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HomeMy WebLinkAbout0020 NATKA DRIVE - Health 20 NATKA DR., CENTERVILLE A = Slate Illl ° UPC 12534 0.2-153LOR HASTINGS,UN 3J' 30�>ux3 �� d, c v�lc�F o»7s ' DIG SAFE NUMBER Date:., June 22, 2001 PERMIT- C.82 S_4O M.G.L_ - - START DATE In accordance with the provisions of Chapter 149.M-G-L.as provided in Section l0A this perutit is gauted to: Name: Anerigas ' (Fr4 vor oCpcno�6r.w r r..jsv.a.) For Permission to:"install and maintain one 50 gallon above ground LPG storage tank. State clearly the piupose for which the permit is granted: -in accordance with CMR6 and NFP 58 Restrictions: Location20 Natka Drive Centerville, MA 02632 Yish residence Fee Paid: t ,— This Pcrtuit Will Expire On: Sigwturc and Tide of Official Granting Permit C-O-M form # 49 =I(TALS PERMU MUST BE CONSP3CUOUSLY POSTED UPON TgE PREMLSES.)c sew i ODVEVENC E 1VED 15200 NPBLE EC�FO H + . CO.M.MOIN EALTH OF MASSACHliSETTS _ EXECUTIVE OFFICE OF ENVIRONMENTAL: AFFAIRS „F DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON KA 0210S (617) 292-550u TRUDY CORE. Secre:ary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Conttnissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 20 Natka Dr . ,C entervilleName of Owner Roger Gardner Address of Owner: same Date of Inspection: Name of Inspector:(Please Print)Wm. E . Robinson Sr. I am a DEP approved s err!inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000) CompanyN�: WM E . Robinson eptic Service Mailing Address: PO Box 0 9, Centerville , MA Telephone Number: 7 7 5_8 0 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 see disposal systems. The system: asses Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails n Inspector's Signature: V Date: T The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS 4b �i E ovILU �, AUG 2 0 1999 1�� low"OFBARNSTABLE y ,: HFALIHDEPT. ,� revised 9/2/98 Page Iof11 n ►�� ✓r led on Rewded Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A i CERTIFICATION (continued) 'rop"Address:20 Natka Dr. , Centerville %)wrwr: Roger Gardner Date of Ins on: 1`3 � ' 9 � INSPECTION SUMMARY: Check A, Q, 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 es, 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 J - 1 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Natka Dr. , Centerville owner: Roger Gardner " 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 the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN 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 revised 9/2/98 Page 3of11 - J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 20 Natka Dr . , Centerville owner: Roger Gardner Date of Inspection: D. SYSTEM FAILS: You mus indicate either "Yes" or "No" to each of the following: 1 ave determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this d termination 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: You ust indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional offic of the Department for further information. revised 9/2/98 Pagc4ortl SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Address: 20 Natka Dr . , Centerville Owner: }� Date of IpAwa - Gardner Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes 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. V _ As built plans have been obtained and examined. Note if they are not available with NIA. _ 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. lJ _ All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: V _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)] _ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenaurik-0f Subsurface Disposal Systems. revised 9/2/98 Page 5ofII .f -tea. � 1..�-� �.. 'r*l. �_-...-- �_'�•-__..o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION 'roperty Address: 20 Natka Dr. , Centerville Owe: Roger Gardner Date of Inspection: 17-3 FLOW CONDITIONS RESIDENTIAL: Design�flow: a U g.p.d./bedroom. Number of bedrooms(design) Number of bedrooms (actual):3 Total DESIGN flow I(.0 Number of current residents: Garbage grinder(yes or no):_A,-% Laundry(separate system) (yes or no):,&—d If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): A O Water meter readings, if available (last two year's usage(gpd): 1998 116, 000 gal. Sump Pump (yes or no):_A,C) Last date of occupancy: 7-3a°-g - 1997 103, 000 gal. COMMERCIAL/INDUSTRIAL: Typ of establishment: Desig flow: opd ( Based on 15.203) Basis if design flow Greas trap present: (yes or no)_ Indust 'al Waste Holding Tank present: (yes or no)_ Non-s nitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last d to of occupancy: OTH R:(Describe) Last of occupancy: GENERAL INFORMATION PUMPING RECORDand source of information: System pumped as part of inspection: (yes or no)—_A, 0 If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM Septic tan kldistribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records,if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: X"t°1 Sewage odors detected when arriving at the site: (yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icontinued) 'ropertyAddress: 20 Natka Dr . , Centerville Owner: Roger Gardner Date of Inspection: BUILDING SEWER: (Locate on site plan) De below grade:_ Maten I of construction:_cast iron_40 PVC_other(explain) Distan a from private water supply well or suction line Diam er Com ants: (condition of joints, venting, evidence of leakage,-etc.) 74 SEPTIC TANK:_ (locate on site plan) 1 Depth below grader 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:`` Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Z/ j) % L Distance from top of scum to top of outlet tee or baffle: 9- 1 Distance from bottom of scum to bottom f outlet tee or baffle: /01 How dimensions were determined: 0 1,,,/L 'omments: (recommendation for pumping, condition of inlet and outlet t�o or ba les, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 4,1' A e GR SE TRAP: (locat on site plan) Depth elow grade:_ Materi I of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) Dime ions: Scu thickness: Dist ce from top of scum to top of outlet tee or baffle: Dis nce from bottom of scum to bottom of outlet tee or baffle: D e of last pumping: ' L Com ants: (rec mmendation for pumping, condition of inlet and outlet tees or baffles, depth,oI liquid level in relation to outlet invert, structural integrity, evid nce of leakage,'etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION(continued) 'top"Address: 20 Natka Dr. , C emterville Owner: R oger' Gard.ner Date of Inspection: 7—3 6 -7 TIGH OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate n site plan) Depth b low grade:_ Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensi ns: Capacit gallons Design ow: gallons/day Alarm resent Alar level: Alarm in working order: Yes_ No_ Dat of previous pumping: Co ments: (c ndition 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 equa evi ence of solids carryover, evidence of leakage into or out of box, etc.) PUMP HAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarm in working order(Yes or No) Com ents: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .r - PART C SYSTEM INFORMATION(continued) lrop"Address: 20 Natka Dr . , Centerville , Owner: Roger Gardner Date of Inspection: I_30- 9 C-1 SOIL ABSORPTION SYSTEM(SAS):_ (locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Altemative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic fail re, level of ponding, damp soil )ndition of vegetatio , etc.l 64 / C POOLS:_ (local on site plan) Numbe and configuration: Depth-t p of liquid to inlet invert: Depth o solids layer: lepth of scum layer: Dimensi Ins of cesspool: Material of construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspections j Com nts: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) P vY:_ ho ate on.site plan) Mat rials of construction: Dimensions: Dep h of solids: Co ments: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) -rap"Address: 20 Natka Dr . , Centerville Jwner: Roger Gardner Date of Inspection: 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) J �na N , t � W I revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) rop"Address: 20 Natka Dr. , Centerville Owner: Roger Gardner Date of Inspectiun: r 736-P 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 I�—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 __L'_1_/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) <Lf revised 9/2/98 Page 11of11 ASSESSOR'S MAP NO J. i PARCEL LOCATION SEWAGE PERMIT NO. O M 14Tk A b k 4<',-Ko 9 VILLAGE SIN TA LLER'S NAME i ADDRESS ROO sl-l- -tv 'eq ,.j Iq 4 S U I L D E R OR OWNER to DATE PERMIT ISSUED SCA 9 (9 DATE COMPLIANCE . ISSUED r 20.E 2 SIR rdj = a G - 3 -z-- rf 1.000 6A fib ASSESSOR'S MAP NO: q ' O H r ' 00 No.. . .. PARCEL NO.: FPS.. ..............:.... SIGNING�EcN' GINEER MUST SUPERVISE THE COMMONWEALTH OF MAS ��5kErT6$N AND CERTIFY IN WRITING BOARD OF HEW sT*+m WAS INSTALLED IN STRICT �.CC^ORDANCE TO PLAN. ........................ ................O F........................................---------.............------...................... Appliratiou far impasal Workfi Tonstru.rtiun rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ..----.... �Z�C.I ...... .�-e..........� .......----•------ ------------------L.. S" h, Location.Address or Lot No. ...., ".Jo . r✓AJ-1.............•-----•-•--........................................_ ......................... Owner Address ar !!9.011.hl � 0© QR l( ..S�... .... !-� --:�---•---------.- M Installer Address V Type of Building Size Lot.../ O O Sq. feet Dwelling—No, of Bedrooms................Z..........._.......__....Expansion Attic (�) Garbage Grinder ( ) `4 Other—Type T e of Building --__---- No. of persons............................ Showers G.i YP g -------------•--•-•-- P ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------- - w Design Flow...................5.5................gallons per person per day. Total daily flow.___.......__-,?0.....................gallons. W Septic Tank—Liquid capacity./AaD.gallons Length_/A_i.5'... Width...515.... Diameter................ Depth...1 ....._-- x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------- -:_-___--. Diameter......6.......... Depth below inlet..... ...-....... Total leaching area..95®....sq. ft. Z Other Distribution box Dosing tank aPercolation Test Results Performed by......... ................................� `_._. Date...._.a. Test Pit No. 1.....2.......minutes per inch Depth of Test Pit------- Depth to ground water..._&o�.l°..... G� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-------_------------- ....................................................................................................-------------------------------------------------------------------------------------------------------------------------- -----"• -- .------------ O Description of Soil 2.".......ZA4" °� '� -5 �------ -- �✓oj •✓ ��` J.. (' .....-- " �............../��'�1�.....----!-1.. •--�o-------�r'�T l°!�. Cw_co w UNature 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 TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i the board of health. Signed ... . --•-•-. . •----•----------------•-- ,f� Dag Application Approved BY ----•-••.-• --Y..:: _•--•--•----• ...... ......• .......-r� 3 Dat� Application Disapproved for the following reasons---------------•--••--------•------------------------------------------------•--•----------...--•----•--......... ---------------------•---....-----•----------------...------....---........-----•----------•-••-----•-------•--------------•----....--------------------•-------•--------------•----------••---......--- Date PermitNo......................................................... Issued_............................ ........................... Date ,i Board of Health Town Hall Barnstable, MA. 02601 RE: Lot 65 Natka Drive Dear Board: I certify that the sanitary system shown on a plan for Robert Manni, dated 6-10-86 was installed according to plan design and is more than 25ft. from the drainage easement .on same plan. Thank you t o MARVIN 4 E. cis MORAN � #23417 ass/Oh.AL��G� Fss............._....._..... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....................OF.......................................................................................... ,� lirtt#inn for Disposal Works Tonotrnrtiun Pami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 6 S ---.:...----•- _. . ...��.... . . ...........0 ��r.....-............... ............................. °--.....---•--.........................._.. Location-Address or LotNN Owner �0 OQ /J c{�Q Is�'ll ress W �I�3�Viv 1 ................. ..--------------------...•••--••••....... .... . . ................ ,.a ---------------------------- .._ .. Installer Address Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms..............2........................Expansion Attic Garbage Grinder ( ) Other.—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q+ Other fixtures -------------------------------------------•-•--------.....---.....---------...-----------....-----•-----•------•-------••--••••......--••••..._•••... Design Flow............ 5...:...................gallons per person per day. Total dail flo ....... -_.__._.....____.........gallons. Septic Tank—Liquid capacity../��%allons LengthlP.: ... Width.Jrr.- .... Diameter................ Depth............ x Disposal Trench—No. .................... Width.................... Total Length...._.._.._..__._. Total leaching area...................sq. ft. Seepage Pit No......../_.......... Diameter......9.......... Depth below inlet......?--.--_..... Total leaching area._2�2.....sq. ft. Z Other Distribution box ( ✓) Dosing tank ) '"' Percolation Test Results Performed by.. �� ©�� Date... �O BG. ,.a Test Pit No. I.....I_.......minutes per inch Depth of Test Pit-----I`f...____.. Depth to ground water..A.. .... Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .......................................................•-----•-•---•--....------......---•--•-••--.............-----•--•---•---------•-......-•-••••......... 0 Description of Soil........................................................................:-.....-----------------....------.......----------------•-----•-----.....-•---•......•••••..... W - .. ---------------- -----------------------•------------ -----------...--------------•---•-•------•-•----------------------------.... . . ...--•--•--------.........----•-......._......._... .._.. ..... x 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 TITU 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i u the board of health. Signed..-• .----••----••------...•.........................•_ G _74 ----_---- y Date Application Approved By.........................................f�.....�:.?..._. _. ..�.. .. - ... _ ... 1 ••-- jf ----. Application Disapproved for the following reasons'�v---------------------------------------------------------------------------------i-.........:................_ .........................................••--•--.......--•--••---•-•-•-....•••. ..................._......_..• .Date -._... PermitNo...................................................---- Issued................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... ntifuttir of wo ( utplittnrr I IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bya. .�►�.�„--.... --1.-`..--�-V_ j4V-4.................................... ...,..a_.----......-----•----. ................... --... --.............._...._ r /� J Installer at----4..677----.---K c " - .1 st .............. ,r,. has been installed in accordance with the provisions of TITLE 5 o The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated..............,.................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSA9"I", ���TALLATION AND CE MUST SUPERVISE BOARD OF HEAL��H SYSTEM wAs I CERTIFY IN WRITING I �.. .........................OF._..................._....._...._.......u.:-n�, o �E pi'pLA"N'N Tq �N S7.RIC�- / aispa l Works Tnns#rixr#iun Vrrmii I -' 1 Permission is hereby granted. . t... ,n/.Fi l.�:.......................••............••••..... ............... to Construct..,( ) or Repair ( ) an Individual Sewage Disposal System /,�,�------�-6.- .!ice eq.i .... - �"P. ?T"Street No.... ��" ......•. -•Street -•...........................•--.............................. as shown on the application for Disposal Works Construction Permir6No_,.p_........... Dated.......................................... ........... P...... DATE............... ....----.I..............................••••:........... �a akth FORM 1255 A�M�S L131P. aSTON Yet s...+E'V • T,dx/C Z 33a >l L SC /� �•4L,.,. 61� /o • 2 /. ' ` LAZj �.�� /03 0 /02 2 p + ,+3 m II" i A-71^1. 442 LESS '7Gw.✓ 1�✓4T�ie .c1./.A�lr��-� /03 . � � i Q /off • � . .. Ems=-- /U/ • v- -/cam ® o— A. / G,dL . IAIV. / �� r✓EL «ram �^� ru qg y 17 N!� 1R/•d� tN OF MARTIN yN ca MORAN - ��. 2 17�° 2 �E/Z7' 1A-;4Q)/,,/1"