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HomeMy WebLinkAbout0145 LAKESIDE DRIVE EAST - Health 145 Lakeside Drive East, Centerville �A= —':. 52 - 090 a 4 C OW NS fi I-A /CORNING • 1_ i rr OMEN■ a E OGiMEMO ®■N O®O0O®� ®®®®®■® 9■OMom ® �®®OEM■■■ ENONE ME 141331Z■■■■■■■■■■■.■■■■■■■■■■N■■■■■■■■■WWI; ■N■■■■ N MEMO ■E O■E■ NNE■■■ MEMO N■ "RONEMEinIEEEe�■NNE ■E■ ■■NNE■ NONE TONE■EE Room■E��OMENO EMr�:? /aJ, ■ MEN ON MENEM ■OEM ."Z®■■E■MErlOMMME■m mmmm■f/!MWENl WERE EEEM ■■ M■E■■E■ :1�'�. ��IEEEE ►� M■N!!! H NE ■ENEE■ME■■� ■■■ MEN WM. mom MENNIVAMEM No ou'llNo No ME mom as■ME NEEME■E ■NNE E M®il®C .r■rl■ ■E■ `�ENEEO,�EME ME ■N■ ■ t i■ ■EM■m M NE ®■ � 1310 JNFA■ mom■■'1�ENMEM Mil ME■NEN MEN■MMEM -BEENIM■®®E��r�E ■EN ©E■®EE Eer v ■■ MM M■EN ■E■■NSEEOEM■M■ECir!l���IIF Ef�.�:�i�!NE ■E EE�7®N■WE��'. ,: ME■OEM■ �% ■-E`NMENNEW■�ijl'li�!fl' �7N :iiiMort.�w ®N/ - �IIEOriiEMmKEE► Li it ENRON I....►T•. . Or'F C Z a...l..MENMERNMERMHON■!lll �ll'li.■ M, � Mfg........■■........■■so OEM N MOM TE sm =MUN■.►CIE■.. M..NN .M....■....■ ■.....1�■. No■/,MEN' , ■o"xim■■■ E\ �� . �E■u■ ....E■..®NNN . 7'�NAMNON ■OEM ■//moor ,. ME.+�Z-■210N■/ iaGf�i1NP ®■N �. ■oME■EE■MMNo m■iorN .POEM- 0 ZZ■E . �.tow��ME■ (�W I NEE■mE No�■��■..mom ■ ■%EE ,MM��J.�1lNEE�/� N IBM ■■EEM■l� Emig;O►3"r- :(�1�3a17EEN■E ■ AM Erb■ ■c�EaNE�►i �� �,� � ■N EEMEm®ENNN■■ iiENN■■EM ME M M MEMO ME .■® ...■... M ME ��.■....i.■. .EEE■m■�i '..■..r..... MM E■ ; ; ; ■1�■ ■■ ■DEEM ■ MM E■■■ .■ . . .. .®.■ .OEM■■■■.ME ■■.■■■.■ - 2SZ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFN� DEPARTMENT OF ENVIRONMENTAL PR ,y TIO-ly ONE WINTER STREET-. BOSTON, MA 02108 617-292-55 T01%0"S (7 1`9`9? ��ryo Psrgel TRL�I'a'COX� WILLIAM F.WELD T. F ' Governor Seeretary ARGEO PAUL CELLUCCI �%)'B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM g Commissioner PART A nCERTIFICATION Property Address 14 S �— Address of Owner: L u_r� Ce Date of Inspection: 1 .L — R _ �) 7 Of different) Name of Inspector: JJL. am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: p •-C C- SL u T k L Mailing Address: 20 6 c�k � o v\.'S Telephone Number: —7 8' CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ZPasses _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: Aj,SYSTEM PASSES: V I have not found any information which indicates that the system violates any of the failure criteria a9 defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: BI 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. 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: httpwwww.magnet.state.ma.usldep ej Printed on Recyded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Lwk�s�d � Property Address: V� S Owner: L (.,., Date of Inspection: 1 Z' -7 e] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). 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 to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 404 Conditions exist which require further evaluation by the Board of Health.in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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 to 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 (revined 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) i Property Address: I t{ S L K��:d e ��c:�1 a S��Ce— Owner: lL LA_, (-► e. L e— t G` Date of Inspection: 1 2 —S DJ SYSTEM FAILS: You ust indicate ekr,er "Yes" or"No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined 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 1/2 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 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. _ 6-/ 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: You must indicate either "Yes" or "No" as 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 1..-4�.1c�s � d e. ���vti �i s�- Ce_.�..�e�-V►' 1�� Property Address: f y C (► Owner: L Date of Inspection: - Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Ye No / Pumping information was provided by the owner, occupant, or Board of Health. 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 part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ 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. J _ 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. 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)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION Property Address: 1 4 Owner: L L-`r't+ - ) Date of Inspection: ► .Z— Cl — q '7 FLOW CONDITIONS RESIDENTIAL: Design flow: 33 D e.p.d./bedroom for S.A.S. Number of bedrooms:- 3 Number of current residents:4 Garbage grinder(yes or no):� Laundry connected to syste (yes or no): Seasonal use (yes or no):2 Water meter readings, if available (last two (2)year usage (gpd): CJ 5 Sump Pump (yes or no):z (f d t 6 n.uS ! g 7 _ $S�,nro Last date of occupancy: COMMERCIAUI N DUSTRIAL: Type of establishment: Design flow:_gallons/day 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 informati LN% System pumped as part of inaction: (yes oi no)_ If yes, volume pumped: / f Gallons Reason for pumping: TYPE,qf 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. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: ��/ /S Sewage odors detected when arriving at the site: (yes or no)L (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C '/ SYSTEM INFORMATION (continued) Property Address: I s , L. K'k S i �� `<' J� � �� CA-VA-k QL%`9- Owner: f" Date of Inspection: l Z- `i -i '7 BUILDING SEWER: (Locate on site plan) t� Depth below grade:.. / Material of construction: st iron �/ 40 PVC_other (explain) Distance from grivate water supply well or suction line Diameter !fl Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:_ (locate on site plan) �I1 Depth below grade: v ,� 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: Sludge depth:_&Ic 31� Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: It' I r Distance from top of scum to top of outlet tee o baffle: r� Distance from bottom of scum to bottom of ou1JeJ tee or baffle: How dimensions were determined: Q11 Coil/- Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet i rt, structural integrity, evidence of leakage, etc.) 5e V k'%L-VIN41-�- t S 'i f%- COO 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.) (revinad 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: I y 5 l,�`.�c e ' d e .J� Owner: L— c,— Date of Inspection: TIGHT OR HOLDING TANK:,, (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 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: (locate on site plan) Depth of liquid level above outlet invert:��� Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Y, PUMP CHAMBER: (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 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C I SYSTEM INFORMATION (continued) t Property Address: 1 S L�,kQ- S ' ��- Owner: L 1 C -e-,\ ` Date of Inspection: i L— `=t SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, num er:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, conditio ofivegetation, etc.) CESSPOOLS: I (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: (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 04/25/97) Page 8 of 10 I - t • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1 SYSTEM INFORMATION (continued) Property Ad ress: 14L � C�\\��t � � Owner: Date of Inspection: Z— ci — cf 7 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) oa (revised 04/25/97) Pago 9 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: L l C e-k� (;,- Date of Inspection: l 2— j — cl -7 NOw�✓ Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers —.S,,—./Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) �����. 1..��- `� ,{fir��s—f r►'�e�� (revised 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE� Je- LOCATION ) �� L►4 �Qft� (�►�5t' SEWAGE # VILLAGE ASSESSOR'S MAP & LOTS/ - - d INSTALLER'S NAME & PHONE NO. G \,.n4A4.,2 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) Q9-e-Ggtp,— I?fcTi (size) , (a-rc,6 ! NO. OF BEDROOMS_ 2 PRIVATE WELL O BLIC W L� BUILDER OR OWNER A 14 u w DATE PERMIT ISSUED: q -�)`W� DATE COMPLIANCE ISSUED: - / VARIANCE GRANTED: Yes No t_ O 4 a� - ,- ...... Fzz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TCX..e._J.•---....0 F... ���w.S/W..._S.`.l`�u1�,,—.......................................... Aur iratiun for Dis'puutt1 Works Tonstrurtiun Frrmi# Application is hereby made tfor a Permit to Construct ( ) or Repair ( Syr Individual Sewage Disposal System at: r ............t.4 ?Y'4...:..::... ................ ^ _ir .SE -............--......-..-- Location-Address or Lot No. .......... ....................................... S.-_V(3_'=�--.......----•-------........... wa Owner Address _....G- =`�... ...................... . .. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms--_-. _....Ex anion Attic Garbage Grinder Other—Type e of Building ............................ No. of ersons....................:__.____ Showers — � yp g p ( ) Cafeteria ( ) QOther fixtures -------•---.......•-------------------------------•--..-----............-•-----------------•----•---------•---•------•-•--.........•••.....-••-....•-- W Design Flow.......... ....................gallons per person per day. Total daily flow...........`.a .................gallons. WSeptic Tank—Liquid capacityj—.gallons Length..... Width. .,Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......,............. Diameter.....1-.D....... Depth below inlet.....J._,.(....... Total leaching area..................sq. ft. Z Ott-Bistribution box ( c)— Dosing tank ( ) aPercolation Test Results Performed by----•----•------•.............••-•-----------••........--•--••-----...... Date.................................. Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..........:__.:....... .. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --------------------------------•...•-----••---------------•...... ...... :••-...----.......------------•...............•••.----------- *... .....••--------•• 0 Description of Soil...................................=.................................................................................................................................... V --------------- •------------- -------- .......--------------- -------- ------------ •------------------- --------------------- ------------ -....... -•---------•----------- W U Nature of Repairs or Alterations—Answer when applicable----- :SLrD........ ........ -•---•...................................................•-•...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of L I'iZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Application Approved By................................................................................................../6�._..... . ,�,p Z�� . — ..._ Date .. Application Disapproved for the following reasons:•------•----•---•••-------------••-•-------•-----•-----•----...--------•----•-•-----•••........._............-- ...........-•-----•••-•••--•-•----•--•-•-----------•••-----•--•........................•-----•-------••••..------.....---•-----------•...----•-----••---•-------•--------••-•-••----•••---•----•••••-•--- Permit No... .. � ................. Issued........__.. _- t � �``....................... Z ate Fini THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �ik-A.. .'..........OF.. Appliration for Disposal Works Tonstrurtion Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( Q_an• Individual Sewage Disposal System at: p 1 ...........j_ �. 14; Q r t _ E r S f CrwT O-U `:-,::.._._.....v Location-Address or Lot No. .........IM�r.__... :::.�.:�a y 1-` --•---•---------------------------------- .....................Sxy! . .'..:.................................................. Owner Address aG ....9.�....-.-_.....L..... `'r' �"���rr -------•.. ..................�..6. -�� G.._... -- M Installer Address Q7i Type of Building Size Lot............................Sq. feet U DwellingNo. of Bedrooms.....R.................... .._..Ex anion Attic — _..__.__. p ( ) Garbage Grinder ( ) a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures ...................1-4 = \'.. - , -r--- . .--------..•--------------------------------------------------------••................ W Design Flow------- ....................gallons per person per day. Total daily flow.......... ..................gallons. WSeptic Tank—Liquid capacity.j� .gallons Length....J, -_--- Width...... __... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length...r:._.__..___.... Total leaching area....................sq. ft. 3 Seepage Pit No......1............. Diameter.....-1---Q....... Depth below inlet...... 1....... Total leaching area..................sq. ft. Z Otter Distribution box ( I-)— Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................•.. Depth to ground water........................ R+' ----------------------------------------------------------- -... •-------------- ••-•-------------.-•------------------------------------------ •.... •... .------ O Description of Soil........................................................................................................................................................................ W W V --------- --------------------------------------------------------------- ----------- ----------------- ----------------------- ---------- -•------------------------------------ ----------------------------- U Nature of Repairs or Alterations—Answer when applicable_._. w :: ........ __. ;_ �<.!N _ ✓Jjl� .... � 'n v,P /-l4 ST r��" ( ;_. [----------------•-•-------------------------..................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned= ......... --- ................... ...... ---- / Dad Application Approved BY••-•••••-• ••-••....... .... ' ---�G_f,Z M- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------•••...._...._ ..........................•---...----•.-... •-----------------------•---------...--••---------•---••••--••-••---•-•-•-••••---------•-----•-•..............------------------------...---------- 2 ����---yy Date Permit No......................................................... Issued-.---------L/�/7 Jam------------------- r� Date � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -g.`�.......OF...,....L`7.cA+(LwSS:�.�v `- ....................... Trrtifirate of Tompliaurr THIS IS TO CERTIFY, That the�ndividual Sewage Disposal System constructed ( ) or Repaired ( �) bY....................... Installer at...........a._L:a n ...... V.ST_-__... /, " '�` / . . •-••-----•----•••-•----•-•-•-•--•-•-•••.....-•-•••-•••--•-_---- has been installed in accordance with the provisions of TITL 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...7S_S-.-- �I___...... dated__..._. /.2. __________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION•SATISFACTORY. 1 � DATE............................... ---------------------- .. Inspector r..� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r �Si � IDS I ''^'... 'OF....................... No..-••-•-•-•-•.......... FEE.............. ... Disposal Works Tonstrudion Vprrmit Permission is hereby granted..........4_6'�_... n :t2------ ............................................................. to Construct ( ) or Repair ( 4)--a—Individual Sewage Disposal System derv,— G�! ` ..----•-----------------•------------------.............. at No.: 1=i '57 f" !�y'T ..._ .d = C 0 r�rZt�If 1tic W-eG L Street � !,E/ G` as shown on the application for Disposal Works Construction Permit No..................... Dated.._.__-( _ .....� ...................•••--•......••-••••-----.....-----------------•--•--• ............................. DATE........... //,_,2- Board of Health ' --------------/--`---- ---------------------- •-------------