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HomeMy WebLinkAbout0017 HADRADA LANE - Health 17 HADRADA LANE,CENTERVILLE � i A= 148110 - I SIIII �QECvCIFOCO J tip, _2 IIII � UPC '12543 No. 553_LOR co HASTINGS, MN ..e.._e......�...�....._. .--._ .._. -='---"---- •.-•`.ae�...__.�,,.-........�...,,..._u........��....�._..,::.s��..a:�..,, .....,.�._,..:.a.... ._._. ....- ...y.r...x-c.aor.�,.,.. - — - _ - -- .�.._ ..v_Y..__ •- TOWN OF BARNSTABLE LOCATION e1 ® G`e L-Nj SEWAGE # VILLAGE �CU�-�°.������ ASSESSOR'S MAP& LOT L6 O i 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACMI TY: (type) (size) �� 100(D$^ NO.OF BEDROOMS BUILDER OR OWNER I)tAtiv a a PFAVoWDATE: Wi!058-COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and a Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) V�411 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) . ��� Feet Furnished by 1� A-1 e 3r° ►► �I� � lt3- 3(o Lkl -s�` - Lls' CO.INIONWEALTH OF MASSACHUSETTS i- EXECUTIVE OFFICE OF FINNIRONME\TAL AFFAIRS � DEPARTMENT OF E:��-IRONME\TAL PROTE 12 ONE WINTER STREET. BOSTON. MA 02106 617-29:-54(10 1. UILLIAM F.WELD 0 JUL 1 1998TR o Govt:rnc _• . ... . :rc ARGEO PAUL CELLL'CCI fA AV L' LL Gompor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO� 41 missio PART A 'CERTIFICATION Property Address; tit c� Q�N ��-"1 - 'rc-L%'L 1 Address of Owner: Cq Date of Inspection: < <l �.' pf different) Name of Inspector: 0 I �e am a DEP ap roved system inspector pursuant to Section 13.340 of Title S 010 CMR 13.000) Company Name:f}/ o yr r'c Ear A-,-r+",h we P Mailing Address: 2 ep /;cnx F_37�p!�t H I-© E-C4-q Telephone Number: rsG2-7 �i=4 4& o CERTIFICATION STATEME\T I ce.^.ifi that I have pe+sonally inspected the sewage disposal system at this address and tha: the information reported be!o% is true, accurate and como!ete as o'the time of inspee,ton. The )nspect.on was performed bases on m, training ant. experience to the proper..function and maintenance o on-site sewage disposa: systems. The cvsterm Passes ConerttonaiN Passes 1eec: Furthe- Evaluation 5%• the Local :approving Authont% Inspector's Signature: 1 1 \I Date: c, l T,,e Svs-e^ tnsaecto• sha!' submu a coPy of this inspection reoor, to the Approving Authority within thirty (30) days of completing this inspection. If the s\•stem Is a shared system o• has a design flow of 10.000 gx or greater, the Inspector and the system owner shall submit the repo-, to the appropriate regional office of the Deparment of Env)ronmenta' Protection. The orig:na! should be sent to the system own and copies s-nt to the buyer, if applicable, and the approving authorim. INSPECfiO. SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: : I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.30: Any failure criteria not evaluated are indicated below. CO ENTS: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system, up completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y. N. or NDt. Describe basis of determination in all instances. If'not determined',explain why not. The septic tank is metal, unless the owner or operator has p.ovided 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: the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tat 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) Pace 1 cf 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addwss: Owner: Date of Inspection: - '- Bj SYSTEM CONDITIONALLY PASSES tcontinj°r- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken. settled or uneven distribution box. The system ill 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 broken or obstructed pipe(s)..The system will pass inspection if twith approval of the Board of Health): broken pipe!si are replaced obstruction. is removed C1 FURTHER S'ALUATION 15 REQUIRED BY THE BOARD OF HEAL H: +� Conditions exist which require further evaluation by the Board of Health in order to determine if the i}•stem is failing to protect th( public health. safe-,,- and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH ETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A D SAFETY AND THE ENVIRONMENT: Cesspool r n 'n r_ spoo o p �ti is within 50 tee, or� surface wale. Cesspool or privy is within 50 fee!j/a bordering vegetated wetland or a salt marsh. 2) SYSTEM KILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAI THE SYSTEM 15 FUNCTIONING IN A MANER THAT PROTECTS THE PUBLIC HEALTH AND SAFFE Y AND THE ENVIRONMENT: ` The system has a septic tan and soil absorption system (SAS) and the SAS is within 100 fee, to a surface water supply ar tributary to a surface wate supply. The system has a septic Ink and soil absorption system and the SAS is within a Zone I of a public water supniy well. The system has a septa tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a sep c tank and soil absorption system and the SAS is less thar. 100 fee! but 50 feet or more from a private water supply well. unless a we![ water analysis for eoliform bacteria and volatile organic compounds indicates tha the well is free fro 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_o(approximation not valid). 3) _.OTHER (revised 0 .25/3') page 2 of 10 SU-SSURFACE SEWAGE DISPERSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Addross: Owner: % Date of Inspection: D) SYSTEM FAILS: You must indicate either `Yes` or '►vo as to each of the following: I have determined that the system violates one or more of the following failure criteria as def ed in 310 CMR 15.303. The bans for this determination is identified below. The Board of Health should be contacted to det mine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded r clogged SA5 or cesspool. Discharge or ponding of effluent to the surface of the ground or surface aters due to an overloaded or clogged SAS or cesspool. Sta:ic howd levei in the distribition bot. above outlet invert due to n overloaded or clogged 56,5 or cesspool Ltauid depth in cesspool is less than 6- below invert or availabl volume is less than 1/2 day fiov. _ Recuired pumping more thar. 4 times in the last year NOT d e to clogged or obstructer pipes . Number o-*times pumped _. Any portion of the Soil Absorption Svstern, cesspool or rrv,)• is below the high groundw2te• eievatio- Ar.*, por.:on o,a cesspool or privy is withir. 100 feet of a surface water supoly or tributar to a surface v.ater suppi� Any potion of a cesspoo' or prt%-%• is %ithin a Zo e I of a public well. Am pc^to- o a cesspool or priv%. is within 5 feet of a private water supply well Am• por,.or. of a cesspool or privy is less t an 100 feet but greater than 50 feet from a private water supoly well with no acceo:able vate• qualtt, anah•sis. h the -ell has boon analyzed to be acceotabie. anach copv of well water analysis for cohiorm bacteria volatile organic eoim unds, ammonia nitrogen and nitrate nitrogen. E) URGE SYSTEM FAIL5: You must indicate either -Yes- or 'No- as to each the following. The ioliow:ng criteria app;% to large syst s in addition to the criteria above: The s%•stem serves a facilin *with a de ign flow of 10,000 gpd or greater (Large System; and the s%,stem is a significant threat to public health and saier� and the en ronment because one or more of the following conditions exist. Yes No . the system is within 00 feet of a surface drinking water supply the system is with' 200 feet of a tributary to a surface drinking water supply the system is I ted in a nitrogen sensitive area (interim Wellhead Protection Area - IWPA) or a mapped Zone 11-of a public water s pply well) The owner or operator of any uch system shall bring the system and facility into full compliance with the groundwatec,treatment_program - requirements-of 31, Cn1R.3. and 6.00. Please consult the local regional office of(he Department forluriher.Jnicr=tatlt_tL_-- (r■vliad SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 11 r pm-j Y�' Owner: I Date of n n: Check if the following f ll w have been done: You must indicate either 'Yes' or 'No' as to each of the following: g e Yes No Pumping information was provided by the owner, occupant, or Board of Health. x _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. As built plans have been cmained and e\a.r.fined. Note if they are not available with WA. The farli� or dwelling was inspected for signs of sewage back-up. _ Tne syste-n does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All sv tem- components. excludine the Sail .Absorption System, have been located on the site. 1 _ The septic tank manhoies were uncovered. opener'. and the interior of the septic tank was inspected for condition of baffies or tees. materia'. o'construction. dimensions, deptn of liquid, depth of sludge. depth of scum. 1, The size and location of the Soil Absorption System on the site has been determined based on The facdat\ o%%ne• .ano occupants. if difterem from ow•neri were provided with information on the prope• maintenance of Sub-Surface Disposal Svsterr.. _ Existing information. Ex Plan at 8.0 H. _ Determined in the field n;am of the failure criteria related to Part C is at issue, approximation of distance is unacceptable (13.302:3iti! SUBSURFACE SEWAGE DISPOSAL SYSTEM I.NSPECTIO\ FORtit PART C SYSTEM INFORMATION Propem Address: .�Q14Elr� Owner: >� Date of Ihspection: � t a , FLOW CONDITIONS RESIDENTIAL: Design ilo., . 6 o_`.�d.lbedroom for S.A,.S Number Of bedrooms ' •2 N Number o:'current residents--cj Garbage g•.:der (yes or not:_JL-.1 Laundry co-•^ected to system (yes or no! Seasonal use Ives or nor:_ Water meter readings. ii available (last two i'11 year usage tgpdt: �'�w : ALN-.r= � Sump Pump (yes or nor_ Lac da:e o°occupanc-,. �+ l COMMERC i*4L'1NDL'STRIAL: Type of establishment Design fio%% eahonsida-, Grease trap present cues or no_ Industrial Taste Holding Tani; oresent. -ves or no ',on•sanita-% %aste discnarger to the T:tie 5 wstem Ives or no_ %dater meter readings if availabie Las:paae o; a c:.:,anC% OTHER: .Z)e;cribe last date of occuoanc. GENERAL INFORMATION PUMPING RECORDS an source of iniorma ior. System pu ped as par, of inspection. Ives or no.-LQ-0 If yes, volume pumped. gallons Reason for pumping TYPE OF SYSTEM Septic tank/distribution box./soil absorption system Single cesspool Overflow cesspool Prnj- Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other - --- APPROXIMATE AGE of all components. date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or no)�a� ray. s as io SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTE..M INFORMATION (continued) Property Address: Owner: S Date of Impection: i BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction. _cast iron _ 40 PVC _other (explain: Distance from private water supply well or suction 1i-i Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK:jx� (locate on site p an Depth below grade-- Material of construaio^• Aconcre:e —me-.a _Fioerglass _Polyethvlene _othertexplain If can's is meta:. Its:ate _ Is age confirmec o,. Ce-.fica:e o: Comptiance _wee.%-I o Dimensions lU00-) A- Sludge depth- 2 N it Dtsiance from top o: s uoee to borom of ou:;e: tee o, ba-:;e 9 Scum thickness- (!-> t . Distance from top o: scum to top o'outle: tee or ba=-e Distance from bosom of scum to bono o;outle: tee c• bar..e I L! How dimensions were determined _L o-cu Comments trecommendation for pumping. condition of miet nd�outlei tees or baffles. depth of liquid level in relation to outlet invert. sir aural in egriry, evidence of leakage. e:c.t ? Q GREASE TRAP:-) (locate on site plan! Depth below grade: Material of construction. _concrete _metal Fiberglass _Polyethylene _other(explain) Dimensions: - Scum thickness: - - - - Distance from top of scum to top of outlet tee or baffle. Distance from bosom of scum to bosom of outlet tee or baffle: _.. ._ Date of last pumping: _ Comments: ---1recommendatton for pumping.-condition+ of inlet and outlet tees or baffles. depth of liquid level in relation-te-outlet4nvert-struaur-al-- mtegrity, evidence of leakage. etc., - — f SL.'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNt_, PART C SYSTEM INFORMATION' (conti/insp-ectinj Propert% Address: OM ner: Date of Inspection- TIGHT OR HOLDING TANK: --Tank must be pumped prior to, or at time, of(locate on site plan, Depth below grade.Material of construction _concrete _metal _Fiberglass _Polyethylene _othe Dimensions: Capacity-_ galions Design flo-A gallons.da. Alarm level Alarm in %korking orde• _Yes. _ No Date of previous pumping Comments (condition of inlet tee. condition o' a!a,rr. and float switches, etc.t DISTRIBUTION BOX:_ (locate on site p an De:!?h o' Iiouid leve! aoove outlet sn%e^ Comments mote :f leve! and d:strib_t,or is eaua' evidence of solids carrl•over, evidence of leakage into or out of box. etc.t PUMP CHAMBER:_ (locate on site plan. Pumps in working order: (Yes or No Alarms in working order (Yes or No•—L_ Comments: (note condition of pump chamber, c�ndttion of pumps and appurtenances, etc.) SUBSURFACE WAAGE DISPOSAL SYSTEM INSPECTION FORtit PART C SYSTEM INFORMATION (continued) Property �cldr-ss: t par Owner: Date of Inspection SOIL ABSORPTION SYSTEM (SAS):Aa:5 (locate on stte.plan. if possible: exca%atton not required, but may be approximated by non-intrusive methodsi If not determined to be present, explain: Type: leaching pits. number._ leaching chambers, number: leaching galleries, number. leaching trenches. number,length: .leaching fields, numbe+, d,^+enston.: overflow cesspool, number Alternative s%-stem Name of Tecnno(og%- Comments mote condition of soli s:grs of h.d ,,)ic failure, lee' of pond condition or ve attoletc.t I-A Or CESSPOOLS: '1�1 (locate on site plan. Numbe• and conftgura:,or•. Deoth-top of liquid to inlet Inver, Depth of solids lave-- Depth of scum layer Dimensions or cesspoo: Materials of constructor Indication of groundw•ate- inflow• tcesspool must oe pumpeC as par, of inspection Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plans Materials of construction: Dimensions: Depth of solids: _ _. .... Comments --- (note condition of soil, signs of hydraulic failure, level of ponding• condition of vegetation, etc.)": ` - :.. tr.v3,..d o.;2s/9') raye a of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C `-� SYSTEM INFORMATION (continued) Proper4. Address: Owner:: Date of In,pection:/ SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reierences landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ce ) M y 1JJJ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C + _ ` SYSTEM INFORMATION (continued) Proper ddress Owner: " Date of Inspect(on C t Q 1 Depth to Groundwater%l.UFeet Please indicate all the methods used to determine High Groundwater Elevation: . Obtained from Design Plans on record Observation of Site (Abuning property, observation hole, basement sump etc.) Determine It from local conditions Cneck with loca! Board o• neaa! Che6 FENAA Maps Check pumping records Check local excavato•s installers l•se L SCS Data r• a PDesciibe in voi, ow-. %.oros r.o•.% �o:: es:abhshed the 6iieh Groundwater Elevation. (Must be completed: -Yo Cocv L'4—Q S-�" k+1 CA r� C C, 't,'I I uemq*�C06 � � L (rev-hod .�;25'9-. Pay. 20 of 10 4<1 LOC_ MVO-N zcs - � i4g, Ito W-5=T-Q.l_l_E-R-S-IJ-�tJIE- -A 44 - - - -U I.L-D E-R-S-tJ��tvl-E- DQ�TE PERM T 1.551JED = 451 � O AT_E-C.OK/_�.P_l._I_/�..t`I ., tee... � '� c z Q. .. . . �x� .. .. '� ... s _ �,+J... . _, f i .*�' - No._` °--.6... Fivic THE COMMONWEALTH OF MASSACHUSETTS BOA RD O �H EA _.........OF........ .......:..�! ............................ Appliratinn -fur Riip ntt1 Worku Cnnnntrnrtinn Vrrntit Application hereby made for a Permit to Construct ( or Repair ) an Individual Sewage Disposal System at: ----------------- -------------...----•••--- Lot K - or Location-Adss ------N--o-.------ Addle ----------------------------• ..................... --•-•- .• -•-•• ................................. Installer d Address UType of Building Size Lot..... j ___Sq. feet Dwelling—No. of Bedrooms...........3...........................Expansion Attic ( ) Garbage Grinder ( ) pi Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fi_ ires ------------------------------------------------------ W Design Flow.............Y 4)______-_____________--gallons per person per day. Total daily flow----------3.07-V...................gallons. WSeptic Tank—Liquid capaci allons Length................ Width..._.__..--._.. Diameter................ Depth---------------- Disposal Disposal Trench—No. ------- dtl •- -----•••------- Total ngth- ------ ----- - tal aching area----�_d,f`..sq. ft. Seepage Pit No............ pi * 3 �_ g t 1.e _ -__ -___ eachin trect------------------sc 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.--.---..-.--._---.--_- �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_---.-..-_-_--_-_-----. --- -- ------------- •--•------ ................................................................................................................. O Description of Soil------------------._ ....................... -----•---•--------•-•--•-•-------•----••-•---------•-------------•----------- V ••••---•-•--------------------------------•-•-•--•• ......................................./----------------------------------------------------------------------------------------------------- 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 Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board 9f2health. tgned- 1 ............ .... ................................ Date Application Approved BY f' � " -TJ Date Application Disapproved for the.following reasons-------------------------------------------------------------------------------------------- --_---------- --------------•-•-•-------------•----••----------------------•-•-•-------•------•---•-----_______----------------••-------------------••------•----•-----------------------------------•--•------------- Date PermitNo......................................................... Issued__ .�-- . Date 16 No.__ .7-G .. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEAL H X�. - ..------.OF......... .......... F.. Applirtttiuu -fur Uhipuottl i9orkii C omuurtiv Vrruiit Application • hereby made for a Permit to Construct ( or Repair )"an Individual Sewage Disposal System at: *t - ---------------------------- ------- f---- ---•----- ....e Location.Ad ess / . or Lot No. ddres Installer Address UType of Building Size Lot...../..C.U ..Sq. feet Dwelling—No. of Bedrooms------------=�--______------.-_.--.---_-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons-.-._-_-."----_-_--_------__ Showers ( ) — Cafeteria ( ) 0.1 Other fi_ res ---------- ---------------------------------- W Design Flow-------------- a.....................gallons per person per day. Total daily flow----------- �--------------------- WSeptic Tank—Liquid capacity/ �allons Length---------------- Width................ Diameter---------------- Depth.._.....-...... xDisposal Trench—No. .................... Width ._ _-----_---_ Total ngth-.-......__��n_..... 6tall aching area.....1��-.�---_:sq. ft. Seepage Pit No.. // � e th�e _ i�leachin trey sc ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.------------------------------------------------------------------------- Date---.-.---__--------_---_---.------------ ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water...--_---------..-.----- �Zq Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ -------------------------•--•-•-----------------------•-----•----•-----------------------------•-•-•----------•-----•---- G Description of Soil. " U ............................•---------'-'..._...........-----------------._.......•...__..______r-...- --.....------•---•-•-•-•-------.............__.----•------------•......--•-------'-•---•'-'-' W UNature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ----------------------------- ---------------------•-- --------•-----------•----------•---------------------••----------------------------------------------•--------------- -------•----•-----•--•----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board o ealth. gned- -.-•------ -------------•- ---------------------------•.. Date Application Approved BY f �✓ ••---- ---- -` "'.----------- Date Application Disapproved for the following reasons---------------------------------------------------------------------------•-•--_--_----------------------------- --•-------------------•------•-•--•••----------------------------•--------------•----------•-----------------------•------------------------------------------------------------•---•------------------- i Date PermitNo----------------------------- ........................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS ./ BOARD F HE LT ..................................OF..... .......................................................... rrtifiratr of 04implittatre THIS IS TO R.TP Y , _.l e I dividual Sewa e Di�, �e constructed ( ) or Repairedby..--••---------•------ • -----. ' ------- i'7 nstaller at.......................... ------------------ - -------- ----------------------------------- ------------------- has been installed in accordance with the provisions of . It MXLI he State Sanitary Code as described in the application P fir/ 7j ." a lication for Disposal Works Construction Permit No._._ _______________ dated.... -_�_ -/dl'_-.-�..�__.____. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE- '---------=-------- Inspector.................................................................................... THE COMMONWEALTH OF MASSA�HU E'rTS ���� BOARD/0� /c/ ---''r— t✓ � No. --------- FEE........................ Permission er by anted------- ` ••------ to Construct ( )3 air/(7) an �'i sett i � g�Dis,p sWA_, em atNo......................................................................................................... Street as shown on the application for Disposal Works Construction P it N __ ______ ___ ____ Dated.../_X_"/© ........._........ � Board of Health DATE.......... -•------------------=----------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS z.r + o 8'. Y yq Iev FOVAIDATi0R/ M1 R r9 •.t s• ��� �.��v ✓sr�^ � l��CD �C /�f, NV'i�"I Wa'�r/ .W'A.+N �i� _ apt � .l.k i. �)�� k.n A T � t • 4 4::'--A✓7-4eA'✓i4G /!/lA:v; /7 �� A.t DO®.� 28/� .=/T N//7"�/f'' D.�' �: 14 t �. Kv `� �' '.�" i�✓�i�e®ti' c�.�T/FY �a,��T THE ®visa/�vCr' .OA/ OAV 7,WC G�s1/' :lN©WN MF?�J'QGeV Gi.vd� 7"NgT /T l)� 41 �:�1 „{ 'Y"0 L�4P/✓$ OG T<•dE 7Z,�OWiV OF il�A,e t/ST�9�3L/ �v e CJCTjt E y � �'`;+ civic. e,v4i,vEE.�s _ _ •�. j ���O � `'�'. G A,v a sC�ev6�ro.es /�/ZS�S 1 a LY. +.�?OC1TE 6A^-`,�•JeMOUT/-ems MASS. DATE a �._ +�;' � x�/���Y�'� � � �. LOCQTIO, 5EW&6-4E PERMIT MO., VILLAGE IMSTQLLER S U&ME DD ESS BUILDER 5 Q 1 AF— AD RE SS Dts,TE PERN VT 155UED DATE COMPLI &I ACE ISSUED ; 1 . Ll }