HomeMy WebLinkAbout0104 OLD STAGE ROAD - Health 104 Old Stage Road, Centerville
'49-tcvcEraco
UPC 12543 o-
No
HASTINGS. MN
t �
�\ COMMONWEALTH OF MASSACHt'SETTS
E?_'ECL'TIVE OFFICE OF EWIRONMENTAL AFFAIRS
DEPARTMiNT OF ENVIRONMENTAL PROTECTIO.N1Vgj
ONE WINTER STREET. BOSTON. NIA 02106 0
J
t 23
�997
T O%O THD pST�Lf
_ T.
Dl C0
W'1LL1AM F WELD � � Sc:reta.•+
Govemc
ARGEO PAUL CELLU&I
DAVID B STRt'}it
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commission
PART A
CERTIFICATION
Property Address: 10(A OVN 9Mv+�t_:'tA.s QXN"M aw l\1 e., Address of Owner: C_V`o.a..les
Date of Inspection. 10�2AA 51_ U2t�3L Of different)
Name of Inspector:
I am a DEP ap roved system inspector pursuant to Section 13.340 of Title 3 010 CMR 13.000)
Company Name:t}/74 ar•-r'c Eir rr•rrj K #" P r.'�.eL/
Mailing Address: Pin Afnx e_32?�f IH Al &4eg- H P� p O-64-C/
Telephone Number: r G �;i—
CERTIFICATION STATEMENT
I cerot that I have personall\ inspected the sewage disposa! s•ste^t a; this address and that the information reponed below is true. accurate
and cornolete as o-*the time of inspe:-,o-. .The inspection was penormed basec on m% training and experience to the proper iunQton and
maintenance of on-sae sewage d,sposa systems "The systern
Passes
_ Conc-no,�a�;% Passes
Neec= Furtne• E-a'uat:on S\ the Local Appro\ rig A:dtnorm
Fa.-!
Inspector's Signature: Date:
The S-s:e^ Inspeco• sha" submit a cop of this inspection reper to the Approving Author^- within thirty (30.1 days of completing this
inspe ,or.. It the s�sterr. is a shared system o• has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit
the repo^ tc the appropriate regional ofiice of the Department of Environmental Protection. The orig:nat should be sent to the system owner
and copes sent to.the buve•, r applicable, and the approving authortm
INSPECTION SUMMARY: Check A, B, C, or D.
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the.failure critEria,as defined in 310 C.MR 15,303.
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 NDt. 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
Cornpltance (anachedi indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not meta!, is cracker, structura!ly unscund, shows subsartial infiltration or exf,ltratton, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
tre,•:r&d 04'.s '9'1 Dw• 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
.' _. PART A _
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES tcontin-i4d
Sewage backup or breakout or high static water level observed in the distributio box is due to broken or obstructed
,pipets):oi'due to a broken, settled or uneven distribution box. The system wi pass inspection if(with approva! of the
Board of Health;.'-Describe observations
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to roken or obstructed pipe(s). The system will pass
inspection if twith approval of the Board of Health) - -
broken pipelsi are replaces ==yw
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALT
Conditions exist which require further evaluation by the Boa of Health in order to determine if the system is failing to protect the
public health, saiea-and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DET RMINES THAT THE SYSTEM IS NOT FUNCTIONING 1% A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND AFETY AND THE ENVIRONMENT:
Cesspool or prn% is within. 50 fee: of a s ace water
Cesspool or pri�� is v�ithin 50 feet of a rdering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF EkLTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MAN 'ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank d soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributan to a surface water s ppl.
Tne systerr. has a septic to and sod absorption system and the SAS is within a Zone I of a public water supa'y we!I.
The system has a septic t k and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septa ank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply ell, uniess a we!I w•a:er ana!ysis for coliform bacteria and volatile organic compounds indicates that
the well is free fro pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. ethod used to determine distance (approximation not valid).
3) OTHER
travlls'_ 04 ".5'f'? face 1 of EC
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either 'Yes" or as to each of the following
I have determined that the system violates one or more of the following failure criteria a< fined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to d ermine what will be necessary to correct
the failure
Yes No
Backyp of sewage into faciliry or system component due to an overloaded r clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground of surface aters due to an overloaded or clogged SAS or
cesspool.
Sta;ic hou,d level in the dis:r6xior, box above outlet invert due to a overloaded or cioggec S1S or cesspoo!
Licuid depth it cesspool is less than 6- below invert or available v lume is iess than 1/2 day flew.
Recu,red pumping more than. 4 times in the last year NOT due clogged or obstrucea pipe s
Numner o' times pumped —
Any pon;on o;the So!! Aosorptior+ System. cesspool or pri is below the high groundwater e;e.•atio-
An. port;or. o'a cesspool or pri•- is wrthir. 100 feet of a urface water supply or tributal to a surface Mate, supply
And po^.ion of a cesspool or prnN. is wit'ir a Zone I a public we!I.
An\, pc^;o-. c:a cesspoo'.or prwv is w;;hin 50 fee: f a prna,.e water suppl% wel!
Any pon,or. o:a cesspool or privy is less.than 1 feet but greater than 50 fee: from a private water supply well with no
acceo;abie Nate, qua!in analvsos 11 the well h been analyzed to be acceptable. arach coca of well water analysts for
cohiorm bacte,ia vo!a:,le organic compounds ammonia nitrogen and nitrate nitrogen.
Ej LARGE SYSTEM FAILS:
Lou must indicate either "Yes' or "No" as to each of the fo! wing.
The io!iow:r.g criteria aop;% to large systems in a di;ion to the criteria above.
The system serves a facility with a design flow- f 10,000 god or greater (Large System; and the system is a significant threat to
public hea!th and safer and the environment cause one or more of the following conditions exist
Yes No
the system is within 400 feet o a surface drinking water supply
the system is within 200 fee of a tributary to a surface drinking water supply
the system is located in a itrogen sensitive area (Interim Wellhead Protection Area -IWPA) or a mapped Zone 11 of a
public water supply well
The owner or operator of any such syste shall bring the system and faciliry into full compliance with the groundwater treatment program
requirements of 314 Crv1R 5.00 and 6.0 Please consult the local regional office of the Department'for further iniormation.
(revised 04 ' 5'9"; ••..
• .- is
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propert,. Address: l o ct o W S111�
Owner.-r„ddt,�,
Date of Inspection:
Check if the following have been done. You must indicate either 'Yes' or 'No`as to each of the following:
Yes !vo
_ 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 recentl% or
as pan of this inspection
As bull: plans have beer o5:a:ned and exarnined. Note if they are not available with WA
_ The iac:li� or d++elirng %%a5 inspecied fo• sign! o'sewage back-up.
_ The systern does not recewe non-Sanitary or industrial waste flow.
The site as rnspecied for signs )f breakout
_ A!I soierr components. excluding the So.: Aosorption System, have been located on the site.
The sep:,c tank manho,e� Aere uncovered. cpene-. and the interior of the septic tank was inspected for condition of
baf ies or tees. materia; c`co,�s;ructlon. dimensions, depth of liquid,depth of sludge. depth of scum.
The size and loca:.o o:the Sol' Absorption Svstern on the site has been determined based on
_ The iac•im ci,ne• janc occupants. if d,neren: troy' oWnert were provided with information on the proper maintenance of
Sub-Surface Disposal S,-•stern..
45 Existing inior'ration Ex Pian at B O H
_ De-ermined in the field ^r an+ of the failure criteria related to Part C is at issue, approximatjon of distance is
unaccevab,e 113 302 3;b j
r �
SUBSURFACE SEth'AGE DISPOSAL SYSTEM I%SPECTIO% FOR34
PART C
'SYSTEM (NFORMATIO%
P^ `•... - ant: A _
Pro pert-, Address
: o
$TAre�,
O wn e .T r• (/
el tJ,t.,c,,
Date of Inspection:I O tzo(97
FLOW CONDITIO%S
RESIDENTIAL:
Design ilo% 336 a o.d.?bedroorr. for S.A,.5
Number of bearooms,4.3
Number o°current residents Oy
Garbage g•.=der (yes or no-
Laundry co-•^ected to system (yes or no! ._._.___......
Seasonal use tees or no•._W
N`ater meter readings, if available (last two :2 yea- usage tgod:: iN0
Sump Pump (yes or nor tt.�
Las dare o-occupanc% ,
COM.titFRCIAL'I%DUSTRIAL-
Type of establ:shmen:
Design Go%% _�a!:onsca%
Grease trap present Ives or no_
Induwriat \taste Holding Tank oresent .yes or no
%on-sanota-% %2ste d,scna•gec to the T:t.e 5 s%•se-n ;yes or no
%%aver meter read!ngs if a•ailabie
Las:Fare o: c
OTHER: .De!cribe
Us', sate of occa:canc•
GE\ERAL I%FOIL'*kATIO\
PUMPItiG RECORDS and source of :nformanon
�ieri4 *__a .5*'1"- Ptaa,o�- To tr ss� 't'an4. VJ1htyV�'C" �
System pumped as par, of rnspeG:on. Ives or no
If yes, vo:ume pumped _ gallons
Reason for pumping
TYPE OF SYSTEM
Sept,c tank./distribution box'so:l absorption system
It S:ng;e cesspool,WeZvtow �T
Ove'flow cesspool
Privy
Shared system (yes or no! (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: C�.Jta.a-•Qom � '.��5�,�t 1
Sewage odors defected when arriving at the site. (yes or nol v`'
ShBSURFACE SEMAGE DISPOSAL SYSTEM INSPECTIO% FORA
PART`C
SYSTEM INFORMATIO% (continued)
Propene Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(locate on site plant
Depth below grade.
material of construction. _cast iron _40 PVC _other (explain'
Distance from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting. evidence of lakage. etc.!
SEPTIC TA%K:_
(locate on site plan
Depth below grade '
Materia! or construction _concre:E _meta _F oe g ass _Pof%Y: Aene _otherfezplrn
If tank is meta:. Iis: age _ Is age cor:.rmec o' Ce-.J,ca:e o-. Co .puance (1es%o
Dimensions
Sludge depth
Disiance from top e: s!udge to bonor, o`ou:ie: tee o•ba�:-
Scum thickness
Distance from top of scum to top o'outlet tee or ba-,
Distance from bosom o**sco-n to bo-e- o;out!e: to c• ba-•e
how dimensions mere dete•mined
Comments
trecommendation for pumping rond�t.on o' nie: arc O J:Ie! tees or baffles. depth of liquid level to relation to outlet invert, structural
integrity. evidence of leakage. a:c i
GREASE TRAP:
(locate on site plan:
Depth below grade
Material of construc�o . _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top o scum to'top of outlet tee or baffle.
Distance from botto of scum to bosom of outlet tee or baffle
Date of last pump, g
Comments:
(recommendatf for pumping, condition of islet and outlet tees e!baffles, depth of liquid level in relation to outlet invert, structural
integrity, evi rice of leakage, etc.;
f
St_'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.%4
-PART C
SYSTEM INFORMATION (continued)
Property Address:
ON ner.
Date of Inspection:
TIGHT OR HOLDING TANK: -rank must be pumped prior to, or at time, of inspectjon:
(locate on site plan,
Depth below grade
Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions.
Capacity- gallons
Design floN ga!ions-da.
A!arm level A:a•m ie „ork:ng o,de•_ Yes. _ No
Da!e of previous pumping
Comments
(condition of role! tee cond-:ior o' a'a•rr. and fioa: s%nches. etc.)
DISTRIBUTION BOX:_
(ioca:e on sae p a-
De:;h o' howd )e.e' aoo.e o,:;e: ln,e'
Comments
tno:e i` leve' and dis:•it;.::-or is eaua evidence o' solies car .er, e��dence of leakage into or out of boa, etc.)
PUMP CHAMBER:_
(locale on site plan.
Pumps in working order. (Yes or No,
Alarms in working order (Yes or No
Comments:
(note condition of pump chamber, conditi of pumps and appurienances, etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (v y CDO $TprfjX,
O»-ner:—(v.XcLLe-.
Date of Inspection: (d
SOIL ABSORPTION SYSTEM (SAS):
(locate on site.plan, if possible, exca%I ion not required. but may be approximated by non-intrusive methods,
If not determined to be present, explain.
Type
leaching pits. number.,
leaching chambers, number._
leaching galleries, number.
leaching trenches. numbe%length
leaching fteids, number, d.•nensio^s
ove fioK cesspool, numbe-
Alternanve s•sterr,
Name of Tecnr.oiog-,
Comments
inoie condition c;so,i. s-g^s o-*h�drailic fa!i.ne, le%e' of pond:ng, condition of vegetation, etc.+
e%QJ .r -4s�.. CiY1
IlYh2NY��O.
CESSPOOLS: 4S
(locate on site p+
Numbe, and cc-f,g.;•a:.Cn - l O wt.-I
Depth-top of hajid to inlet inter, 3"
Depth of solids lave- Q"
Depth of scum lave- CO"
Dimensions of cesspoo: Y din
Materials of constructio^ ccx- -rt-e %\C'C L
Indication of g•ound�,%a:e• ►).o
inflow icesspoo; mus: oe pumper as par of inspection C)o - ti�0 knl--eA I
Comments.
(note condition of soil, signs of hydraulic failure, level of ponding. condition of vegeta •etc)
S o�
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.)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM I%FORMATION (continuedt
Propert% Address: NVL� 6Q%KcL
OKner: TWAL
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 (locate where public water supply comes into house)
i
K
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO% FORM
PART C
SYSTEM INFORMATION (continued)
Propert% Address: %GLk Oda STAcFr�.
Owner:TV&�
Date of Inspection:
Depth to Groun6%ate•.irZO Fee:
` Please indicate all the methods used to determine High Groundwater Elevation:
Obtained iron Design Plans on record
Observation o;Site (Abutting propem. obser anon hole, basement sump etc.)
Determine it from local conditions
Cnec'K %%,m Iota' 5card o, nea':'
Cniec: FE1 A n;aos
Check pumping recores
Chect, Iota' e%.ca.a:o•s ms:a'ie•s
Lse LS_5 'Da-.a
r
Describe in 3j, 0.%-. %%0'--e %C_ es:a7"S6%et: ine �:£`_ Groun0%a!e, Elevation. (Must be completed
M/136M@5 GRIST CHU�DM, PAGE. 01.
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MAP 208, PARCEL 36
#104 OLD STAGE ROAD
CENTERWLLE, MA _
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SEPTIC SYSTEM SHOWN OLD STAGE ROAD
1S DRAWN FROM AS-BUILT
ON FILE AT THE TOWN
HEALTH DEPARTMENT
CER TIFIED PL 0 T PLAN
ANTHONY RESIDENCE
I CERTIFY THAT THE IMPROVEMENTS SHOWN of MA #104 OLD STAGE ROAD
HAVE BEEN LOCATED WITH AN INSTRUMENT ��,P` Ss9c CEN7ERVILLE, MA
SURVEY o`' ROBE yGj, DDATE: DEC. 13, 2005 DRA JOB �• RBS
c SYKES SCALE:1 =40' 00675
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LAND SURVEYING, INC.
P.0. BOX 442
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No................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............)DWD...........OF.. L�.JI ------- .--••--.._...........
Agiliration for Disposal Morkii Tomitrur#ion jhrmit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
system at:
--.1.. ... ? . . . : � ---------------------------- -------------------------------------------- ---------------------------------------------------
�I�ocation-Address or Lot No.
.. •- - ..
yy� r0w�n/er / �/,�y� yip ,)/' I/ Address
a ....it��1:!!d_L�LJ_....L__. � (,�:-•---•-------- --------`�,�lJ-G.�fIFLI-........... ---.....-. -.-.----......-------..
Installer Address
Type 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............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length......:......... Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-• Percolation Test Results Performed by...................................................................... ---- Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.--._.--_-___-__--___.-.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil - - � .9rrd.0 -- .... - - .. ...................
W
U Nature of Repairs or Alterations—Answer when applicable.------ --__-- 1-__ J11 _._9,Q,Il.9.......................
•---------------------------------------------------------•----------------------------------.....----•----....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has en issued by the board of health.
d•-••---- .. .. e�l�i- -----•--
t"4.... ate
Application Approved By.....--ASIg
....�.. - ; -�-................ `- l1_ ....
Date
Application Disapproved for the following reasons---------------------•------- ------------------------------------------------------......-••-----.........
..................
---••••.........................•-•--•-------•-......•-----........-----------•--•----------•.....------•------------•---•••---•-----•--------•-••-•--•---••-•-----------•-----• ......................
Date
PermitNo....................................................... Issued.......................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
s5�
No......................... Ficz..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f ii� OF. ..
ApphrFa#ion for Disposal Works Tonstrurtion 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
f 1�+ Ir
................_...._.._.............._.. .... •--• -----------•--•---------- --•--•--•-------------•---•----------------------- ----------•-----•----•-•--------.-------.
ca Lotion-Address or Lot No.
-
.... ......_...��_:C�t J .....----•.....•............................... •.......................... --�=-..� -•-----•------................................
'Owner Address
•ress
►Wa + _y ; i' 1 + r�.... ......
Installer Address
Type 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............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity............gallons Length................ Width............:... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ---•.............•------------------------•-----------•--....------.......---.,....•--•--..........•.........................................................
0 Description of Soil.....:_.................................................................................................................................................................
x
U •--•.............••-•--....•••••••••-•••-•-••-----••...............---•--•---.......---••......•••••----••-•••••-••-•••--•--•••....--•••-•-••••••--•-••••••-•------•---••-------•-•--...........---••••.
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-----------------------------------------------•------------....-------------------------------------------------------------------•-------------------......----------------------------------...---•--
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 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 issued by the board of health.
Signed..........-.........1'•t= / I If_,,_y--- �
..........................
Date
Application Approved By......... �
Date
Application Disapproved for the following reasons:............................. ..............
...............................•---•-----....._.....-----.•....-----------------------.......--------••--••-•---------•---•••-•--••--•-••---•--•---••------••---•-•-•••-••----••-•••-••••...-•-•....•••-
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................................:...................................................
(9rdifirate- of Tuutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( I)
•------•-•-__--�.. I..... % ./ / - T.
by ---•-•......----•-'- •/.....-rr`-------------------•-••---------------.................-•---•-----•--•-------•--•--•---------
Installer
1 11
:_ i i
has been installed in accordance with the provisions of T
5 of The State Sanitary Code as described rin the
application for Disposal Works Construction Permit No ---••••-• dated.----Pr_,L_-'Z-d--==-�d-----_----•-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE /� ,� Inspector.o 1 l� - ---------------------
--------
............
THE COMMONWEALTH OF MASSACHUSETTS
�f BOARD OF HEALTH
....... ..... r........ .......:......
No........
FEE........................
Disposal Works TwnnsirWiun rrutit
Permission is hereby granted....... __ ._._.% :!%rf/........
!!:./.: ..� .................
1_..
- . . .. . •. ................ .........
...................................................
to Construct ( ) or Repair (' ) an Individual Sewage Disposal System
atNo...."•••• . ........................................ .... .:.....�.'........... .....- -•----Street--•--.._..._----.....---••--••--•-•-----•-•-••-•-•---•--..'�`...............
i
,1 .
as shown on the application for Disposal Works Construction Pernnrt No.. .... .........1.. Dated.... ............
f- ar f ealth
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LOCATION SEWAGE PERMIT NO.
/o 61--b 5-T-A G e �A
I�
VILLAGE _
an i e
IN,STA LLER'S NAME i ADDRESS
P
' I
R UILDER OR OWNER
DATE PERMIT 'ISSUED
DATE COMPLIANCE ISSUED—�/9�8C�
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