HomeMy WebLinkAbout0029 LAKEVIEW AVENUE - Health 29 LAKEVIEW AVE., CENTERVILLE
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UPC 12534 '
No.a�O,R
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N -- -- COMMONWEALTH OF jv1-kSSACH,SETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL ,RS
DEPARTMENT OF ENVIRONMENTAL PRO `O �f�c/V�'Q ✓r
ONE VhNTER STREET, BOSTON MA 02108 (617) 292-550 IJ
2 1999
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TRU XE
A etary
1
ARGEO PAUL CELLUCCI TRUHS
Governor otrunissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
LOT r I N CERTIFICATION Property Address:- C� r i�L-�I/!=w AVE Name of Owner l filCN t Ls i ie(v
Address of Owner: _S!}Y"1E &'AFD1
Date of Inspection:7"/0 4q 91
Name of Inspector:(Please Print) (z)WIIRO C:,(301SFlr`/-p
1 am a DEP approved system inspector pursuant to Section 15.340 of True 5(310 CMR 15.000)
Company Name:
Ma7ng Address: t_W001D 1SUE SnNOW t 'i I') s-3
Telephone Number: SO$ 63a
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:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails '7
Inspector's Signature:�uu/cz� �� Date: /'IC� C�OLj
� 7 /
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•Sporophate regional office tff-the'Departmentof-Environmental Protection: The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS 't�QQ �j/����i1/ SiCoO L 7 1WK TFL Si`'00 S Pul/ "I p6(3 t !)S3" y64k:�
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/ADD G�c��N LE"r�VI �l r �a�Ur �JrNr ys C F., ao lb` lwslo(�:
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rev:ised 9/2/98 Paget ortt
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: .LT, EOELSPW
Date of Inspection-7•10-/95y
INSPECTION SUMMARY: Check B, C, or 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:
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
revised 9/2/98 F Page 2of11 p.
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address,)`Irr�� (-414-(s Jlr✓v1I AVM
Owner: I, 60EtSl fC V
Date of Inspection:
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 th'e 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 11)(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.
I
21 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 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
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address-�� 01 kC ViEw ��C
Owner: E,COe", —Ilu �7
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 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.
_ 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: i
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)I 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
i
the system is within 200 feet of a tributary to a surface drinking water supply
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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 15:3040. 'Please c ' ult`IA6 local regional
office of the Department for further information.
revised 9/2/98' Page 4of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART B
CHECKLIST
Property Address:)'i CrT"eOCW rz*jL
Owner: T;eog(s1 wu
Date of Inspection: 7-io-iw`�9
Check if the following have been done:You must indicate either"Yes" or "No" as to each of the following:
s No
Pumping information was provided by the owner, occupant, or Board of Health.
I
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.
1 _ 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, , 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:
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)1
_ The facility„owner (and occupants, if different from owner) were provided with i 1.nformation on the proper maintenance of
SubSurface Disposal Systems.
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revised 9/2/98 Page sof11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: L l%` i'S�CIN
Date of Inspection:.
7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ,l,9 g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms(actual):3
Total DESIGN flow��Q_,
Number of current residents:
Garbage grinder i 0- or no):�b-f
Laundry(separate system) (yes or(o):IVO; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or(&:IVO
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or(b):/"
Last date of occupancy: �;PQdCG OEV
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( 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 so rce of information:
QED OW
System pumped as part of inspection: (yes or f�f )ft."
If yes, volume pumped: gallons
Reason for pumping:
TYP OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool (: :'r
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: /q�/rC 0 wf /rs Qv/(—
Sewage odors detected when arriving at the site:(yes oro
revised 9/2/98 Page 6of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:aq V I&J
Owner: �r COP-L 5 i ew
Date of Inspection:
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 line
Diameter
Comments: (condition of joints, venting, evidence of leakage,etc.)
SEPTIC TANK:'
(locate on site plan)Depth below grade:3ol/VCHS
Material of construction:Xeconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: )Q,
Sludge depth: I J A)Cq-
+ /�
Distance from top of sludge to bottom of outlet tee or baffle: / cos
Scum thickness: f rVl l
Distance from top of scum to.top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: 7-P P15 121 6
Comments:
(recommendation for pumping, condition of inlet and outlet to s or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.) �U L " V ER e��ti ��L�N C L'?� TFE
COPLE r AFF1 " 1Qy1A A'r 601-tC"n OF QVtlEr rl
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 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�+ n SYSTEM INFORMATION(continued)
Property Address. 1
Owner: T,EfjGILSTO0
Date of Inspection:7-10 �94�j
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 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:
(locate on site plan)Depth of liquid level above outlet invert: t'/�
iT MIT'h
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No) r'+
3
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition' of pumps and appurtenances,etc.)
it
revised 9/2/98 " Page 8or11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:l LM" CV IEO AU C
Owner:
Date of Inspection:7_JO_( , l Y
SOIL ABSORPTION SYSTEM(SAS):Y`'
(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:CW'51 10OU GG�LIO LEA«� ���
leaching chambers,number:_
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 f ponding, damp soil, condition of vegetation, etc.)
/t ;vcD Cc,vU�rrnit/ �n,2Ms O C� vlo JJU� ivr - G�rvo pool<5 f9S iF �ir�wU
E S t0t e5 ANN
CESSPOOLS:_
(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.) " '' o ' ..
revised 9/2/98 ' Page 9of11
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
,,r�� SYSTEM INFORMATION(continued)
Property Addres's:L(W'VI.GW R'J
Owner: Z,EDI;I.STE W `
Date of Inspection: -,O"1/'��
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)
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revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
7C� n SYSTEM INFORMATION(continued)
Property Address:✓
Owner:(�, E0E1.5TCIGt1
Date of nspec6
0n:7,10 t l I(�(�
n
NRCS Report name
Soil Type_ '--
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
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) '
revised 9/2/98, Page 11orti
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LOCATIO ���� s � � ', SEWAGE PERMIT NO.
VILLAGE
INSTALL R'S NAME i ADDRESS
t UILDE � OR,,, OWNER
U ►
T •"
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �� �
r _ _� «_ __ _ _ __
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____.._-- --�c.�___ ___...
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No.. ..3 :.... FIz$..��........................
THE COMMONWeALI)r'-4 OF MASSACHUSETTS
-,-� BOAR OF HEALTH
-.-----[O.W.4..................0 F... 4qrA&6;----------..-•----.--------..-----------
Appliration for R-4posFal Works Tonotrnrtiun Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Avg
at........�kga.v�. ..- .--•- l .i . f .u�..�. •---•- . --------•...............i=i ........1_4........................
Location-A Tess or Lot No.
............................ IAW;.-...... Ems` TWA..-------= .................................................................................................
Owner Address
W ....................................................... ..........• -•-...-------•...........---.._........-----••.
Installer Address
Pal Type of Building Size Lot.... _ t-3PQ.....Sq. felt
U{/
Dwelling—No. of Bedrooms.......... ---------------------------Expansion Attic ( ) Garbage Grinder p),
rs, Other—Type of Building .......................... No. of persons.................._......... Showers ( ) — Cafeteria ( )
P4 Other, fixtures .....
W Design Flow............... .-...gallons per person er dad. Total daily flow.................SS0............. Ions.
WSeptic Tank—Liquid capacity.10 allons Length. "'.. Width.. Diameter-_-_-___••_••.•- Depth_. ._."'.
x Disposal Trench—No..................... Width.................... Total Length......... _ Total leachingarea..... s ft.
Seepage Pit No....__..-.:�....__... iameter........P...-.... Depth below inlet....... Total leaching area.. ...sq. ft.
Z Other Distribution box (ie Dosi tank )
Percolation Test Res is Performed b . . ..: `�.._ Date..._ 1� ......................
a Y t ---------------
,� Test Pit NO. .... ..........minutes per inch Depth of Test Pit....... Depth to ground water.......:..------------
fZ Test Pit No. 2................minuters per inch Depth of Test Pit.................... Depth to ground water........................
OWx Description of ...................`
.. . :: : .
......... ...... . .....•----•--•-•.......••----•• : .--------•..--.---••---------
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 i IT1E 5 of the State Sanitary C e The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee i sued by the b I
Signe ..... •... . ..•--•----- 2.61(:1-
Application Approved BY• `: /� Date
............. ........
Date
Application Disapproved for the following reasons:..................................... —-- --•---•------•--------•.............•----......_. ----•---------
-•-------------------------•-•--------•-•----------------•-•---------------•--••------•....._.
Date
PermitNo.......................................................- Issued.........................................................
Date
THE COMMON6EALi-,H OF MASSACHUSETTS
BOARD OF HEALTH
Appliration flan Uiipoial Works Tonstrurtion 1hrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: { 0
Leit.
..... ........__---•---- ---.......... -- Av&z,, 6;!�--..._....... .....----•---------...---------------------- ........
•-- --....--------......---
Location-Ad ress or Lot No
• - - ..........-•..........................................•--•--••----.._.._..---•-----...............
!._ Address
a ....................................... .-."-...--•---•-- ....................................... ......-•------•-•-----....----------...--^_.._._..-•----
Installer Address �f
U Type of Building -•__-
YP g Size Lot____:_�.�___ �"-� _._Sq. fe t
Dwelling—No. of Bedrooms_..........___...................._-----Expansion Attic ( ) Garbage Grinder ),
a Other—Type T e of Building C4 YP g ---------------------------- No. of persons---------------------------- Showers „ ,—
d Other fixtu s
W Design Flow...............__`�_�___,..........!______..__gallons per person Per day. Total daily flow_ .__.__.___. �_ � ___...._.___gallons.
WSeptic Tank—Liquid capacity:tP;��I __rlons Length_ .`:- __ Width._:_:M _�_ Diameter________________ Depth__. .W:__--
x Disposal Trench—No_____________________ Width.................... Total Length_..__.___.._.;.................... Total leaching area-------_____.......sq. ft.
Seepage Pit No___________ __ Diameter___...._'__.._. Depth below inlet_.__..{1%__._..._. Total leaching area__ -' %...sq. ft.
Z Other Distribution box,( Dosing tank ) d� j
'-' Percolation Test Res lts Performed by_ `'r?................0,4k"' `' !� `: ! 9 U
•---- •---•-•-•-••---•••---•-• Date-=-.••----• ..-•-- ••..............
Test Pit No. l *r"_..._minutes per inch Depth of Test Pit....... ..... Depth to ground water.____.:'_.........................
f3� Test Pit No. 2......_____._._minutes per inch Depth of Test Pit____________________ Depth to ground water........................
1
O Descri ton of Soil---••••• {�' 3a " 1t :..
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 TITi.Z 5 of the State'Sanitary C e The undersigned further agrees not to place tIe system in
operation until,a Certificate of Compliance has be�'ued e bo It -
Signe •-• - --•••..... ...............................
Date
Application Approved By....._/ C � �-- . ..............
Date
Application Disapproved for the following'reasons-.........-.................................................................:-....................................
•---•..................•---...-••--._...-•-•-•-•.....-----•-•-----••--•--•---••-•----•----•----•--...••-•..•-••-•••--•••----••---••---•••------•--•--•----••---.........................................
Date
P Mt No.............. Issued ::_...,-•-•------••--•----
Date
THE COMMONWEALTH OF MASSACHUSETTS
-R BOARD OF HEALTH
'3J .........oF..... '�' ltf. . .. ....................
Tntifiratr of fauntphaurr
THI IST��� CERTIFY, That the Individual Sewage Disposal System constructed ( r Repaired ( )
by > . ._._..__...
Installer
at. 1.�t.�tr.�:z !- - --•-•-=---e�c�L�l--t--- ----`•�= •--��� �__� ,rr_�'1_�_r�_ 1�?�-'------- -�'t�'r- -�---------- ���
has been installed in accordance with the provisions of T�I' 5 of The State Sanitary Code..as.described in the
application for Disposal Works Construction Permit No.[[ r.e_____ _ ______________ da.ted_-...,�� ` _ .........
THE ISSUANCE OF THIS CERTIFICATE'SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM 1I8AL FUNCTION SATISFACTORY.
DATE.........-` . .............................................. Inspector--------- ...... -----------
f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
31 Fc� OF...... �... � rx
Nb-....... .....:� .... FEE S??..............---
�t��o�o1� o�l#� �on��ttr�ion rrotii
to Cons uct o ai an ndi `dual -
Permission hereby granted �' .........................:_:..-----------------------..._._.--------...---__.....----.._..•-•....".......
t� ; ( ) ,,tl Sevt�agyDisposal System
p
Street
as shown on the application for Disposal Works Construction Permi" No. 'e* x Dated__ _'Ar�....... ......
DATE__.::.:... `_`__t�
Board of Health 0*1
............................ 1 "-
FORM 1255 HOSES & WARREN, INC.. PUBLISHERS '"�.
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TOTAL TEE-StG►J = d25 G.P.rJ. � $� �`
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