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HomeMy WebLinkAbout0262 ELLIOTT ROAD - Health == 227 RD. LE j - Owf®rd. NO. 152 1/3 ORA ;:�. 10% No. ( / -7 7 e Fee ✓ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes F BARNSTABLE B HEALTH DIVISION -TOWN O s MASSACHUSETTS PUBLIC 01pprfcatfon for Mtopogal *pgtem Construction Permit Application for a Permit to Construct( . )Repair( /)Upgrade( )Abandon( ) Ej Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Addre s and Tel.No. 1 Assessor's Map/Parcel jot 7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 1--� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �� O Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co nd not to place the system in operation until a Certifi- cate of Compliance has been is by this B and of He ( _ Signed Date � `CJ W Application Approved by Date. Application Disapproved for the following reas ns Permit No. ' 9°/ -7 Z- Date Issued r 4 , ` taus a a a_ a a 1 fL 1t�e lriark a ,i uw}h:uis�t s '�-^ ••},. - y �.�'�'��� TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE I ASSESSOR'S MAP & LOT Z Z� INSTALLER'S NAME&PHONE NO. 1�. SEPTIC TANK CAPACITY (F)C( x LEACHING FACILITY: (type)� ­At a\ (size) NO. OF BEDROOMS BMDER'OR OWNER PERMIT DATE: j. / V COMPLIANCE Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom:of Leaching Facility Feet Private Water,Supply Well and Leaching Facility (if.any wells exist on site or within 200 feet of leaching facility) A)/,,k Feet Edge of Wetland and Leaching Facility (If any wetlands exist n within 3,00 feet of;leaching;facility):.. Feet Furnished by xc J 1 e, VIP- No. { / / 7 c._ Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIpphration for Miopooal bpotem Conotruction 'ermit Application for a Permit to Construct( . )Repair( j)Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. Owner's Name,Addre s and Tel.No. Assessor's Map/Parcel ^� 7 A: Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Sizesq.ft.� , Gaibage Grinder( ) Other Type of Building 1 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow. Mgallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank \_`)0(S Type of S.A.S. Description of Soil; Nature of Re airs or Alterations(Answer when applicable) cx Date last inspected: ,a Agreement: ' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Co a and not to place the system in operation until a Certifi- cate of Compliance has been is by this B and of He ( _ Signed Date 1 6 Application Approved by i Date 1): 0 Application`Disapproved for the following reasons Permit No. WO Date Issued �� D THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Cpmp Lance THIS IS TO CE�Y,that the On-site Sewage Disposal System Constructed( )Repaired(✓)Upgraded( ) Abandoned( )by ` ,I c-\1G'r C at < d C has been constructed i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.�� 7-7 2— dated 0 Installer :3 t- Designer The issuance of this permit shal not be'construed as a guarantee that the syst ill fu iotna designe G' Inspector Date— CV No. %'�'" -- -------- -- ---Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ai5pooal *pgtent , ongtrurtton Vermtt Permission is hereby granted to Construct( )Repair(V )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructiop mu t be completed within three years of the date of this Mpe . Date: �� Approved by _�z 1 5/25/01 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated L cS'(C�< , concerning the property located at meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than fourteen (14) feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation + adjustment for high G.W.I r3 = e DIFFERENCE BETWEEN A and B a SIGNED : DATE: NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:percexmp e r a � � �' � � t ._ No. l�Z Fee •�" ` / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for �Bigaaf *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.l c.�2 T (� Queer's Name,Ad ess an No. Assessor's Map/Parcel or"GI oct ^b2 Install s Name, ss,and Tel.No. Desig e,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re ai lteratio (Answer when applicable) �T�V '����C�C\V y Y. (no Y 9 �S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is . ed b th . Signed Datelf )17[(ZA Application Approved by o Date —/7 Application Disapproved for the following reasons Permit No. ' 7 7 Z Date Issued I/— /7- --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TI n-site Sewage Dis al System Constructed( )Repaired( !/ Upgraded( ) Abandoned at p L\ has been constructed in acco dance with the pr s of T' the for Disposal System C nstruction Permit No. � —7 7 Z dated /`/7— Installer 'd� \ Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. �g �, • ." .. .rev, �,.�' . / ` - 44 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: k `� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpprication for Migpogal *pgtem Con.5truction Permit a Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ElComplete System ❑Individual Components Location Address or Lot No.2�p2 C Lt O er's Name,Ad ress an No. ' Assessor's Map/Pcel1 — Installer's �— �� Name.Ad4ess,and Tel.No. esgnei,s�e,Address and Tel.No. z.- <�-r k- 2> TT �� i Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) " Other Type of Building No. of Persons Showers( ) Cafeteria( ) " Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date j Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re air Alteratio s(Answe when applicable) �� �C�C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed 4 t Signed Date l l 4 719A, Application Approved by Date --f 7- 9 Application Disapproved for the following reasons Permit No. `,' , ` 7 7 2 Date IssuedTHE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS T TIFYrtha n-site Sewage Disp sal System Constructed( )Repaired ( V/ Upgraded( ) Abandoned atI has been constructed in accordance with the pr s of Tide 5 odthe for Disposal System Construction Permit No. datedInstaller Designer Designer r, The issuance of this permit shalltnot be construed as a guarantee that the system will function'as"designe& Date i i f ;'I Inspector 4+,, ,c f — ------------------------------- No. / / _ 77 2- Fee THE COMMONWEALTH OF MASSACHUSETTS S`T� PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwi!5paaf *p5tem Construction Permit Permission is hereby granted to Construct( )Repair Upgrade( ) ndon,�_) System located at 2CODL CF—C U and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this t. r Q Date: Approved by '• 1i6i99 I Y NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIF'ICA17ON OF SKETCH AND A2PLICATION FORA DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) he:e' oy c..e for that the application nor disposal works construaion permi sued by me dated 7 concerning the property located meets all of the following cite:ia: • T'he failed system is canneo;ed to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • I ne soil is classified as CLASS 1 and the;ercclatilon rate is Less than or equal to 5 minutes per inch. • There are no wetlands within 100 fee;of the proposed septic system • There are no private wells within 1f0 re--,or the proposed septic sysem • There is no incea_se in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility 111 not be located less than five Eee;above the ma dmum adjusted goundwater table elevation. [Adjust the g-oundwater table using the Frimpior meahod when applicable] v • If the S.A.S. will be located with_f0 fee;of am vegetated wetlands. the bottom of the oroposed (enticing facility-will not be lccated less than °eureen(1:) jet, above the maximum s adiued groundwater table -!evaLcri , Please complete the following: A) Top of Ground Borate =!e•�ation(using cis intomiation) V B) G.1Y. E!eva6on7 the �La�C. ugh G.W. a•djustmeat D TTEREv CE E a.and 3 Lf SiG FED : Da.i (Sketch oropcsed plan of system on bac' 1. a:.,caich 60idcr.-c r 1 x f TOWN OF BARNS11TABLE LOCATION 0 '� �_c1 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. -5L,QA V« "7767,Qcicc, SEPTIC TANK CAPACITY C)Lt.CF' [M DRo X LEACHING FACILITY: (type) Cb'� +(`$ CJn (size) ck NO. OF BEDROOMS-9 BUILDER OR OWNER Ste. �C"d - PERMTTDATE: w' — d l COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) /VUAR, Feet Edge of Wetland and Leaching Facility(If any wetlands exist A � within 300 feet of leaching facility) /Ud/v, Feet Furnished by 'i i. -,LOC,ATION L SEWAGE PERMIT NO. ��- �',� �� -5 79 VILLAGE C } INSTALLER'S NAME i ADDRESS TT 11UILDER OR OWN- DATE PERMIT ISSUED DATE COMPLIANCE ISSUED G ��' I1 2�� �i 3Y� �a ; a 5 �� ;. �� � /� A No . .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................................OF.......................................................................................... Appliratilon for Disposal Works Tonstrur ion 1hrmit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Syst .. ta- Ilk— l.L®. .. .: �'1--.. ... ­--------- ------- .................. --------------------*-------------- ------------------ ------ J OL e r Lot No. ...............0.... 7.. -��ner_ ...... ------------------------r dress .s........................................... ................................................. ..........Ce'd ............................................... Installer Address Type of Building Size Lot............................Sq. feet u Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................ No.. of persons._.___.__._.____._.__._..__. Showers Cafeteria ( ) Otherfixtures ------------------------- ............................................................................................................................ Design Flow............................................gallons per person per day. Total daily flow...........................................gallons. 1:4 Septic Tank—Liquid capacity............gallons Length________________ Width_..__._._._..___ Diameter____________-___ Depth_____._.__.___._ Disposal Trench—No_ .................... Width____._.__.____._.___ Total Length._._..._____.__.____ Total leaching area....................sq. f t. Seepage Pit No_____________________ Diameter.__.._._.___.__..___ Depth below inlet_____._____.___.____ Total leaching area..................sq. f t. Z Other Distribution box Dosing tank Percolation Test Results Performed by-------------------------------------------------------------------------- Date.___._.._____________________.......__-. Test Pit No. 1................minutes per inch Depth of Test Pit______.___.__.._____ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit__-__......___.____. Depth to ground water.....-__.._.__.____.____ ............................................................................................................................................................. 0 Description of Soil.......................................................................................................................................................r............... x U ....................................................................................................................................................1.................................................... --------------------------------------------------------------------------- ......................................................................................... -- ------------------ Nature of Repairs or Alterations—Ans er when ap ............. . . ....... ............ ... . .In . . . ........................................................................................... Agreement: The undersigned agrees to install the aforede bed /ftdivid Sewage Dispos System in accordance with the provisions of THTTLE 5 of the State Sanitary e un siVjied fu ther a ees not to place the system in operation until a Certificate of Compliance has be ssue b the oa 1 Ith. Signed--- ... ............. ................ .................................. .......................... D t Application Approved By...... .. ... ... . . .. ......................... . A/*1------------ Date Application Disapproved for the following reasons:................................................................................................................ ...................I.....................................................................................I............................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair ( V/) an Individual Sewage Disposal S S, FIN r 0 1 //c- .. ........zl�...... ........... .......................... -- ----......................------------------------------------................................ or Ibt No. Installer , Address � Type of Size Lot feet � � Garbage Grinder ( ) Other—Type of Building ............................ No. cfperaone----------' Showers ( ) -- Cafeteria ( ) Other fixtures ......................................................Design Flow............................................gallons per person per day. Total daily flow............................................ . Septic Tank—Liquid ............gallons Length................ Width.............. Diameter---------------- Depth................ Disposal Trench--No -------------------- Total Total ft. � Seepage Pit BJu------- Diaooctcr'-.--._'' Depth b6mv inlet.................... Total leaching area..................sq. ft. Z (}tbcr Distribution box ( ) Dosing tank ( ) � ~~ Percolation Test Results Performed by.......................................................................... Date.----------------_- Tcut Pit No. L----.--'oioutcaperinob Depth of Test Pit.................... Depth to ground water........................ [� Test Pb No. 2...............minutes per inch Depth of Test Pit--.--.----- Depth to ocouo6 water........................ '- -..--_-------'-_._--'---_--_-____--'-------'-'-------------------_--'---.. � 0 Description of Soil ---`-----''----------------------'-`-----------``-`-----`-----`-`-----`------`----`--- The undersigned agrees to install the aforedescarbed I 'dividt/l Sewage Disposa System in accordance with the provisions of'TTIE 5 of the State Sanitary Co e und red fu Aher ag ees not to place the system in operation until a Certificate of Compliance has beeri issued�by the 16oajX.( 71 lt h. Signed....1.1aX ......;ATZ .......... ............ ................ Date ---' —'-------- . Date � Permit � Date � | - THE COMMONWEALTH oF MAssAcHussrrs BOARD OF HEALTH ' - �F---+r�.�=��----- . . .............................................. 0 ��� ���ux���u�� �u Toutplimnu THIS IS TO CERT 'FY, That the ndividual Sewage Disposal,System constructed or Repaired has been installed in accordance with the provisions of 9I Code as described in the application for Disposal Works Construction Permit No.-1--- ............. dutrd------'----_.----.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASAGUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- ........................'............. Y�/'/LJ�'/ ----- Io»pccbor------' ----'-----'_--_--'-_' | . ' THE COMMONWEALTH orMAsaxoHussrrs BOARD O LTH *���� �� --- � ---- -� -----��v-- ~" ' I�u FEE........................ Disposal Works T11notrurtion "trutit Permission is --_-.-.._--_---._------- to Construct ) or Repair | at No '''-'---'----'---'-''----'- Street uo shown uothe application for Disposal Works Construction ................. .......................................... . DATE................. � ponw /zss xoaos ' WARREN. /wc' PUBLISHERS � LOCAT ION � �� � I SEWAGE PE SIT N0. !d d VILLAGE �L2 I N S T A LLER'S NAME i ADDRESS rc� (76 2,1 9 l B U I L D E R OR OWNER 31, ' DATE PERMIT ISSUED _ 7y DAT E COMPLIANCE ISSUED ._� y �� 1'� ^, oti �-`� 7 �3 g � -- � � �� �6 .5 / � ,_,� lS _ a �� 79 73 No............. .... Fs THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ® 0 OF...., itJTiC .... .........Appliration for Uhip seal 3Vnrkii Tumuncnlan Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..............._._.. ..................... :._......._...---.......L 7— - - ..._..._..-..................................... --ocati Address --o: Iot No. .....-- �:' - �. - -- -------- ------ ..0 . Owner ' L ddress aw - ... .................................... Installer Address Type of Building Size Lot__o�__ ..Sq. feet U Dwelling—No. of Bedrooms.......4---___-••-----_----•••_______Expansion Attic ( ) Garbage Grinder (&)) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) w Other fres -----••••------•••---•••----••-- Design Flow____ '_____________________ _ gallons per person er day. Total dail flow____ W..................:........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 ( ) Dosin tank ) �t •---•--••----•---•----._. Date.--41117F`-' Percolation Test Results Performed by- . _. _. � :. :._._. _______________�, aTest Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water................... fT4 Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water......................... O — r' -;/ Description of Sop-----�-•--- - ----=---t� �------�-�-�---�e-e=-------------�----•---------•----- -�'-��.... 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'THE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b sued,by he board of health. Signed ................................. ... r/... ............ ,/. "'"``"'"IIIL_.._.`-�••-- ----,. X_ (/ Date Application Approved BY.....-- �� ------•--••---••-•------- ----------------------7 -?----------- Date Application Disapproved for the following reasons:................. -------•-----------•-•--------•---••-------------------•-----------------._....---•---- .................•---•--•:--.........-•-•--•••••----•••••-•._...--•-.........--••----------•-•-•--...•••-•••----•--•-----•-----•--------------•-•-•�•--------•`-------•-----••-•---••--•-•----_-••-•- Date Permit No......................................................... Issued..---_�.... -`•t---- 1...----.....--•-------- Date w, No...... 7_.5..... � Fxs....��........... THE COMMONWEALTH OF MASSACHUSETTS .-�- BOARD OF HEALTH .............................. OF. Applirtttion for Disposal Works Tonstra rtiun rumit Application is hereby made for a Permit to Construct ) or Repair ( } an Individual Sewage Disposal System at: i � ocati Address Uo Lot No. Owner ddress ........ :�-.��..----:vx.'.�...... ..:.. ----• �� ...... a................................................... Installer Address n/j_ ®y,� q Type of Building Size Lot.___... _ ____5 . feet U Dwelling No. of Bedrooms_____________________________ _____Ex Expansion Attic►-a g— -----••-- p ( ) Garbage Grinder (A.)o Other-Type of Building ____________________________ No, of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -----------------------------------------------------••••••••-•••••••••••--•••-•-•-----• ......... Design Flow.... `�......................... ....gallons per person Der day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity __gallons Length .•...••• Width.._` ___... Diameter..._..... Depth................ x Disposal Trench—No_____________________ Width__ ................ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.___I__________.... Diameter........ ........... Depth below inlet.......6......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosin 4tankPercolation Test Results Performed by- �/''. `.=••=". _�Sw---------------------------- Date__�� _ -1� ...-------......._. Test Pit No. I----------------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........................ O Description of Soil.....47••y Z t-��__�-��P• ...........................J � �.�..,...�`_.... 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:?TLu 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ssued by ,he board of health. Si . .................................. !/I__Date Application Approved BY ..: .Greet f r l� r ---------------- f Date Application Disapproved for the following reasons:................---------------------------•----------------------------•---------=.. •-•-••••...................................•••-•••-••-•••._...-----••••••--•--••••••-...•-•-••-•••-...--_.._.._.__...._....-•••••••--•-•••-••-•--•••••••••----•••••••••-•...--•••••--•••••••_.._.._----•- Date PermitNo......................................................... Issued_.........................................---•----•--•• Date - - a THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH d...4✓�k4...................OF.... L�! ..................................... . �rrtifirtt#.e ,af f�n�t��tttnrr THIS JOS TO CERTI&Y,That the Individual Sewage Disposal System constructed (j/ror Repaired ( ) bY............. 1� '. �" ... -': e •-- - --------------------------- ---- •-----._ at has been installed in accordance with the provisions of T_P 10 The State Sanitary Code as described in the application for Disposal Works Construction Permit No. _______.-�___________________ dated__.':_"_�..':_T_ _....._._...________. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. n 1.�.... ....................... DATE .. ... -------- THE COMMONWEALTH OF MASSACHUSETTS ``-- '' BOARD OF HEALTH !r.•1 'j^ ..............0F... No..................... .... FEE.. ,..��... Disposal nrk� aan tr rtiarn hermit Permission is hereby granted---- f7 .......---------•-�--'`--�_r&................................................................................. to Const.ruct (t1')Gor �}epair ( ) Indiv• -al Sewage Disposal Sp tem at No....�-0.- L.► 1 _iv.; ._ $✓ .t: - !' rv= } Street as shown on the application for Disposal Works Construction Peripst No ./__j.__�_�_r __�___ Dated__ _"_ ':___�'... ............... Board of Health DATE................................................................................ FORM 1255, HOBBS & WARREN, INC., PUBLISHERS _ _ 1 I ti F t maw 1 I `t'l*-1V I L)SC'_• L.. F e At P1T u5E IC, GAt....�,2� •+t, ..-;Uvx/ALL, AeE.A. = t5a 5.�. xZ- %3oG= tiR Ir� SF � �L.S + �"'tS C.�.P.D.tl=�(sue � � • "20 I f i r fob t .c� -' S(b ez :C 6}.�?D. .�„._•o + i / p r{ I 12 -i a't,&t_ '0 4.t t -( C-"1�w = 44o 6.F'D• �C� L+'\ = �cSdC.i>lflT1U�.! 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