HomeMy WebLinkAbout0142 GREELY AVENUE - Health 142 GREELY AVE.
Centerville
A=245 - 140 - 001
i
I
UPC 12534
No.2�OR
YAATIYAi.IIY
COMMONWEALTH OF MASSACHUSETTS �/P o?516-,
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS G
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
i
JUN 13 2001
TOWN OF BARNSTABLE
HEALTH CEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address• 142 Greeley Ave.
W u. �� 4,1" �Z—
Owner's Name: Nathan Braunstein
Owner's Address:
Date of Inspection: '
Name of Inspector:(please print) 1d111 i am R_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7 6
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 the inspection.The inspection was performed based on my
training and experience in the proper function an maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sec ' n 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: - 6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Hea&-cr
DEP)within 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
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 4 2 Greeley Ave.
W Hyannisport
Owner: Braunstein
Date of Inspection:
Inspection S mmary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the . for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
• Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION continued
Property Address: 1 4 2 Greeley Ave,
W Hyann. - t
Owner: BraLn- Pi n
Date of Inspection: C —0— ® Z -
C. F er Evaluation is Required by the Board of Health:
Co ditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to rotect public health,safety or the environment.
1. Syst m will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
syst m is not functioning in a manner which will protect public health,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. Sy em will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the.public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
rface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
priv to water supply well**.Method used to determine distance
**T is system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bac ria and volatile organic compounds indicates that the well is free from pollution from that facility and
the resence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fa ure criteria are triggered.A copy of the analysis must be attached to this form.
3. Ot er:
3
Page 4 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address- 142 Greeley Ave
W Hyannisport
Owner: Braunstein
Date of Inspection: 6,"0 a /
D. System Failure Criteria applicable to all systems:.
You ust indicate"yes"or"no"to each of the following for all inspections:
Yes o
Backup of sewage into facility or system component due to 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
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ 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 wader
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Y No)The system fails. I have determined that one or more of the above failure criteria exist as
escribed in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
ealth to determine what will be necessary to correct the failure.
E. Large S stems:
To be consi ered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must' dicate either"yes"or"no"to each of the following:
(The folio ing criteria apply to large systems in addition to the criteria above)
yes no
th system is within 400 feet of a surface drinking water supply
the ystem is within 200 feet of a tributary.to a surface drinking water supply
the s stem is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zon I1 of a public water supply well .
If you have ans ered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Sectio D above the large system has failed.The owner or operator of any large system considered a
significant at under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The sy tem owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 142 Greeley Ave.
W Hyannisport
Owner: Braunstein
Date of Inspection: —D
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
T//Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
-" Have large volumes of water been introduced to the system recently or as part of this inspection?
-,4-1- Were as built plans of the system obtained and examined?(If they were not available note as N/A)
J— Was the facility or dwelling inspected for signs of sewage back up?.
.✓ Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of l 1
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 142 Greeley Ave.
W H annis ort
V P
Owner: Braunstein
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents: A,
Does residence have a garbage der(yes or no):46
Is laundry on a separate sewage system(yes or no): ,!feD[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): i
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 0 1 21 .0 0 0 gal.
Sump pump(yes or no): A-,d 1999 530,000 gal.
Last date of occupancy:
COMMERC L/INDUSTRIAL
Type of establ' hment:
Design flow ased on 310 CMR 15.203): gpd
Basis of desi flow(seats/persons/sgft,etc.):
Grease trap resent(yes or no):
Industrial w ste holding tank present(yes or no):
Non-sani waste discharged to the Title 5 system(yes or no):_
Water met r readings,if available:
Last date f occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Wass stem pumped as art of the inspection(yes or no):,,Y P P P P Y
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP 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)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installe if own)and so ce of information:
Were sewage odors detected when arriving at the site(yes or no):�'✓d
6
f
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 142 Greeley Ave.
W Hyannisport
Owner: Braunstein
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ate on site plan)
Depth below grade:�_
Material of construction: oncrete_metal_fiberglass polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: L
Scum thickness: y —
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom o outlet tee Ur baffle: P
How were dimensions determined: 6 ) -�a4
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): G
IV
GR SE TRAP:_(locate on site plan)
Depth elow grade:
Materi 1 of construction:_concrete_metal_fiberglass polyethylene_other
(expla' ):
Dimen ions:
Scum ickness:
Distan a from top of scum to top of outlet tee or baffle:
Dicta a from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Comm nts(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as relat d to outlet invert,evidence of leakage,etc.):
7
I
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 142 Greeley Ave.
yannispor
Owner: Braunstein
Date of Inspection: d 1
TI HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materi 1 of construction: concrete metal fiberglass_polyethylene other(explain):
Dimen ions:
Capaci gallons
Design low: gallons/day
Alarm esent(yes or no):
Alarm I vel: Alarm in working order(yes or no):
Date of ast pumping:
Comm nts(condition of alarm and float switches,etc.):
DIST BUTION BOX: (if present must be opened)(locate on site plan)
Depth o liquid level above outlet invert:
Comme is(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage i to or out of box,etc.):
PUMP MBER: (locate on site plan)
Pumps in orking order(yes or no):
Alarms in orking order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9ofll
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 142 Greeley Ave.
W Hyannisport
Owner: Braunstein
Date of Inspection: 6 — G J
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Typeleaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CES OOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number nd configuration:
Depth—t of liquid to inlet invert:
Depth of s lids layer:
Depth of s m layer:
Dimension of cesspool:
Materials o construction:
Indication c f groundwater inflow(yes or no):
Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Material of construction:
Dimens' ns:
Depth solids:
Comme is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 142 Greeley Ave.
yannisport
Owner: raunstein
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Loc to all wells within 100 feet.Locate where public water supply enters the building.
A "
1 � el
a
10
Page 11 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 142 Greeley Ave.
W Hyannisport
Owner. Braunstein
Date of Inspection: ,r—/-mod
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water�—feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
"served site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must desc 'be how you established the high ground water elevation:
y 9 Gl
11
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TOWN OF BARNSTABLE
LOCATION /' Ari�',eellexl / e SEWAGE # r
VILLAGE ASSESSOR'SIP & LOT,/
INSTALLER'S NAME & PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)_ Z&g Z / ma`s' (Size)
NO. OF BEDROOMS PRIVATE WELL OR PUBICWATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ��-. 4.
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LOCATION SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME 6 ADDRESS _
BUILDER OR OWNER
/YO1?/2 d4 o 2r�� Y
DATE PERMIT ISSUED /0 -Z7 -��
DATE COMPLIANCE ISSUED ?_ �
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No.._.. .�_-_-6Z1 �"ILE GUNSCR!/ATjC,!
THE COMMONWEALTH OF MA 'SACF J ZTT �• tj
BOAR® OF HEALTH
row.,00................oF.................I/ 47 9.H.4n.e.'....----------
Applira#iun for Uiipuial Works Tunitrnr#iun 1hrmit
Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
--•-•-............................... .. ........-----------..........---•--... .........................................
--_..
Location-Address or Lot No. (/�
•---......,ft Jf?�- j(-T .....��..®. re ................ 4. ... l . :..............__....
wner u Address
--------------•- --
Installer Address
Type of Building Size Lot.... ....r--- -.Sq. feet
V Dwelling—No. of Bedrooms............... Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ------------------------- ------ .
Design Flow......__.._ p p y.
W .....................gallons per person r day. Total dall flow__-------_33-6-----_ --------_--_gallons.
W Septic Tank—Liquid capacity/ OLgallons Length----- ........ Width............... Diameter................ Depth...... ...
i..--
x Disposal Trench—No. .................... Width.................... Total Length---------- ___ Total leaching area....................sq. ft.
Seepage Pit No---------/jt.47 Diameter--__,/.Q- -- Depth below inlet__..-X>, y��_ Total leaching area...ZDo...sq. ft.
Z Other Distribution box ( ) Dosing tank
`-' Percolation Test Results Performed by.___.6_EC3 --GC_--LOW-•--- _ C® . Date.__/� ... p----.
Test Pit No. 1_�1_...:; _..minutes per inch Depth of Test Pit._f.g...... Depth to ground wat
f=, AI
Test Pit No. 2!.Z.._..minutes per inch Depth of Test Pit... . ....... Depth to ground water.................
p4 ......................................................... ------•------•-----.......-•----.....--- •--••-----•---•--...---------------------------.......
O Description of Soil..tZ.... ��...- _ .N f��!L.... �awl3So/L------18 c, - �� 1 L-J•-•-`S�IvD
v - z ° c ----------------------------
W ---------------------------------------------------------------------------------------------------------------------------------------------------------- .........................................
U Nature of Repairs or Alterations—Answer when applicable....................................................................................._..........
----------------------------•-------•----------------------•-------------------------.............--------------•---------------•----•-----•-•---...-------•--------•------•----•---•---.._.......------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:iTL:,
p 5 of the State Sa ry Code—The undersi n furtl agrees not to place the syste in
operation until a Certificate of Compliance has b n issued by bo -d f 1
Ig d _ /d ?7
y� Date
Application Approved By._ . - ....... ............. -
Date
Application Disapproved for the following reasons:.................................................................................................................
--------------------------------------•------•-.....-----•-•---------•-•---•--------.........-----------------------•-•----•....----•------------•-------•-----------•----••---------•--•------._...----
,�� Date
PermitNo......................................................... Issued....Y�-_ _- � _!._.... --.._..._..
Date
i
17
No.--- F:zs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOA RD.,,OF HEALTH *4 44 - �r 9; $'y' At
/.. e.j .............._OF.................l�rL�:�-�7 i`�2��; ..............
C
Apptiration for Uiipnsal Workfi Tonstrurtinn Vamit
Applicat on is hereby made for a Permit to Construct (x) or Repair ( ) an Individual Sewage Disposal
System at:
C-u—y— /
Location-Address _ or Lot No.
caner Address
w Gz /_q/J ls���? T
a -`............................... ................... ... ...:..___________.....
Installer Address
Type of Building Size Lot...T _._ '� _Sq. feet
U
Dwelling—No. of Bedrooms_______________�__.__._.________________Expansion Attic ( ) '<.Garbage Grinder ( )
pa-, Other—Type of Building ............................ No. of persons................_----------- Showers ( `)__ Cafeteria ( )
P4 Other fixtures C11 ............................ .
= ------ -- -------
W Design Flow......__.._S .......................gallons per person er day. Total daily flow..........-7 3.0._........_.._.___:gallons.
WSeptic Tank—Liquid capacitv/bUG..gallons Length____ _-___-_- Width-___1�c_-___- Diameter_______________ Depth...... _......
x Disposal Trench—No..................... Width.................... Total Length..............;,,-... Total leaching area._:____--__-_---____sq. ft.
T Z Diameter.... ._0__-_ _- Depth below inlet._,-4 �._ Total leaching'.area.. ZC�p s ft.
� Seepage Pit ?�o.--------�-� -� - -- P g;. -------• •-- q•
Z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by..... �?l1_! .................. GO , Date_.: �,,1... �_---- -_-_..
aG
Test Pit No. 1 C..._.-----minutes per inch Depth of Test Pit./4 ........ Depth to ground wate ________�>GT
44 Test Pit No. 2 !_.Z..___minutes per inch Depth of Test Pit---/_44.____.. Depth to ground water4ti4x�g
Ix ...--•-----------------------•--•---•--......_ ..._-----.....................................
D D�esscription of Soll � �'- ---l 7 ..............................................
.=`-��12i.•---�
V .......................................................... ..' G v.7 -- `..uf3S D/L `IL r �4�� '`Z�� •---- ..........`tt-),1--- •--------_--------
W Z
UNature of Repairs or Alterations—Answer when applicable._____...........................:................................... .........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Se age Disposal System in accordance with
the provisions f-1T of 1'1 i ,' .,^.
5 of the State San Code—The undersi e furtl: agrees not to place th syste in
operation until a Certificate of Compliance has be issued by t oa h tAV
C�
y� Date
Application Approved BY- ---- t9'n+l� �.-war! .......
ae 'a �t.
Application Disapproved for the following reasons: ---------- --------------------------------------------- ------t,
*i_
_________________________________________________________________________________________________________.__..____.__.__.__________________i_._._______.._______
-------------
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1_......................OF... ...........................................
T tifiratr of Tout rliatta
TH I T ER F at the naividual Sewage Disposal System constructed ) or Repaired ( )
by------ �jl - '""------------------------
Installer
at--- r......... - ............ ;
......................-..............................................
has been installed in accordance wiveltie provisions of TI T iE 5 oState Sanitary Code as described in the
application for Disposal Works Construction Permit N _C3"_______________________________ da.ted_.--------_---_______----__.___.___-_-_-____---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM W L FUNCTION SATISFACTORY.
JDATI....'.... ..`.:...`�:Z.-_Q�__�-------------•------•---•---------•-•---- Inspector_.. --•----- -- -----f-----------------------••--•----.._..:...-•---------
THE COMMONWEALTH OF MASSACHUSETTS
i
BOARD OF HEALTH
w...........:.... .....®��,X � - ......................................... F ......
��...
ivr �t >ar n rrmit
Permission is hereby granted------ . __
--•- . --._... ......................................................
to Construcr ('°- ) dr Repair ( ) an Individua"1 Sewage Disposal System' -
as shown on the application for Disposal Works Construe Permit N ...... Dated... `��--�"
PP P .. �-� ='
- s �,nysE fsFr 'Bo/,0e th ----------
.e
DATE �,/ 7/ L�-----------------------
FORM 1255 HOSES & WARREN. INC., PUBLISHERS
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