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Home My WebLink About0354 OLD STAGE ROAD - Health A4OLDSTAGE RD., CENTERVILLE = 190 74 URC 12513 NO. 53LOR HASTINGS, !!N AM I ' a TOWN OF, STABLE v LOCATION ®��J° SEWAGE # ASSESSOR'S MAP & LOT ^ V INSTALLER'S NAME&PHONE NO. ' SEPTIC TANK CAPACITY �l Qlou LEACHING FACIL=: (type R1),- (size) ( NO.OF BEDROOMS U- X(S) �jc-kA(—:- BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) — Feet Furnished by �C.� �hef� P beet S4 � 4, ok 5 0_ aA 8� Commonwealth of Massachusetts Executive Office of Environmental Affairs Dept. of Environmental Protection IN One winter Street,Boston,Ma. 02108 ,John Grad D.E.P. Title V Septic Inspector P.O. Box 2119 Teaticket, MA 02536 WILLIAM F.WELD (508)564-6813 Governor ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 354OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Address of Owner: Date of Inspection: 11/30/98 (If different) Name of Inspector: JOHN GRACI DONALD CHASE I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: x Passes This Inspection Is based on criteria dented in Title V _ Conditionally Passes code 310 CMR 16303.My findings are of how the system Is performing at the time of the inspection.My Inspection does Needs ur er Evaluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the Fells septic system and any of Its components useful life. Inspector's Signature: Date: 11r3om The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. 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. INSPECTION SUMMARY: Check A, B,C,or D: A] SYSTEM PASSES: x I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Co7hpliance(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 conforming septic tank as approved by the Board of Health. (revised(MMI) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CHASE Date of Inspection:1113019E _ Sewage backup or,breakout or hioh.static water level observed.in.the distribution box is due to a broken, or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 Cj 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 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 a 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersuppiy well. The system has a septic tank and soil absorption system and 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 frorn 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or 3)Other less than 5 ppm. Method usedto determine distance (approximation not valid) D) SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in 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 cesspool. SAS is in hydraulic failure. (revlaed 0427)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property AddresS: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CHASE Date of Inspection:11130/98 D] SYSTEM FAILS(continued) Yes No 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). Numbers 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 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 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 must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (reylsed 007197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CHASE Date of Inspection:11130198 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _c_ — Pumping information was requested of the owner, occupant,and Board of Health. x None of the system components have been pumped for at least two weeks and the 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. — x As built plans have been obtained and examined. Note if they are not available with N/A. x — The facility or dwelling was inspected for signs of sewage back-up. x — The system does not receive non-sanitary or industrial waste flow. -x— — The site was inspected for signs of breakout. x _ All system components, excluding the Soil Absorption System, have been located on the site. x 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. x — The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x Existing information. Ex. Plan at B.O.H. x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is — — unacceptable)[15.302(3)(b)] (revised 04127)87) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CNASE I Date of inspection:11130/99 FLOW CONDITIONS RESIDENTIAL: Design flow: 3m g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 3 Garbage grinder(yes or no): No Laundry connected to system(yes or no): Yes r Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): Na Sump Pump(yes or no): No Last date of occupancy: n1a COMMERCIAL/INDUSTRIAL: Type of establishment: nla Design flow:U gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system:(yes or no) No Water meter readings,if available: Na Last date of occupancy: Na OTHER:(Describe) Na Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: Na System pumped as part of inspection:(yes or no)Yes If yes,volume pumped:26W gallons Reason for pumping: MAINTENANCE TYPE OF SYSTEM x Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc.Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: ORIGIANL 1972 W17H A NEW PIT INSTALLED ON 9882 Sewage odors detected when arriving at the site: (yes or no) No (revised O W7197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property AddresS: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CHASE Date of Inspection:11130199 SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:x concreate metal FRP Polyethylene_other(explain) If tank is metal, list age n1a . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: 6'X6'BLOCK CESSPOOL FUNCTIONING AS A SEPTIC TANK.NOT TIGHT Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness:1' Distance from top of scum to top of outlet tee or baffle:2" Distance form bottom of scum to bottom of outlet tee or baffle: 10" How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) MAIN CESSPOOL AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM EVERY YEAR. GREASE TRAP:_ (locate on site plan) Depth below grade: rda Material of construction: _concrete_metal_FRP_Polyethylene—other(explain) Dimensions: rda Scum thickness:rda Distance from top of scum to top of outlet tee or baffle:rda Distance from bottom of scum to bottom of outlet tee or baffle: n1a Date of last pumping;. Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) r9a BUILDING SEWER: (Locate on site plan) Depth below grade: 1' Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction Iine:TowN Diameter: Ala_ rwalmments: (conditions of joints,venting,evidence of leakage, etc.) (revleed 04/27197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CHASE Date of Inspection:11130/99 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: nfa Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: nre Capacity: nla gallons Design flow: Na gallons/day Alarm level:_nla Alarm in working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Ma DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: nla Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.) ria PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Ye: Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) rda (revlaed 04127)97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Add re SS: 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 Owner: DONALD CHASE Date of Inspection:11130/98 SOIL ABSORPTION SYSTEM (SAS):x (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: roa Type: leaching pits,number: 10W GALLON LEACH PIT leaching chambers,number:Ne leaching galleries,number: Na leaching trenches,number,length: Na leaching fields, number, dimensions:Na overflow cesspool,number:e'xe'BLOCK Alternate system: Na Name of Technology:_Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.THE NEW PR WAS 112 FULL AT THE TIME OF THE INSPECTION.THE BLOCK CESSPOOL HAS HAD SOME SOLIDS. CESSPOOLS: (locate on site plan) Number and configuration: Na Depth-top of liquid to inlet invert: nda Depth of solids layer: Na Depth of scum layer: Na Dimensions of cesspool: Na Materials of construction: Na Indication of groundwater: Na inflow(cesspool must be pumped as part of inspection) Na Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) Na PRIVY:_ (locate on site plan) Materials of construction: Na Dimensions: Na Depth of solids: Na Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Na (revised 007197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 DONALD CHASE 11130198 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) Dec( Q/l old 0 c O� e AA y f Ae 556 gA 2� Pic (revlaed04Q7197) Pape ! of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 354 OLD STAGE RD.CENTERVILLE MAP 190 PAR 174 DONALD CHASE 11130199 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property,observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers X .Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) USGS MAPS AND CHARTS (revised04127197) sage 10 of 10 la® No.- -._....... x$. ..e.................... THE COMMONWEALTH OF MASSACHUSETTS `BOAR® OF HEALTH ...........................................OF............ ....................... ............................................... Appliratinn for Dhipmai Works Towitrirtiun famit Application is hereby made for a Permit to Construct ( ) or Repair (Van Individual Sewage Disposal System at: 1 CE&Tikll.1.1 ................................•....... ............... s.. 4� .S ' .--. .. c��^ -.......L0 tion- dress Jy or Lot No. ---......L.21._.�- rd� 1. ........ 1-f. ..............•--- - ,i,�'— O}�!er � � "+� i. ,,Address ��-- . a _ ... AJ fir ' / � s`11 !Vn.... 1.� --• $ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms..._._................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons---------------_------------ Showers ( ) Cafeteria ( ) Q' Other fixtures .__...-----•-•---------------------•---------- 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........................ �T4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------- - / 0 Description of Soil.................�� 1.1..- __-__._...._..--__._ x UW .............................................................................................................. ----------- --------------_------- --------- Nature of Repairs or Alterations—Answer when applicable..._ ________ ______________________ ,&v----_--------_____ ------------------------------------------------•-•-----•--•------------•--•--••--------•-•----...-•------.....----------------------------------------•---�--------------•-------•---------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ` 5 of the State Sanitary Code— The undersigned further agrees of to place the system in operation until a Certificate of Compliance has been issued,>the boar f health p Sign ........ ----- ----=--------------- --. .... .. •----- ••••• �••.' Date Application Approved BY -----...... r !..../` .. Date Application Disapproved for the following reasons:__...---•-•---••---•-------••-------------•---_..-----••---------•-••--•-•-----•-------••-•-••-•-----....._...-- -----•----------------------•-•....---------•--------•--•---•-----•-•-•--...........---••--•-•••......--• - Date Permit No........................................................... Issued................ ...................................... Date' S THE COMMONWEALTH OF MASSACHUSETTS 44 BOAR® OF HEALTH ......... . ........................O F.......................................------.............---------.......---...---------- Apli iratinn for UWVaaa1 Works Tnnitrttr iun rrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at:ax�vTo s.1l��A 1� ' ° ......1 ... - Lo tion- dress! j or Lot No. -N/� :l-,( .....�.. ,- ¢��`�t!-!�t--......... ...... .----r-jam •-----•-----.....-• y� ---- W �toXA1� /`/ 11h��- r` R7�!!'�f!�w+wd�'�' ...... l�eA�J70-AfS 1yf, a ........................................e---.._---- ......•......••.............. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms._.....3......................... .Expansion Attic ( ) Garbage Grinder ( ) ....._..... No. of persons............................ Showers — Cafeteria a Other—Type of Building _________________ p ( ) ( ) P-4 Other fixtures ---------------------------••-•• • -• 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........................................ a Test Pit No. I................mmutes per inch Depth of Test Pit.................... Depth to ground water........................ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------•-• ....................................................................................................................... O Description of Soil .. -/-I_.�±`':._..._�/'-•------------------•-----•---••-----------------------------------------------------------------------------•------------- x V •-- 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 boar healt 4..... ........N72 r r"� Signed .' ,..= ':.................. Date Application Approved By................... !. �!.._�°' .. .:. 8-d`- Date Application Disapproved for the following reasons:----•••------•--••••-•••---••-•-------------•-------•-•-----•-•-------•-•--•-••••-••--•--•--•---•.._.........._ r ...................•........_...._............_......__......._......................................._............_......_..._._...------.._.._.....__._._.............._.........._.. ............_... . Date Permit No.__....... ------•--•---------•------••.. Issued.... q. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. . '' < .. r Tnrtif irtttr, of f�nmplittnrr THIS LF TQ,,)OERTIFY That the ivid Sewage Disposal System constructed ( ) or Repaired by r --- ......................................... _.._ - /�y -- nst ller s-� i P.,, .i/JM•�� • 1 L EG.^ 'tY G._/.,.f..'/a�."- E,I'` f at �� r - �� -.. ----------------- `' has been instillefl in accordance with the ptorvisions of TITLE j of 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. ............ . v. Inspector a ------------••- THE COMMONWEALTH OF MASSACHUSETTS BOARD �O�F HEALTH— awl'� ...........................................OF...... ................ S No......................... FEE........................ %Vocal Workii Twnnitrnrtion firrmit Permission is hereby granted..................•---•---....._..............-•••••••-•••-••------•-•---..........._...-----------•..................•••.................... to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................................................... Street as shown on the application for Disposal Works Constructorr-'P�mitt No................... � ' Dated.......................................... .._.......-• ----- ------ •• --.---• - Board of Health DATE.. ------ ------------- - FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 1` J OCR LOCATION 6/Vj %XV SEWA"GE PERMIT NO. VILLAGE INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� i�� _ �� _ s ti t i' �� _�` . . , , � xx � I `� d L� ��J � � �� ,� N F biJ ..,