HomeMy WebLinkAbout0084 HERRING RUN DRIVE - Health 84 HERRING RUN DR., CENTERVILLE
A �
I
I
UPC 12534 '
0.2.153LOR �,
NASTINO8.YN
IL
TOWN OF BARNSTABLE m
LOCATION e e2 h SEWAGE # Tio
VILLAGE ��h ASSESSOR'S MAP & LOT-2 2
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) l-/ y�-� (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER l
PERMITDATE: 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) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by t..�: t': wn. ��y��
� 7r
aa'
5c)
Commonwealth of Massachusetts
0 - P13
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville I/ Ma 02632 8/13/18
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
filling
out forms n A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
VQ H.P.S.
,� Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644 .
City/Town State Zip Code
774-274-2581 12866
Telephone Number License Number
B. Certification
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 and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/13/18
Inspector's Sign re Date
The system inspector shall Cubmit py of this inspection report to the Approving Authority(Board
of Health or DEP)within 30completing 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::'
****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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form -Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System 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:
Septic is in working order. No failure criteria was found during inspection.
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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ 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 ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yy� 84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is Centerville Ma 02632 8/13/18
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System 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 surface 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 private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 Y2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
, °- 84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'( 84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is Centerville Ma 02632 8/13/18
required for every
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ 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:
® ❑ 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(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: unknownDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: no info
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1973
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2'feet
Material of construction:
® cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 gal
Sludge depth:
4"
t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
30"
Scum thickness less then 1"
5.. I
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
20"
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump every 2-3 years as maint. to protect leaching. tank is a 1000 gal H10 with square covers on
inlet and outlet. center cover has riser for pumping. baffles in place no visable cracks or leaks. no
major decay
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass El polyethylene El 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
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dbox is level with 1 inlet and 2 outlets. Dbox is structually sound with no visable leakage
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ya< 84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions: 1)12'x35'x8"
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
inspected through dbox no signs of hydraulic failure. post hole dug down to stone level. stone was dry
and clean. Piping is made up of thin walled PVC
Cesspools(cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
' d
2
L
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
84 Herring Run Drive
Property Address
Lane
Owner Owner's Name
information is required for every Centerville Ma 02632 8/13/18
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 7
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed 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 describe how you established the high ground water elevation:
Augered hole to depth of 7 feet next to field. encountered GNV at 7' bottom of leaching field is 46"
below grade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massaoh
Title 5 usetts
Subsurtace Sewage l Inspection
wage Dis Form
Aosal System Form_Not for Voluntary r
lop
84 Herrin Run Drive tY Assessments
Property Address
Owner Lane
information is Owner's Name
required for every Centerville
Page. City/Town
E. Report M t_ 026�— 8/13/18
p rt Completeness ChecklistZ1p Code
Date of Inspection
® Inspection Summary:A, g, C p or E checke
d
® .Inspection Summary p(System Failure Criteria
® System Information— a Applicable to All Systems)completed
depth to high groundwater
® Sketch of Sewage Disposal System either
drawn on page 15 or attached in separate file
�•313
Title 5 Official insPecticn Fes:Subsurtace Sawa_n,___
TROY WILLIAMS L
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Vk
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION 11
Vir :h.� LaHc
h Property Address: 8y Nerr4 I J Name of Owner % iQ.d o.�r L t..r c-
CL Address of Owner: /(o b C,a,...+.a,.w a 4 1 f, A u
Date of Inspection: 9/�y /y' ')e V ?0 7
Name of Inspector:(Please Print) Troy Williams Cos--o a /t't o A I/6
am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Cor+pany Nam: Troy VYlliams Se ..c Inspections
Marling Address: 19 Hummel Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEIMENT
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:
ZPasses
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
kupectoi s Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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 ttte
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working co r1�.l. _1,9/
of system,piping or components. This inspection represents the conditions of the system on the �t�uf" sA
Inspection noted above.
m SEP '" 9
A
rpvi cpri Q c)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (coff inued)
Prop": Andre _
Owner: 84 Herring Run Drive, Centerville,MA
Ow
Date of Inspection: Virginia P. Lane
September 14, 1999
INSPECTION SUMMARY: Check A, B, C, of D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: N(�
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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 levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
I
t
revised 9/2/9� Vuge2orll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 84 Herring Run Drive,Centerville, MA
Owner: Virginia P. Lane
Date cf Inspection: September 14, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
Public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF.HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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 ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN AMANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic-tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
9 C7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirxied)
84 Herring Run Drive, Centerville, MA
Property Address: Virginia P. Lane
Owner: September 14, 1999
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due-to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume Is less than 1l2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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 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: A/1,9
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 P.gr 4of „
p�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKUST
Property Address: 94 Herring Run Drive, Centerville,MA
Owner: Virginia P. Lane
Date of Irupection: September 14, 1999
Check if the following have been done: You must indicate either "Yes' or 'No' as to each of the following:
1'es, No
_ Pumping information was provided by the owner, occupant, or Board of Health. /` l
None of the system components have been pumped-for art least two weeks end-the system has been-receiving"),flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
V// _ The facility or dwelling was inspected for signs of sewage back-up.
aL/ _ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes.were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
All Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(15.302(3)(b))
The facility owner land occupants,if different from owner) were.provided with information on the.proper maintenanceof
Subsurface Disposal Systems.
re V l C'r? <:: 9P. Page 5 of I I
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 84 Herring Run Drive, Centerville,MA
Date of Inssmo«t: Virginia P. Lane
September 14, 1999
FLOW CONDITIONSRESIDENTIAL:
Design flow: /14) g,p,d./bedroom.
Number of bedrooms(design):-,I Number of bedrooms(actual):,3
Total DESIGN flow
Number of current residents:
�d
Garbage grinder(yes or no): 7
Laundry(separate system) (yes or no):Nd; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no): !/GS
Water meter readings,if available(last two year's usage(gpd): 0?rf D pp /y o Uo y a l/0 a s
Sump Pump(yes or no): No
Lest date of occupancy: X_,.,�,-f I t v fA. 64,e-,
COMMERCIALANDUSTRIAL. N/A
Type of establishment:
Design flow: ppd ( Based on 15.203)
Basis of design flow
Grease trap present:(yes or no)
Industrial Waste Holding Tank present:(yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of� Information-
� �G ti�".
Syste pumped as part of inspection: (yes or no) P6
If yes, volume pumped: gallons
Reason for pumping:
TYP F 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known) and source of information:
17 3 .
Sewage odors detected when arriving at the site: (yes or no) NO
revised 9/2/98 rage6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 84 Herring Run Drive,Centerville,MA
Date of Irnpection: Virginia P.Lane
September 14, 1999
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron_V/40 PVC Zothe,(explain)
1 i.,AJL da.-4 Puc-
Distance from private water su ply well or suction line iV/g
Diameter 41"
Comments: (condition of joints, vie Q/ti ng,oevidence of leakage,etc.))
.4!f G✓C TbJwN- CICt+✓ b. f 77 rN IN /C C�jb
SEPTIC TANK: f
(locate on site plan)
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions:__ ,S r)C g �X[ /6 i)V y 6L/'/o
Sludge depth: 4y
Distance from top of sludge to bottom of outlet tee or baffle: 02
Scum thickness: A161VZ
Distance from top of scum to top of outlet tee or baffle: No SC-c.;i+,
Distance from bottom of scum to bottom of outlet tee or baffle: Vo S C-
How dimensions were determined: Pry(0 C..
.Comments:
(recommendation for pumping,condition of inlet and outlet tee or baffles,depth of liquid level in relation to outlet invert,structur"tegrity,
evidence of leakage, etc.) Cv„c « ov (—f � 6a.{LEA 17
C► r,, G. ✓'�
G 1 v L
_ G H p
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 bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2 98 Page 7of„
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 84 Herring Run Drive, Centerville,MA
Date of kupmtion: Virginia R Lane
September 14, 1999
TIGHT OR HOLDING TANK:Al 119 (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions: ----- -• .._ ...._.
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V--'
(locate on site plan)
Depth of liquid level above outlet invert: It—,J
Comments:
(note-if level and distribution is equal,evidence.of solids carryover;evidence of leakage into or out of box; etc.)
77
PUMP CHAMBER: NIA
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 ["�r 9ofii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property adore:::owner: 84 Herring Run Drive, Centerville,MA
Date of Inspection: Virginia P. Lane
September 14, 1�99
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type:
leaching pits, number:_
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields,number, dimensions: 0&1 c 12 "Al 3$ ix I L4_"c i.. X i k .
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of pondin , damp soil, condition o vegetation, etc.)
,AJe S: c.6 _,.e' CAL o V 1: I..> r
w i N H �h 'T ki
CESSPOOLS:_'Ly 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 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: Al//nj
(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.)
revised 9/2/98 Ng'9 or I
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 84 Herring Run Drive, Centerville,MA
Date of Inspection: Virginia P. Lane
September 14, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
I
� rYOH't
I
I
VKr,
1 �000 y,, Ilu>1
a-� 6 So '
Ww+C�0- C' t
130 ' .
� 3s �
revised 9/2/98 P.Rr 10„r „
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Adelfeu'
owner: 84 Herring Run Drive, Centerville,MA
Date of Inspection: Virginia P. Lane
September 14, 1999
NRCS Report name A/49
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked 2 ONL 17 6 .3
Groundwater depth: Shallow Moderate
Deep_
SITE EXAM Slope ✓
Surface water 1
Check Cellar ti/
Shallow wells
Estimated Depth to Groundwater&Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
t//Observed Site lAbutting property, observation hole, basement sump etc.)
v/Determined from local conditions
Checked with local Board of health
Checked FEMA Maps.
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
wrtc..
�.,e ,s 6 . 3
t t-+sp� fi.�..
revised 9/2 /9R
No.... - Fps.. .
THE COMMONWEALTH OF MASSACHUSETTS
��BOARD F HE LTH
_.-. D..�".."�-.-......
OF........ ............................
Apphration for Btapuiittl Works Tomitrurtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at: —
ation-Add ..r Lot
Nr Owner.- A dre
Installer Address
U -?Type of Building Size Lot----
___Sq. feet
`-, Dwelling No. of Bedrooms.............. .......................Expansion Attic ( ) Gag,�_e Grinder ( )
Q, Other—Type of Building ............................ No. of pet-sons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ...... __
W Design Flow........................ - ---•_ Mons per person per day. Total daily flow._._..____. �--j�__A---------gallons.
WSeptic Tank Li 'd capacit/. ....____gallons Length................ Width................ Diameter____._._________ Depth-_.-_-_-_.------
x Disposal 0..................... Width....P........ Total Length----X_�..... Total leaching area_�.�_ --sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing"tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date.------------ ..........................
Test Pit No. 1......�' _-...minutes per inch Depth of Test Pit.................... Depth to ground water.-____--_--____-__--.._.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_____-_-__-__-__-_-----.
O49 Description of Soil..--------�. -`--------•-----•----------•----------------------------------------------------- -------------------------.......
U ------------------------••---•---------------•------------••-•--••--.._........------------.../-----•-------------------------------------------------------------------------------------------------
W
V 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 XI of the State Sanitary Code— The unUboard
d further rees not to place the system in
operation until a Certificate of Compliance has b is ed by the h 0
C
Sign d--- .
-- -------------- --
Date
Application Approved By----- _ . .__... ...
f Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•-----------------
}' Date
Permit No......................................................... Issued---%- le -
No.-- ------ FEE:. r-..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
-------7.1hp, 1011
N$
Appliration for 43iiposal Workii Tonitxnrtion Prrmit
plic tion s hereb de for a Perm* to Const t ( ) or nZidual Sewage Disposal
S�st a i y.
--- - -- - -----
5 &b td ress 3 �q 8
.����'�"`-
ett .............................
C Address
= 11
- - -----•-•••--....._.._
Installer Address ,.
UType of Build g Size Lot___.___---__________________Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures --•---•-------•---•-•---------•--------------•--------------------- -•-"""�
Design Flow....................... "
------------------
W gs _ - per person per day. Total daily __________________________._.___'____.______gallons.
WSeptic Tank 'A L I+I d capaci !____. _gallons Length________________ Width---------....... Diameter-------------- tl _______-__--.
---
z Disposal o_____________________ �hidth___� .__.; Total Length_ '_ ------- Total leaching area__-----------------sq. ft.
Seepage Pit No_____________________ Diameter..... Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------- -•-------•------•-•-•-•-------•-•••-------------•-------•-•-•••-- Date----------------------------------------
Test Pit No. I.................minutes per inch Depth of Test Pit.................... Depth to ground water_____-_________________-
f�, Test Pit No. 2.... ......minutes per inch Depth of Test Pit____________________ Depth to ground water------------------------
----------------------- ---------------------------•---------------------------------------------------•-----------•------------------------------------------
0 Description of Soil..............................................
U ----••• - -- --- ----
W
----------------------------------------------------------------------------------------------------7---------------------------------------------------------------------------------------------------
V 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 XI of.the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beesued by the board of health. rn
Signed .....••. -
-= r :-.. +
a�aiee 4
Application Approved By_____________
••---••.••------•-•--•-- ----- • •-------•-•---- ---------------
Date
Application Disapproved for`lf g you .................... -----------------------------------------------------------------------------------
-••-••----•••--•----•------•----•--•-•-••--------•••••----•••---•----••-•-•----••-••-••----••---•-----------••-•-•-•-------•----••-•--•----------•---•---- --------------------------------------------
Issued 27to
Permit No.........................................................
` / ---------
Date
THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALT
..........OF......6 ' . . ... ....:
...................
.............
elk ` i1rdif iratr of Tompliana
CA. IF Individual Sewage Disposal System constructed ( �oRepaired )
b '
-- c ----•------ -•--- -'"Installer_ _...-•-•-----------•----...-----•---------•---------••-----•---•----------------------------
at ° ,'� r . I 5
=- -
ha ehmstahem ac e 1proV1.5'Ions of Article`XI of The State Sanitary Code as descr e in the
�, f,^-
applicat*on''for Disposal Works Construction.'Perm*t No_
....... .2___ _______________ dated___. .______________
ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
,r.
SYSTEM'WILL FUNCTION SATISFACTORY.
DATE.....
--'-` 1-----------............................... Inspector----- -
C
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
No. ..... . .. @
a --------------------------- ...�
; ems ..---- } FEE.... -----•-----
if orkCnontr�tsrttion �rnttt
, ,,
Permission is hereby grante _- .A: � �° -- --------- --- ----- !
to Construct of Repair an Indivlckialfwage Disp al S stem
-----
, S eet
as shown on the application for Disposal Works Construction t No el.__l,___C'1_ Dated_____ .......................
_�
i.
. __
3w Bo d`�of IIealth
DATE ---------------------- --- ................. °
,t(,yy ty' p
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS �f.
J