determined", explain why not)
The septic tank is metal, 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.
1 (REVISED 11-03-95)
One Winter Street Boston, Massachusetts 02108 Fax(617)556-1049 Phone(617)292-5500
r
Town of Barnstable
Department of Health, Safety, and Environmental Services
Health Division
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 'aromas A.McKean
FAX: 508-775-3344.. Director of Public Health
TOGINEER�L�ET ] l— ate !Y '0"A
ivies
62(47
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5.
The septic system owned by you located at 3 I Cre,6-_rr La•ia Cf-, vAe- was inspected on
-e 20�tR9 by �� �s a Massachusetts icensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE
5 (310 CN&15:00) due to the following:
—C S' Z c
You are directed to hire a licensed professional engineer (PE) to design a system that will bring the septic
system in compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within twenty-one (21)
days of your receipt of this letter.
You are also directed to hire a licensed septic system installer to install the system components within forty-
five(45) days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system
to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface
waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court of
competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.3., C.H.O.
Agent of the Board of Health
Town of Barnstable
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
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):
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled 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:
X 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 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and 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 is within a,Zone I of a public
water supply well.
The system has a septic tank and soil absorption within 50 feet of a private water supply
well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50
feet or more from a private water supply well, unless a well water analysis for coliform bacterial
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.
3) OTHER .
X—PER JERRY DUNNING BARNSTABLETHEAL"THTDEPARTMENT INSPECTOR
HIS OFFICE WILL REVIEW WATER LEVEL ADJUSTMENT SCHEDULE.=THIS`SCHEDULE
IS.QUESTIONABL=E=FOR'THIS AREA. SYSTEM-_PRESENTLYABOVE WATER TABLE AND
WORKING-AS-DESIGNED.
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
N/A 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.
N Backup of sewage into facility or system component due to an overloaded or clogged SAS or
cesspool.
N Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.
N Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool.
N Liquid depth in pit is less than 6" below invert or available volume is less than 1/2 day
flow.
N Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s).
Number of times pumped
Y Any portion of the Soil Absorption System, 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.
N Any portion of a cesspool or privy is within a Zone I of a public well.
N Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N Any portion of a cesspool or privy is less than 100 feet lout 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:
The following criteria apply to large systems in addition to the criteria above:
N/A 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 exits:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA)
or a mapped zone If 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.
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
FLOW CONDITIONS
RESIDENTIAL:
Design Flow: 220 gallons
Number of bedrooms: 2
Number of current residents: 0
Garbage grinder(yes or no): NO
Laundry connected to system (yes or no): YES
Seasonal use (yes or no): YES
Water meter readings, if available 94-95 20,000/95-96 38,000
Last date occupancy:
COMMERCIALIINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present:(yes or no)
Industrial Waste Holding.Tank present:(yes or no)
Non-sanitary waste discharge to the'Title 5 system:(yes or no)
Water meter readings if available:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
N/A
System pumped as part of inspection:(yes or no) NO
If yes, volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes, attach previous inspection recods, if any)
Other(explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
8-23-89 PERMIT#89417
Sewage odors detected when arriving at the site:(yes or no) NO
5
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce'
Date of Inspection: June 20, 1997
Check if the following have been done:
X Pumping information was requested of the owner, occupant, and Board of Health.
X None of the system components have been pumped for at least two weeks and the
system has not been receiving normal flow rates,duling that period. Large
volumes of water have not been introduced into the system recently or as part of
this inspection
X As built plans have been obtained and examined. Note if they are not available
with N/A
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow
X The site was inspected for signs of breakout.
X All system components, including the Soil Absorption System, have been located
on the site.
X 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.
X The size and location of the Soil Absorption System on the site has been
determined based on existing information or approximated by non-intrusive
methods.
X The facility owner (and occupants, if different from owner) were provided with
information on the proper maintenance of Sub-Surface Disposal System.
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
SEPTIC TANK:_X_
(locate on site plan)
Depth below grade: 12"
Material of construction: X concrete metal FRP other(explain)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 33"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 12"
Distance from bottom of scum to bottom of outlet tee or baffle: • 1 3"
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.) TANK AT WORKING LEVEL,
INLET TE OUTLET BAFFLE, COVERS 12" BELOW GRADE.
GREASE TRAP:-
N/A-(locate on site plan)
Depth below grade:
Material of construciton: concrete metal FRP 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:
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.)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
TIGHT OR HOLDING TANK:-
N/A-(locate on site plan)
Depth below grade:
Material of construciton: ccncrete metal FRP other(explain
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: X
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of
box, etc.) D-BOX IS 16" X 16112211 BELOW GRADE, BOX IS CLEAN, SOLID AND LEVEL, ONE
LINE IN, ONE LINE OUT.
PUMP CHAMBER:-
N/A-(locate on site plan)
Pumps in working order:(yes or no)
(note condition of pump chamber condition of pumps and appurtenances, etc.)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
SOIL ABSORPTION SYSTEM (SAS):_X_
(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: 1
leaching chambers, number:
leaching galleys, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.) 4' PRE CAST PIT, 12"WATER,WALLS ARE CLEAN AND NEW, PIT AND COVER 12" BELOW
GRADE..
CESSPOOLS: N/A
(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 cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc)
PRIVY:_N/A_
(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.)
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 31 Cranberry Lane, Craigville
Owner: Bowen, Bruce
Date of Inspection: June 20, 1997
SKETCH OF SEWAGE DISPOSAL SYSTEM:
INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES LANDMARKS OR
BENCHMARKS
LOCATE ALL WELLS WITHIN 100'
4�SA)e
0
o O
DEPTH TO GROUNDWATER
Depth to groundwater: feet
method of determination or approximation:
9
PERMIT NUMBER DATE
COMPLETED BY
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: 31 Cranberry Lane, Craigville Lot No.
Owner: Bruce Bowen Address:
Contractor: Address:
Notes:
STEP 1 Measure depth to water table n
to nearest 1/10 ft. .............................................................................. Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well.................................................... .3-
Water-level range zone .....................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ........................... s �l7 g
month/year
STEP 4 Using Table of Water level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3).
and water level zone (STEP 28)
determine water-level adjustment . ........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water,
level adjustment (STEP 4)'
from measured depth to water PY]level at site (STEP 1) .........................................................
Figure 13--Reproducible comutation form.
10
Fzcs.....AD............
THE COMMONWEALTH OF MASSACHUSETTS
-� BOARD OF HEALTH
.............1.Wn........I......OF !I4 .t,.............:............
R�-
a � d Appliration for DispasFal Workii Tomitrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal
System at: n �r.yk
� vhan6,cf .. lbrlril4� 5.�4� I..!%. ................................
5
-------------------
/ Location -.-dd.ess or Lot N .
1/// .��aw .•..I r � ....--.. 31_�.°can ett. ..� a (!VAPer..JJdJ9
Owner Address
a
Installer Address
Type of Building Size Lot............................Sq. feet
., Dwelling=No. of Bedrooms............................................Expansion Attic ( ) e-. Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther 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......................T.................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
G%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 -------------------------------------------------------
•.........
.------------
•-----------------
•---
----------------------
----------
•--------------
----------
0 Description of Soil........................................................------......--------•--------------....----------...-------•--------------------------------•-•--.._...-•------
x
V -•--------------•••---------------•--•--•-•-----------•-•--•----•-......•----••--•------------•--------•••----•-•-•-------------•-------•------•-------•--•-------------......-----•...----------•-----
W
x ---- ------------------------------------------------- - •----------- ---------•---••------•---------------------------------- -------------•----------•------ ----
V Nature of Repairs qr Alterations—Answer when applicable. raw-W...l1.o-aD-.. j-.-100*_,?0A.•�RGC ..Pz....__.
__Dta--Q3---rw$ai�%Q..............................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITLiE 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. .................................. = '._Ib-.8 ...........
-
Application Approved By.............
-. . _ Date
_ Date
Application Disapproved for the following reasons:-----•--------------------•-------------------------------•----------------••-•-•-------- •-----•--_.._.....
--------------------•-------••-----------.....------------•--......--•-•--•••-•------••-------•-................-...................... ---------•-----------------•---•--•-----............•---•-•-----
Date
PermitNo.------. .'.. ---•----------------• Issued.......................................................
Date
No... FEs......r..::?.-...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 OF.. �-, a
........................................... ...............T..>.-.s:_..._.......
Apphration for Dispo,ial Works Tomitrurtion throb#
Application is hereby made for a Permit to Construct ( ) or Repair (- ) an Individual Sewage Disposal
System at:
.. , 1., . t (. f -
1 11
.... . ...._...--.. �•••-•-••-•------------------------- --- -----------•--------•---- --..._...._...----------...._.._.....--------------------------------------------............-----
Location-Address or Lot No.
................. ..........-•--... -__^--_____--'--•---_._........_-__...__-_---_ _-_'__----^_______.__..._____.._...... ........................................................
Owner Address
1�..
Installer Address
Type of Building Size Lot...........................Sq. feet
Dwelling-No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' 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 ( )
PercolationTest Results Performed b ..---••-------•---••••----•-•-••---•----•---•-•••••-•-------------•------- 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........................
R+' --------------------•-••••..__...•---••••-••••-•-- -------------.........---•------------------...------------•-------•------.._.__....__......------••--
ODescription of Soil........................................................................................................................................................................
U -------------------•---------------------•---------------------•---•----------•-----•--.....--------------------•-----------------------•-------------------------------•-------------...-----•-----•-•-
W -••-••------------------------------•------•----••-•----------.....•-•...__.,-.....•••••----•-...••--------•_..------------------...•--•-••---------••-•••-----••-••••-•-•••-•-•--•---•---•----.....--•-
UNature of Repairs or Alterations—Answer when applicable.1...... .......................................` .........................
l i_r C r r -�
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 by the board of health.
Signed-• _-•1.....= =- •`( .... T `---- -
Date
Application Approved By...... <-Y '`~� \��` -._�.,.t�- --------------------------------- ..........p-' Date
Application Disapproved for the following reasons:------•-----•-•--•••-•---------•--•-•-••-•----------•--•---••-----••--- ........................................
--•------------------------------------------------------------------------------------------------------.---------------------------------------------------•----------------------------------...--•---
Date
Permit No.---...2r-__2---...1-1z.7...................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�............... .........OF...`............t.}-.........................................................
Trrtifiratr of Toutplionre
THIS I TQ CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by............... r ` ------........-•---------•---------------------......-•----•---•---•----•---•--------------...........----•---------•--.._.._.._....----
Installer /j
at.--•-•-•- ./_...--•--•-- ... �}._..... ec. `-E ,K!-?Ll_`t..=� ----------------------•-----------------•---------•-•--------.._..----•------
has been installed in accordance with the provisions of T11 71' 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..___a_I"-_... l_ ........ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... -............................ Inspector................ ..................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No......................... FEE.........._............
Disposal Works Tonitr ion amit
Permission is hereby granted...--- .r. .�..__.✓/ '-•--•---------•-------------------------------------------------------•-•._............---
to Construct ( ) or Repair( ) an IndivTal Sewage Disposal System
at N9......... f ..................... �._.._-:_....-•-----�. •c- � �f
- !'
Street `,
tv
as shown on the application for Disposal Works Construction Permit No!' _�!,7____ Dated..........................................
-----------------------•-----------
�_/� Board of ealth
DATE ..
............................................................
...........................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
L
��
LOCATION 41fCt�N Srd- SEWAGE-#
VILLAGE �i% tayi/�{ ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC:-TANK CAPACITY looO
LEACHING FACILITYAtype) �o� (size) �� 6
NO. OP BEDROOMS PRIVATE WELL,OR PUBLIC WATER
BUILDER OR OWNER /j k&e a Aew rll
DATE PERMIT ISSUED: A 1 [dot
DATE COMPLIANCE ISSUED: 3 �1/
VARIANCE GRANTED: Yes No c�
�31
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