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HomeMy WebLinkAbout0052 MERIDETH WAY - Health :')' 2 Merideth Way Centerville N A— 148 152 N SMEA, No. H163OR UPC 10259 smead.com • Made in USA Aoyctp 2J c�a m � z I -� CO;1IMONVkk EAL;TH OF 1VLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS.' - O PROTECTION yr > �1EFA�.TME?ITT OF ENVIR `N P MENTAL ROTECTION TITLE 5 OFFICIr,1L INSPECTION FORM, NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: d j Owner's Name Owner's Addre Date of Inspection: (/?j•P>yX i5: 'sue r P (P p ) � �86r42 � � Name of Inspector: lease rint � E^ � ,.Company Name' � e N .> PU Mailing Address: C7 _ Telephone Number: ': t" CERTIFICATION STATEMENT I certify that l have personally inspected the sewage disposal system at this address and that the in rmation 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 ofon:site sewage disposal systems. I am a DEP -approved system inspector pursuant too Section 15.340 of Title 5(3.10 CMR 15.0001). The system: /Passes i Conditionally Passes I Needs Further Evaluation by the.Local Apprjoving'Authority Inspector's Sighnture: _ Date: 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 as a design flow of 10,000 gpd or!b eater,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 theicondifions.of use at that time. This inspection does not address how the system will perform in the future iinder the same or different conditions of use. r Title.5 Inspection Form 6/15/2000 page I Page 2 of l I OFFICIAL INSPECTION:FORI'o7[=NOT FOR VOLUNTARY .ASSESSMENTS SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION]FORM PART A / CERTIFICATION (continued) Property Address: Owner Date of+b-dpection. Inspection Summary: Check A,B,C,D or E./ALWAYS comp]ete.all of Section D A. System Passes: I have not found any nformationwhich.indi'cates 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 be replaced or repaired..The system, upon completion of the replacement or repair; as approved by the Board of Health-will pass. Answer yes,no or not determined(Y,N;ND)in the 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. . ND explain: Observation of sewage backup or break ouror 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 obstruction is-removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: Paee 3 of 1 d OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSLJR ACE SFEWAGE.DISPOSAL SYSTEM INSPECTION FORM PART :A CERTIFICATION (continued) Property Address: ) lxxiy Owner: Date of'Wectidn: d 0 . I C. Further.Pvnluation is Required by the Board.of Health: f 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. j 1. System will pass unless Board ofHealth 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'. I _ 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�saltmarsh. I i i i 2. System will fair 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 surface water supply or tributary tb a surface'water.supply. The system has a septic tank and SAS and the SAS is within'a Zone ] of Ia public water supply. I } 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 blut50 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 coliform bacteria and volatile oreanic 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, provided that no other failure criteria are triggered. A copy of the analysis most be attached to this.form. i 3. Other: i . 1 Page 4 of. 1 1 OFFICIAL.INSPE+CTIOiti FORIM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SENVAGE I)ISPOSAI .S:YSTEI'd INSPECTI01 t.FORM PAIN A CERTIFI CATI ON,(continued): Property.Address: 'Owner: sV 021-1 Date of Iop.ection. D. System.Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each.of the.fo.11owing.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 SASorcesspool 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 Iess than %day flow Required pumpir'g 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&round 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 alcesspool.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•privyis:less than 1.00 feet but greater than. feet-from a private water supply well.with'.no acceptable,-water quality analysis,.[This system.passes:if the well water analysis, performed at..a iDEP certified laboratory,for colifor.m.bacteria and:volatile organic compounds indicates that th,e.well is fr.ee.fr.om,pollution from that.facility and the:presence of arnmonia: nitrogen and ii'Arate' 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 forrim.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria.exist as described in 3101 CMR.15:3.03;therefore the system fails. The.system owner should contact-the Board of _ Health,to determine what.wiII-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• 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) 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 nitrogen sensitive area(Interim Wellhead Protection Area—IWP,A)or a mapped Zone II of a publicjwater 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 thelarge 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 3.10 CMR 15.304.The system owner should contact the appropriate regional office of the Department; s Page 5 of I OFFICIAL INSPECTION FORM, NOT FOR VOLUNTARYIASSESSNi]ENTS SURSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART F CHECKLIST Property Address: D 1 Owner: Date of ll ection: 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 anv 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) T Was the facility or dwelling inspected for sians.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 ? . v _ 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: Yes no Existina 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 C�iR ]5.302(3)(b)J 5 Page 6 of 11. OOFFICIAL INSPECTION FORM—- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.C SYSTEM INF.OR1MATI01 d Property Address? _ � Owner: Date,of spection: f (p FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms (actual).: DESIGN flow based on 3 I,O,CMR 15.203 (for example: 11.0 gpd x'of bedrooms): Number.of current residents:._ 'tJ Does residence have a garbage grinder(yes or no) p Is laundry:on.a separate sewage system (yes or no):JY.C)f if yes separate inspection required] Laundry system inspected(ye .or no):_M{b Seasonal use: (yes or no): 0 Water meter-readings. if available (last 2 years usage.(gpd)): O (115 Me Sum u es or n o Sump P ) Last date of occu ancy: COMMERCIAL/INDUSTRIAL Type of establishment:. Design.flow(based on3I0.,Cv1R I5.203): gpd Basis of-design flow(seats/persons/sgft,etc.): Grease trap present(yes or no); du Q 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/user OTHER(describe): GENERAL INFORMATION Pumping Records r Source of information: Am? t Was system pumped as part of the i spection (yes or no): If yes, volume pumped: gallons --How was quantity pumped determined?,-,' Reason for pumping- TYPE. OF SYSTEM •,, eptic tank, distribution box,soil absorption system _Sin*ale 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): proximate age of all com onents, date installeda"e (if known)and source of information: _:mac !,��� X eC'7 u . Were sewage odors.detected when arriving at the site(yes or no): 6 Page 7 of F1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INEORMATION(,Continued) Property Address: it- 4 k Owner: Date of ection: f ,,, BUILDING SEWER (locate on site plan)) /o Depth below grade: Materials of construction:_cast iron 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: d✓(locate on site plan) Depth.below grade: Material of construction: v-'concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:— .Is age confirmed by a Certificate of Compliance (yes or no):—(attach a copy of certificate) Dimensions: ' ',�(r✓O X' � Sludge.depth: Distance from top of sludge to bottom of outlet tee or baffle: . . Scum thickness: ^ h y Distance from top or scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffler JI How were dimensions determined:�K)Aj�,1w 6 � Comments (on pumping rerommerkationt in and outlet tee or baffle condition, structural integrity, liquid-levels a related to outlet invert, evidence of leakage, etc.): ' 2" GREASE TRAP (locate on site-plan) Depth below-srade:_ 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 oflast pumping: Comments (on' pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,-evidence of leakage, etc.): 7 I Page 8 of I bFFICIAL.INSPECTION FORM-NOT FOR YOLUN` 'ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of IA pection: d � . TIGHT or HOLDING TANK: l (tank must be pumped at time of inspection)(loc.ate.on.site plan). Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(ezplain).:- Dimensions:' Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no):. Alarm level: Alarm in working order(yes'or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site.plan) Depth of liquid level above outlet invert: s Comments (note if box is.level and distribution to outlets al,.any evidence of solids-carryover, any,evidence of. le_*age into 9r.out 9f box, ete : AM 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.): Page 9 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INF.OR.MATION`(continued) Property Address: d Owner: Date of Ii ection:-.,; „ SOIL ABSORPTION SYSTEl!/I (SAS): i (]ocate on site plan, excavation not required) If SAS'not located explain why: Type . 'eaching pits,number: r leaching 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 Lz .CESSPOOLS: cesspool must be pumped as part of inspection)(]ocate on site plan) Number and configuration: on: of liquid to inlet invert: Depth'of.solids layer: iht Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow(yes or no): . Comments (note nndition,of soil_, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY:/LO (locate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition of soil, signs ofhydraulic failure, level of ponding, condition of vegetation, etc.):. 9 Page 10 of 11 OFFICIAL INSPECTION FORM .NOT FOR VOLUI^ZT'A7. Y ASSESSMENTSSUBSURFACE SEWAGE DISPOSAL SYSTENI.INSPEC`I`ION FORM PART,C SYSTEM:JNFOPNIATION(continued) Property Address,:1f � s� dam' Owner' , Ate. Date of Siplection:. A../Jr ' ', � 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. a° �10 ad i �t i �aP� Paee 11 of l l OFFICIAL INSPECTION FOR-Mf NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / A Owner: Date of I ection: SITE EXAM Slope . Surface water Check.cellar Shallow wells Estimated depth to ground water .J� 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: 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) t,/Accessed USGS database-explain: You must describe how you established the high ground water elevation: t ll LOCATION l_ SEWAGE PERMIT NO. Lc l l iM e�'✓' C7 1 f^ w a1 Y VILLAGE r INSTA LLER'S NAME & ADDRESS e 1 W. `bI UILDER OR OWNER V DATE PERMIT ISSUED C— DAT E COMPLIANCE ISSUED Feb �� ®cr- p L4© 'VZ r/ Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION d' Site Location: j' ///y, Lot No. Owner: j,$f� C1� 9 /�2�` Address:" Contractor: fit^: Address: 15­,� ,�5� "Sz STEP 1 Measure depth to water table tonearest 1/10 ft. ............................................................................... .Date. month/day/year STEP 2 Using Water--Level`Range Zone and Index..WO Map locate site an&determine: O.ApPropriate index well.................................................... . OBWater-level range zone ..................................................... .........._ .. _...__................... ......... STEP 3 'Using monthly report"Current Water Resources Conditions" determine current depth to water level for index well ........:........ . month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .......................................................................................... *7 STEP 5 Estimate depth to high water by.subtracting the water- level-adjustment (STEP 4) from measured depth to water level at site (STEP"1) 1 C Figure 13.—Reproducible computation form. 15 LIM :r C THE COMMONWEALTH OF MASSACHUSETTS EE tic -�i BOAR® OF HEALTH . ....................OF. . � � -------------------------------- firation for' hspoaal Works TomiUn tiun Vprrmit S�0 % on is hereby made for a Permit to Construct (C-''or Repair ( ) an Individual Sewage Disposal System at: /------------ �.1 e+----------------------------------r _.. ---------------- ....... Lo 'on-Address yl Address O ner - •-- s __..•...............................:............ � � � ......kZ�. �/ �. Installer Type of Building Size L Size Lot__1f1,..�.��.�. feet Dwelling—No. of Bedrooms................_........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) 04 Other fixtures..........:............... ....-•---------•----------••-----•••---------••-•-----•-••...-•------•-••••---•• ............. -----•----•--- W Design Flow.................:676..................gallons per person per day. Total daily flow.................... ____............gal ons. WSeptic Tank—Liquid capacity/ .gallons Length__/O__ v Width_.,/V. .__ Diameter................ Depth.... x Disposal Trench—No. .................... Width.....__........_._.. Total Length............. Total leaching area___-_•--___•.•______sq. ft. _._.. Diameter..X.y�. s�.. De th below inlet._...��_ .�� Total leaching area.... Seepage Pit No....__ _..._ p g igvao Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed ... Date_ j _ e _-.. Test Pit No. 1......Z......minutes per inch Depth of Test Pit--- Depth to ground water _ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ KI �C-----•/v--•--------••••••-••-••.......'_'_'•'-'•••'....'__" "................. ......................................... O Description of Soil-----�.�.I&..--•-/�C�..S.tdl� ,�����c� �� 'f��T �.�✓�...- - x -----------------------------------•-•-----•--••---•-----------••---------•••-•-----••----••-•••--•----•••----••-----••-•----•.....•---••-------••-•••••-••-••••-•---•---•-----•--••----••-----...•-•••- 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 '!'T_ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc ha4is ed d of igned - --------- ---------•---•-------- ....... --- Application Approved By.... ••• ••-•---•••------••--•-••• ..................................... ---•-� -p. _It ��.-•---- Do Application Disapproved for he following reasons:--•------------•------------------------------------------------------------•------------------------•-•----•--- Date Permit No......v ----..Sg----•---•--.....-•--•------- Issued... j Date N .F � Fps.............................. OF M THE COMMONWEALTH OF MASSACHUSETTS �o ROBE BOARD OF HEALTH T v% a �rA .. '✓:�� .... OF..0 D • �r,% �. c. .................................. oRAY a IirFa#ion fur Diii'op al Vor . y Cnayustrj�rtinn rrmit cr fE�� FS�1riv tion is hereby made for!i Permit to Construct (4- •'or Repair ( ) an Individual Sewage Disposal ............. ._.... ---------------- ...._..---•---------- �.--....�(�`---- ----- -----•--•--------- --•- Location-Address or Lot No O ner �� Address ) a / �s' !.:....................•-•-----•---.._...._...... Q,w✓! li ._. ��? .?"° � �' Installer Address/ .d Type of Building Size Lot_&.$WZ_........Sq. feet Dwelling—No. of Bedrooms.............. _____________ .........Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------•--•--•--..................._.._........----------------------------...•-•-:•------..........••................-----•---....-----•-- d W Design Flow................* . ...____gallons per person peer day. Total daily flow...............A✓' .................. lons. WSeptic Tank—Liquid capacity/ ...gallons Length.V 1 Width.'.. _._. Diameter______---------------- Depth_ x Disposal Trench—No..................... Width f.....rr_.._._.__. Total-''Length........... _...�s Total leaching area....................sq. ft. Seepage Pit No.....„e__.._...... Diameter./V..':�S/°.._... Depth li low inlet.... _' ..... Total leaching area-_ ..6 Z Other Distribution box Dosing,tank Percolation Test Results Performed by4. 1 .!V4 ' ! S!__rlaC _. Dat a minutes per inch-'Depth of Test Pit �� F.�f.�Gx'+1. /eCb Test Pit No. L._._�.._.__. _. Depth to ground water ._ Test Pit No. 2...............minutes per inch. .Depth of Test Pit.................... Depth to ground water...........:_____....... W ----•----.. ......-•------_.. .......-•••- ••--•------ ---- -•-- O '� *�................................ ., x Description of Soil---- - � --------�e?�-���'� ��1r���r.�..�---{�----•/��?�_��,��"--� - �?�!�✓.��'__ W •••---•-••-••._---------------.................•-•-• ---•--------------•--•-----•---------••-•••--•---•---------------------------------------•-------------- -------------------•--•--. ---- UNature of Repairs or Alterations—Answer when applicable............................................................................................... Agreement; The iiiidersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued b the board of health. ��___••-••------- ApplicationApproved By.... ••_----• •--•-r---•--•••--•4................................................ Date Application Disapproved.for the following reasons:.......................................--•-••-•-•••-••-••-•••----------••--••-•....--•••-......•-•-•-•--------- ........................................... ---•_._. .._•_ � ----------------------------------------------------- Date Permit No------------------ - --------------__----__ Issued Date THE COMMONWEALTH OF MASSACHUSETTS BOARD .QF-. HEALTH Lf.� f.0 ......... OF.,...... r. - .............................. Irdifirtt#.r of Toutplihitrr N�THIS IS. Y, TlW t %Widual Sewage Disposal System nstructed ( ) or Repaired ( ) by -- ------------pr..._.......fhb 'f=:� --'$ .t: ------ ..................................................... Installer at..............................................................................•. has been installed in accordance with the provisions of TITSE . 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---------_____ _____________________•___• dated----------------- !� THE SYSTEM IAIILLANCE FUP�®�O�THIS CERTIFICATE TISEACTO_RY. SHALL NOT BE MOUE®���� RANTEE THAT THE DATE................................................................................ Inspector.................................................................................. Yr THE COMMONWEALTH OF MASSACHUSETTS r ` BOARD OF HEALTH r ' SJtg '. ..................OF......: ............................. ®� No......................... FEE....�..........-- Disposal nprkv 199nnotrurjtion rraYtit a Permission is hereby granted......R_-j•••••.`� ..0!.\ -••---•---------------------------------------•- -----•----......... ............. -...... . to Construct X or Repair ( ) an Individual Sewage Disposal System at No........try....�5- --------Y1/L 4_j' .4.i �{ Street as shown on the application for Disposal Works Construction Permit No._ .-. ,_ Dated..... .`.�.. .-....................... ................. --- - - - -------•------••--•------------------------- DATE-------'=-- ---�-5------••--•--------------- _________________________ Board of Health FORM 12551 HOBB & WARREN, INC., PUBLISHERS .i3i!...°It7Ri'F.21'a 13r+4's.rfa•:nwtiFmr*+.,Sro:r,..:Axier •¢:+«^sp,EMaraa:w •>x'+. `.rr-,�v.r^aaF.._..n.,,..u..,,.»."..urea.n,_.vv..wm arsacsr,:x.u,.-er3a:w.an+,:vuraww+o.. to AM I .- r _ 4 n _ Y ��'Js- ? + � ? rf ..._....F,' f ��`.r�.�� �.�f.y _.-_.�.__-..� �t � �f �tps1_�.. 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