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Home My WebLink About0076 OUTPOST LANE - Health 76 Out Post Lane Centerville A= 172 115 Slll �Y� UPC 12534 No.21153LOR rrs MASTANG16 YY fiyy: F.. TOWN OF BARNSTABLE LOCATION 7-6�4e e4- t—a v.i. SEWAGE # VILLAGE Ce Ak&v 6 tLe. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f 00c) C4/ LEACHING FACILITY: (type) (size) O NO. OF BEDROOMS 3 BUE DER OR OWNER 1'7Yiur Ca- .0,4 vro PERMIT 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 7� sv r COMMONWEALTH OF �ASS4CHLTSETTS ExEcuTwE OFFICE OF ENVIRON'MENTIAL—P.,,z ?RS t DEPARTMENT OF ElV'VIR.ONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: kol S Owner's Name: A a Lr'aro Owner's Address • mayDate of Inspection:_ 1 a ( I S 1_._. 5— Name of Inspector: ple c print) f 1 Company Name: r(G v� �i16�2LT/ort5 Mailing Address: $q Telephone Number: 15,08. 38r- . 66� CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reuorted below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. i am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: i 06 45 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000' gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of II OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM FART A CERTIFICATION(continued) Property Address: 76 O T42n IPA _ y o Et2 Owner: Co.IJ4 ro ro Date of Inspection: 12 15 OS Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: KI have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section ope to be replaced or repaired.The system,upon completion of the replacement or repair,as approved b e Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the folio statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the ptic tank(whether metal or not)is.structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank approved by the Board of Health. *A metal septic tank will pass inspection if it is stru Ily sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old i vailable. ND explain: Observation of sewage backup break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broke ettled or uneven distribution box.System will pass inspection if(with. approval of Board of Health): broken pipe(s)are placed obswarom iis:removed distribution box is Ievmled or replaced ND explain: The system quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system-will pass inspection if ith approval of the Board of Health): broken pipe(s)are replaced obstruction is removed N'D explain: 2 Page' of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q q, .e v e Owner: CG I« rciry Date of Inspection: (a GT6o5- C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in ord to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance i h 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public h lth,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 vegetat wetland or a salt marsh 2. System will fail unless the Board of Health(a d Public Water Supplier,if any)determines that the system is functioning in a manner that protects a public health,safety and environment: _ The system has a septic tank and soi bsorption system(SAS)and the SAS is within I00 feet of a surface water supply or tributary to a s face water supply. — The system has a septic tank d SAS and the SAS is within a Zone I of a public water supply. _ The system has a septic and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a se c tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply w **. Method used to determine distance **This system pass if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vola' e organic compounds indicates that the well is free from pollution from that facility and the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri are triggered.A copy of the analysis must be attached to this form. 3. Oth 3 Page 4 of I i OFFICIAL INSPECTION FORS----NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DEPOSAL;SYSTEM INSPECTION FORM ` PART.A- CERT'IFICATION(continued) Property Address: ot( i. Owner: �:- 20-4Lro Date of Inspection: Jtj j9-jQs— D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool P� 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'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 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.IThis system passes if the well water.-analysis, performed at a DEP certified laboratory,for celiform bacteria and volatile organic.compowids 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 S plim,provided that no other_.failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails.1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve.a fa ' ' with a design flow of 10,000 gpd to 15,000 gpd• 6 = You must indicate either"yes"or"no"to each of ollowing: (The following criteria apply to large systems' dition to the criteria above) yes no — the system is within 400 f of a surface drinking water supply _ the system is within 0 feet of a tributary to a surface drinking water supply _ the system is to ted in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a p lic water supply well If you have answer "yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section above the large system has failed.The owner or operator of any large system considered a, significant thr t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The ystem owner should contact the appropriate regional office of the Department. 4 Page 5 of i 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 6 0 T r-jPOAA uv, Ule Owner` Ca aro Date of Inspection: Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as par:of this inspection? A Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? i Were all system components,excluding the SAS,located on site? S _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition —&baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper mnte_nance 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 V _ Existing 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)j310 CMR 15.302(3)(b)] 5 Page 6 of I i OFFICIAL jNSPECTION FORM m NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (Q) L4T� ..c Owner: CC'k&fAaro Date of Inspection: ( a ( t FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_2 Number of bedrooms(actual): _ DESIGN flow based on 310 CM( 15.203 (for example: 110 gpd x#of bedrooms): _ Number of current residents. Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):— [if yes separate inspection required] Laundry system inspected(yes or no): AV Seasonal use:(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:TALr-� COMMERCIAL/INDUSTRIAL Type of establishment:_ Design flow(based on 310 CMR 1 . 03): gpd Basis of design flow(seats/pens s/sgft,etc_): Grease trap present(yes or n ._ Industrial waste holding present(yes or no): Non-sanitary waste disc ged to the Title 5 system(yes or no):_ Water meter readings ' available: Last date of oc;* e): y/use: OTHER(desc GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): AV _ If yes,volume pumped:__gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM �K Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Ca d'S Were sewage odors detected when arriving at the site(yes or no): 6 i Page 7 of I OFFICI.4i, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 74 Quf 05i vi .2 Owner• CaAkiA—A.ro Date of Inspection: 1 a Eklo.S BUILDING SEWER(locate on site plan) , Depth below grade: 3 o`' Materials of construction:_cast iron IK 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: K (locate on site plan) Depth below grade: �c Material of construction: 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: t000 4. Sludge depth: a, u Distance from top of sludge to bottom of outlet tee or baffle: 3D Scum thickness: oZ` Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to botto of outlet tee of baffle: 1.3 How were dimensions determined: � eA,5 urea Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid Ievels as related to outlet invert,evidence of leak pe,etc.)• �, c Try C f GREASE TRAP:`(locate on site plan) Depth below grade:_ Material of construction: concrete_meta _fiberglass,polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to f outlet tee or baffle: Distance from bottom of scu o bottom of outlet tee or baffle: Date of last pumping: Comments(on pumpin ecommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet in rt,evidence of leakage,etc.): 7 Page 8 of i i OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: vsks— 7K 4A-1 ,,AA a v• Owner: la U p ray ra Date of Inspection: TIGHT or HOLDING TANK: (tank must b;pumped time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete me fiberglass_polyethylene other(explain): Dimensions: Capacity: gall s Design Flow: lonslday Alarm present(yes or no): Alarm level: Al working order(yes or no): Date of last pumping)o4a—rmin Comments(condition and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc. PUMP CHAMBER: (locate on site plan Pumps in working order(yes or no):. Alarms in working order(yes or Comments(note condition of p chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 72 Ou o Vr Owner: Date of Inspection: ( _S k SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Tyxleaching pits,number: I 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.): i p v�e, S l 1r& tA CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: .. Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundw r inflow(yes or no): Comments(note con tion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condi n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM x PART C SYSTEM INFORMATION(continued) Property Address: L.C,a.k nn 2s&A&A Owner: Calo�le,I Date of Inspection: L2 I I s-1 o.s 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 ehters the building. 3� in Page 1 I of I I OFFICIAL:INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 76 a5-fLa ,l 6 tke Owner: Q4 / Date of Inspection: l,,/4t os SITE EX�1 Slope (N v Surface water A)O Check cellar ?V6 Shallow wells 00 Estimated depth to ground water_10 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) Accessed USGS database-explain: You must describe ho you established th high ground water elevatigqn: �1 U� PA-4 to-5 �15"um a.w 2 C 1 CLI-w r` I1 L0,CATIO ' SEWAGE PERMIT NO. VILLAGE INSTA LLER.'S NAME & ADDRESS ,lj-,C1?eD FUl-4 F'R. nlh' . . B U I,L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 0 �� e3�' ii �--- ____l THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEA T O .... i ...-- .OF............f..... .. .:......... ......... Apphrttfion -for Uiiivoiitt1 Works Tonsfrurfion Vrrmit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: --••• ------_._.. Nl ` pion• --- —��- Q-®�--'- -�- --- �, Owner ddress a .. �•- -••-----••-- -.._._.. ..... ••-•---• ••-------•--••--...--- Installer Address Q Type of Building Size Lot_..._-.:__i_______________Sq. feet U Dwelling—No. of Bedrooms Expansion Attic Garbage Grinder ( Other—Type of Building --._-_-_----______________ No. of persons..-____.---_________.___---_ Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacit/dons 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--------------------------------------.. a Test Pit No. 1................minutes per inch Depth of "Pest Pit-.------------------ Depth to ground water-----.-.--..-..-.-.----- G%, Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water__.._..-__--___.-___---- �'+ --•---------------------------------------------------------------------------------........................................................................ ODescription of Soil----- •---------------------•--•--•--•••-•--•-•••----•-----•-------•.-..---•-•---------------------------------------•-•----•--•--••-•---------------------------------- x U --•----•-------•-----------•---------------------•-•-••--------_._._---•-••--•-._._..•-----•••-•-------------------•-•-••--••-------------------•--•--------•-•••---••--••----------------------------- w ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- .......... .............. U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewa e Disposal System iil ccordance with the provisions of Article XI of the State Sanitary Code—The undersigned f rther agrees not to la e the system in operation until a Certificate of Compliance has been iss ed by the board gofalth.Signed- ---------------�'?a----��------ - --�=----------.....---------- --------------------- Date/ R ` ApplicationApproved By................. ....1�..........---•---------------------------------------------------- ----------4...... 0..---72------- Date Application Disapproved for the f lowing reasons:----•-----------•-•----------------------------•------------•---_-__-_---•---•----------------••-•--•-•-•------- -•________________________•--•----•-•-------•-----------------••.._...._.._-••-------•------•---------_-.. -------------- Date PermitNo.....` �� .................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. `ou-w........OF......... J k. 1T��ec ................... ..................... �rrfifirafr of fI'outpHaurr THIS IS TO CERTIFY; That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) nstalle� - at----------------Z-vr-------A. o 07- �OS(------- Installer_ I/s/ltiC �'' t 4/6 Z*Ac- - - ---------------------------- ----------------------------- has been installed in accordance with the provisions of :Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------,_5.'�-______________________ dated--------4-------a3n.-_.?_7........... THE ISSUANCE,OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE = - Inspector ............................. ........................ ............... Ficim.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... ..... .. __.............OF..................................... ................ - Applirtttion -fear Bhipwitt1 Worko Tomitrurtion Prrutit Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i�- ./ G Ste. . , "..............................................' `. - " / ------/--/-----------------------------------•••--- rA • •......------cation-• .0 '^ ............. s�!__ ._!.- / ....... ------------•-----••---- fW-1 . f. F ,............-.__.. Owner � �----- ---------- ..._...!. ..........t.-• dress._...._.. ........................ Installer i Address �r-p UType of Building Size Lot......... ...............Sq. feet a Dwelling—No. of Bedrooms---------------3----•-_--____-__--_-Expansion Attic (AYc) Garbage Grinder (1<6 aOther—Type of Building _.-----__________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. P4 Septic Tank—Liquid capacit _?�lllons Length---------------- Width................ Diameter................ Depth..-._-_--.----- xDisposal Trench—No. .................... Width------------------- Total Length-------------------- Total leaching area--..-._-____.--___-•sq. ft. Seepage Pit No---_--------------- Diameter..........(e;:n---- Depth below inlet.................... Total leaching area-------.........._sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~ Percolation Test Results Performed by----------------------- •----------------------------•-------------------- Date......------------------------------ a Test Pit No. 1________________minutes per Inch Depth of "Pest Pit-------------------- Depth to ground water..--_-----.-_--.---. -- 1:4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.---.--___--_----.-. 9 --------------------------------------------------------------------------------------------------------_------------------------------------------------ 0 Description of Soil--------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ x V ---------------------------- -------------------------------------------------------------------------------------------------------- ------------------------------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------. .--_•--------------------•-----•----•---•------------------••-----.------__----------------------•--------------------••-•------------------•--------------•----------------- --------- ------ --------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System iI cordance with the provisions of Article XI of the State Sanitary Code— The undersigned fu er agrees not t pla the system in operation until a Certificate of Compliance has been iss- y the of he th. Signed-- ----------•-••-• = „_�tct v ---------•-----------------••------- Date Application Approved BY----------- -- .... 11 � __,:3r.:: 7-? Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- .................•---------•------•---...-•••--------------••---------------•-----------------------•---•-------------------------------------------- --•----------------------•--------------•-------- Date PermitNo.•• 1.'�.../--------------------•--•----------.. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................. /1....1............OF.......... 1/!e i, liCc ............................................................... Trrtifirtttr of Tlimplitturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) .................................. --------------•-••-------•----•-••-----•------•------•------------------•-•--•••---••....----••---•-- _ Installer at.....•---•-•..../-,/ J - L r `>�r L/./-C� - / 6, %C L:zll� c- ------•-•-•-•----------•-----------------------------• -----------•-•------------------------------------------------------•.-__.----- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-------- ______________________ dated......../-.____4.�_-----2---)........... THE ISSUANCE OF THIS CERTIFRCATE SHALL NOT BE CONSTRUE® AS A ARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY.I -�--•• DATE ' ------ ----•.� - ------------•------- Inspector -k-----------Iv-..--�--� VU- --------------•------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r �.. ...�.-..........OF .. ..� i. . . .. d..i iL I7/af+� G No.........."'a �� FEE........................ �i��ttl �rk� Cn��,�tr�rti>ttt� ��rrtttit Permission is hereby granted----------------- --- - f a Ff'cr;' --- --------------------- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No..---•-••.f `.. -) . ". r /y< ' f f.<,( /`' ,,.err//r /l='/ t , (/"", !- Yr -•--------------------------------------------` ' -- -`----._... Street 7 as shown on the application for Disposal Works Construction Permit No------ __ _. Dated._-_-..._-. .................... �� 7 ? Board o Health f DATE.-J'•--•-••-L---•-- -------------------------7---------------------_----- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS 77rx ray _ d 1 -4 �t -v I jE l � f't'r' 27 .r r?I J i (`LL � r T 41, h L bCA T t O'-4 E 1,,�-T E- CrtZTII=Y TNAT TNi= Vc?u Suawl.l PL_A1J RF=,i= ZE614c a Wr--JZGO&-4 CCU\PLYG WIT" THE r) �. A1.iD SETBACK tiZE4U1LZE,t/lc►,1'TS Ol= TNT L_ . �.. • �, �. � r..; 1 � `'r (1121 ^ v� .�. �_< !^ .may._ B�4XTEV- W E-m- I',-JC-. �; REGISI�IZcD '�.A►Jp SU2vc`fc��''. US'TE(LV%LI� c� MA►SS. -('14 15 l?'�A 1-•1 1 S +-�OT BA-,Et7 U►-► A" � 4 1M�J5't`i2iJ�EW'i StJZVE�{ � THE OF�S�i'S S��o�ln APPI..I GAI�JT A L ,�N �, cjM sty,. . . hkiT �€ Ue _:o To o�rceMc�� LGT t_�HIES r' , I I h!) o d�Sf Q 2 « It b) Q � �✓co v .� U i Cl 1 o a _ 0 iJ T P 0 ST L ',t\,� .C,. , CEQT�FIED pl.bT PL-.b;1� rvv�X i l oCA T l o" C e..ry F- k L Lr E CERTIFY Tf,{AT' TNG— TGGur•1 5t O%AJ►J _A►J RE.i=ERE�GE Wr--ZGO" CC>AAPLVS W ITN TwG: SIDE LI►-1t= 1. 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