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Home My WebLink About0030 MALLARD LANE - Health 30 Mallard Lane' U Centerville P 187 012 4 0)) i [4, :ford NO. 1521/3 ORA �� 10% RECI�IVED COMMON6VEAL71i OF SSACM SETTS S P 0 1 200 i E-xECU-fIVE OFFICE OF ENVIRONMENTAL.ELF` bWN OF TABLE DEPARTMENT OF ENVIRONMENTAL PROT TH DEBT. Y \�n +1�r7P - PARCEL TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A. n CERTIFICATION Property Address: 36 /YIa I��a�A� (ems-f Owners Name: ,1nc. Fy6 `o,%ej ® K iu��1� p,G m4t/k Owners Address: . Date of Inspection: 710t 3109'Name of Inspector:(please print) AM;c4ae Kee [It 14 Company Name: el MA 1-1.5redlo is Mailing Address: P02 154.,f .wit, Telephone Number: 38S` —76 0R CERTIFICATION STATEMENT I certify that i have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function 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 Needs Further Evaluation by the Local Approving Authority FailsZZ ZOCl V Inspector's Signature: hl— Date: 7 eZ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I I = 30 sP x :7 i0 13 AtY Page 2 of 11 i OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE INSPOSAL SYSTEM INSPECTION FORM PART A nCERTIFICATION(continued) Property Address: 30 No.l�G/dC ViM4 Owner:_M t0 Date of Inspection: ]� Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have mot found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to laced or repaired.The system,upon completion of the replacement or repair,as approved by the Boar Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following stateme .If"not determined"please explain. The septic tank is metal and over 20 years ol(f*or the septic tank ether metal or not)is structurally unsound,exhibits substantial infiltration or exfiitration or tank failure" imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approv the Board of Health. *A metal septic tank will pass inspection if it is structurally so not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break or High static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, uneven distribution box.System will pass inspection if(with approval of Board of Health): ke. pipe(s)awzqAaced obstvcfm iaremoved distributi(m box is leveled or replaced ND explain: The sys equired pumping more than 4 times a year due to broken or obstructed pil*s).The system will pass inspection" (with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property'Address: SO qrd �. P Vr--f— Owner: K Q 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 dete ine 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 31 MR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,s ety 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 wets d or a salt marsh 2. System will fail unless the Board of Health(and Pub c Water Supplier,if any)determines that the system is functioning in a manner that protects the pu tc health,safety and environment- - The system has a septic tank and soil absorp 'on system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface w er supply. _ The system has a septic tank and SA d the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and AS and the SAS is within 50 feet of a private water supply well. — The system has a septic d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". hod used to determine distance "This system passes if th well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile o is compounds indicates that the well is free from pollution from that facility and the presence of amm is nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are caered.A copy of the analysis must be attached to this form. 3. Other: 3 I Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DMOSAL.SYSTEM INSPECTION FORM PAI.tT..A.- CERTIFICATION(continued) Property Address: 3 !xl(c k t Owner: Date of Inspection: d�( 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 pondmg 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 �r Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00 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.IThis system passes if the well water.analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic_co 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 5ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CUR 15303,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 mnst serve a facility with a design flow ,000 gpd to 15,000 gpd. E You must indicate either"yes"or`no"to each of the following: (The following criteria apply to large systems in addition to the ve) yes no _ the system is within 400 feet of a surface water supply — _ the system is within 200 feet of utary to a surface drinking water supply the system is located' nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone Il of a pub' r supply well If you have answe "yes"to any question in Section E the system is considered a significant threat,or answered si "yes"in Sectio above the large system has failed.The owner or operator of any large system considered a significant eat under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304 a system owner should contact the appropriate regional office of the Department. 4 • Page 5 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: v Owner: c�l Date of Inspection: 416 _ 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 m enance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no c _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15302(3)(b)] 5 r Page 6 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0 A,� d Owner: Date of Inspection: 7 A2 3764F FLOW CONDITIONS , RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): .S DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 33C7 Number of current residents: 10 Does residence Ea've a garbage grinder(yes or no):/AJ0 Is laundry on a separate sewage system(y s or no):_A6(if yes separate inspection required) Laundry system inspected(yes or no): Seasonal use:(yes or no):/ r7 /� Water meter readings,if available(last 2 years usage(gpd)): 1�1 Sump pump(yes or no):1— Last date of occupancy: - * COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): pd. Basis of design flow(seats/persons/sgft,etc.) ,^ Grease trap present(yes or no):— Industrial waste holding tank presen es or no):, Non-sanitary waste discharged a Title 5 system(yes or no):, Water meter readings,if av ' able: East date of occupanc se: OTHER(des ' e): GENERAL INFORMATION Pumping Records (� Source of information: p t -GG0/U` V U NM@I Was system pumped as part of the inspection(yes or 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age f 511 compo nts,d insta d(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 6 . Page 7 of 11 OFFICIAL. INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION(continued) Property Address: 0 t Owner•. a Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade:_ Materials of construction:_cast iron it 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: f (locate on site plan) N Depth below grade:X?5 Material of construction: concrete_metal—fiberglass polyethylene _other(expia* If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /O Sludge depth: a Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: I " Distance from top of scum to top of outlet tee or baffle: I of Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: M-easo� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leal=e,et .)- d' 11, -f, h " J% GREASE TRAP:_(locate on site plan) Depth below grade:— Material of construction:—concrete_me _fiberglass_polyethylene____other (explain): Dimensions: Scum thickness: Distance from top of scum to p of outlet tee or baffle: Distance from bottom of m to bottom of outlet tee or baffle: Date of last pumping: Comments(on pu ing recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to ou t invert,evidence of leakage,etc_): 7 O Page 8 of 11 OFFICIAL INSPECTION FORME—NOT FOR VOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM[INFORMATION(continued) Property Address: �•c/ �a•.�• Owner: cf e Date of Inspection: 7 J-0 r FIGHT or HOLDING TANK: (tank must be pumped a of inspectionxlocate on site plan) Depth below grade: Material of construction: concrete m fiberglass_Polyethylene other(explain): Dimensions: Capacity: ons Design Flow: Ions/day Alarm present(yes or no): Alarm level: in working order(yes or no): Date of last pumping: Comments(conditi of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: a wjo 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.): .b o it i3 f'a Ne(is.rr�` �./► 7 to f x 6 a Ir a Ina t r_T 00l PUMP CHAMBER: (locate on sig plan) Pumps in working order or no):. Alarms in working or (yes or no): Comments(note c 'tion of pump chamber,condition of pumps and appurtenances,.etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION(continued) Property Address O ail e-j 4.�( — C ! Owner: yr Date of Inspection: SOIL.ABSORPTION SYSTEM(SAS): /f (Iocate on site plan,excavation not required) If SAS not located explain why: Type teaching pits,number: Xleaching chambers,number. leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions:. 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.): ` 4 c k� C > 6 r CESSPOOLS: (cesspool must be pumped as part f inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwat inflow(yes or no): Comments(note con ' ion 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 c 11 ondition o il,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L.a w Owner: An"Aae- -- Date of Inspection• 6 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. sn Page i I of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,'� G s • Owner Date of Inspection: SITE EXAM Slope 00. Surface water /00 Check cellar f/ Shallow wells V rj Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: __j( 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 ho you established the high ground water a evation: 11 Page 6 of 11 OFFICIAL INSIPECTION FORM-NOT FOR VOLUITI'ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner: e to ttq b cl Date of Inspection: 6. now cONDInoNs RESIDENTIAL Number of bedrooms(desip):_,&OOY Number of bedrooms(actual): r DESIGN flow based on 310 CMR IS.203(for example: )10 gpd x;#of bedrooms.): YyQ Number of current residents: 8 Does residence have agarbage grinder(yes or no):A-10 Is laundry on a separate sewage system(y or VO): [if yes separate inspection required) Laundry system inspected t or no):LW Seasonal Use:(yes or lto):/ ears usage d readings,'f available Last Z y (gp )� Water meter g ,t Sump pump(yes or no):A-10 Last date of occupancy: COMMERCIA[/IN'DUSTRIAL Type of establishment: Design flow(based bn 310 CUR 15Z03): d Basis of design flow(seatsfpersottstsgftetc.): Grease trap present(yes qr no): Industrial waste bolding tank pre es or no): Non-sanitary waste discharged a Tide 5 sysretn(yes or no): Water meter readings.if,a bie: East date of occupant OTHER.(d c}: GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or 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 ;_brained from system owner) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of 311 comp; nts. in (if known)and solace of information: 10 & `� Were sewage odors detected when arriving at the site(yes or no): A)Ir 6 i Page 10411 OFFICIAL llVSPEC'I'IOPI FORM-NOT FOR VOLUNTARY ASSESSMENTS ACE SEWAGE If SYSTEM M P'ECTION FORM SUBSURFACE DISPOSAL PART C SYSTEM INFORMATION{comti=4 Property Address: 26 Owner: Date of inspection: o R e dr S eX tot%31 oy SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal System iticludiug ties to at least two permanent mfemnee ladmearks or benchmarks.Locate an welts within 100 feet.],orate where public water supply ebtas the building. i� Y LO CATION SEWAGE PERMIT NO. M114 VILLAGE ce. INSTA LLE'R'S NAME i ADDRESS 6 U I L D E 0 OR OWNER Ze v DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �^T �, �� es �b s�P r <�> �� THE COMMONWEALTH OF MASSACHUSETTS,JEC1 TO BOARD OF I-IEALTHitysTABLE r CONSERVATjcN c>[. . U--------------OF.-.-. ......--. CQM � ....--...... �v�P7 --------------- - SS101Y Appliratilan for Disposal Works Tonstrnrtinn Vrrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ................ _....._.....Iq �!��,r.& .., ,t .. ! ,, -: ..................... •o ti -A dress ._..f .:... t ...�....`......................••-••-..... fir o1 ... .- � P � ,� -- -. Owner / ��, Address - -- Lr7 --lY`L/LG.irS tl�� ...............•-•--_..._.................-•-•-.... "1.l ..... Installer i '.. ..................... Address Type of Building Size Lot............................Sq. feet Dwelling�o. of Bedrooms_____________��_ ___.________________.__Expansion Attic 41 Garbage Grinder (� aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -.................................................................... W Design Flow................ '................gallons per person per ty. Total Nly flow------------- __.3_�'J........___._gallons. N Ri Septic - nk— i��d capacity_kX)Ugallons Length_^_�a.___ Width________ _______ Diameter................ De th_4v .....(M Disposal,`1Vo.......1............ Width__:'F. i...... Total Length....s�.L�.a�----Total leaching area. _Q_....sq. ft. Seepage Pit No________________,___ iameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (�') Dosin�jtank ) aPercolation Test Resul s Performed by...I? ...... =t Date_+tgfe t ._..._... a Test Pit No. 1.�..z'_minutes per inch Depth of Test Pial___: ______.. Depth to ground water a` __ P 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water___9..k............. O Description of Soil---•----oa1..... 1. ...�r � ........................' (xj --••-----------•--------�--•------------- ---------------•--------•--........_----•-•--•---•-..._...-------I-----------------------•----•--------------------------......---•--•....._...-------- W �when _ - 9�__________________________________________________'________________________U Nature of Repairs or Alterations—Ansplicab� ..----------•-------------------------------------------------•-------------_..._. ...........................................................-............................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT1 U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ed by—the boar health. Si ned......_... --- -- / Date Application Approved By --- ' 5`---L-0...81............ Date Application Disapproved for the following reasons________________________________________ -- ..._.._..._ --•-------•-------•--••-•-------------------------•----------- ----------•--------•-----------------•-----------•-•-...------ Date Permit No._E.......•-- ....---..... Issued_ Date NO.. FEs...3.o../....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ! --W..�..............OF.......1..... c f-........ Appliration for Disposal Works Tnnstrnrtiun Vrrmit Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal Sys em at: _ dress Lot No. ........... __ ..._. ....................................... / �x__...a. : ... y lt1 Y. ;.► , ----- Owner Address Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............__).........._.._._.......Expansion Attic ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -•---•------------------------------------------------------------•---•--------------------------------....---••-•-•------....-•----••............--•• W Design Flow................G]5 .................gallons per person per qay. Total daily flow.......... .............gallons. WSeptic it 'd capacity.lq(?Ugallons L`ngth!R::-.6_.... Width.4-:..!P. Diameter______ ________ De th_4-__~-.40.� x Disposal h=: 0. ......t........'_. Width.._k..2--._._._.. Total Length-___;A_-_.... Total leaching area.KLO....sq. ft. Seepage Pit No* •-•___-___.-.__,-_--Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (Y ) Dosinr�-;tank ( ) e Percolation Test Results Performed by...i V_ ? __�`" _"_�_ _ ' '... Date.+ ?-a_1._%1............ Test Pit No. 1................minutes per inch Depth of Test P -___t..A......._ Depth to ground water4dJ _fa'._.1 J fs, Test Pit No. 2.........._.....minutes per inch Depth of Test Pit__�.............. Depth to ground water... -.!.............. �i t................. .... I Descriptionof Soil-------. tb ,0 -- ........ = ...................................... J..... .............•-•-----•••••.... .U .........................-----------------------------------------------------------------------------------------.•---------•--•-•--••--------••---•••------....._..........._•---.............---•---- W .................. L/- -"�`-1T------=---�-.. .�--- - "-' . ---------•-------•--------•--------------------------- ------------------ M. : 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 TITTIE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be in is ed by the boar health. Signed.---• --- ----u--••t...............-••--- •-•=---------..:------.._...---•----- ................................ Date Application Approved BY ........... ........ •...... --/.. --------------------•----•-- ..--T, Date Application Disapproved for the following reasons-------------------------------------------------------------------------•----------....._........----.....----- ----------------------------------•--•--•---•----------------•-•-------••..... --•------•--•-••---•---------••-•-••......•...---•--....._.__. f �Permit No. . - Issued ate . ..---- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................I....................OF....................................................t................................ Trrtifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY---------------- s�------.-.--.---.----.--..-----------------------------------------------------------------•--.-.------------------------------------------------------------------------•------------ 7 �n Iler ....... ............................ has been installed in accordance with the provisions of TIT .F 5 of The State Sanitary Code as described in-the s application'for Disposal Works Construction Permit No.__.R.!_�_..�_S.6.............. dated----------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / DATE...................................J 2 c?{��•-•--•---------------•---- Inspector.............. - -.L. ..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �'`ri/t 4^...............OF........ � �rhdalc. 41 ............ ............. .............. ... ,...------•--•--...•----............... ..� . L�............... FEE..--..r"T._tf.�t........ Disposal Works %Tnnstrnrtilan rrrmit Permission is,hereby granted......... 9zc./?�'n--........... ./i, 4--f 5��...... to Construct ) or Repair ( ) an Individual Sewage Disposal System at No....... ......... .-- --!!.'''f'�=;- ...................................................... .._...•- ^ *r^ a +4, ``•., — - Street a .y%! as shown on the application'f'or`�isposal Works Construction Permit No�................... . Dated.._ ................. 1 oard of Health DATE__'`./._..._�__^.� I I --•-•- ....-•---- ................... '» r. }} Y F x• FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS h r N-4,(j 41 3-1 c� �16 ti cY,c� i Piu 14 MOT IZ or- r1olula 4 a f i , tt�f�lt1 t c.c�f� ' ls� /��.7 - ! �::r _ .-- —-- WO, I1av c. i - + . i -x a k1C5 (,1 a s-rA lw. ikk OF t_ S fis Jk #4 k1l�t t,EAMTIN ' , T 'G. �"..i.>S 6c✓ e 3Sw . rA�1 ` z. t � ..s ` C�. .. : �f" r .14 It r Yl * . �r.8 ) (r (` .;- ..., ,.� � ..'^.. . ; .. :.... . a f} �.. .. fwy��wf 4 5 ✓' � 'w* .4nL a✓`''r�p,«d' '«w,,,'° .: K '^' i...K . 1 "*' 5..* �� '°'a F 5�.J M A...,,., �.7 "'(� {{ "' i c Maas a �.Ra'.y..Fsr^. .--s