HomeMy WebLinkAbout0214 PARK AVENUE - Health 214 PARK AVENUE, CENTERVILLE
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,,�m�Q�O =UPC 12543
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HASTiD'OS.MN
TOWN OF BARNSTABLE
LOCATION 2=J 1-/ SEWAGE # 1 CE3
VILLAGE ,ti 1 ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.,`Q"t�
SEPTIC TANK CAPACITY Q
LEACHING FACILITY:(type) »S (size)
NO. OF BEDROOMS_�/ PRIVATE WELL OR PUBLIC WATER R ZC/
BUILDER OR OWNER ,d
DATE PERMIT ISSUED: h
DATE . COMPLIANCE ISSUED: 10
VARIANCE GRANTED: Yes No J�
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A-3
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:�1705 VZ5 Cate. 9 C-21.,Q&60 0ins
DIG SAFE NUMBER
Datc_.August 72 2001 PERMIT-
C.82$_4O M_G-L_ STARTDATE:
in accordance with the provisioas of Chapter 149,M_G_L_as provided in Section 1 10A this perrnit is grautcd to.
Name: Amerigas' '
For Permission to: install and maintain one 50 gallon LPG storage tank above ground.
State clearly the purpose for which the permit is granted: in accordance with CMR6 and NFPA 58
Restrictions: - - - - -
Location: _fl-Park- Avenue, Centerville M�02632 Gilmore Residence
Fee Paid: US y - This Permit Will Expire On.
Signature andf rtic of Official Granting Pcrmir
t
C-O-M form 1 491; =CF1RS.PERMj7MvsrBECONSPICUOUSLYPOSTEDUPONTttEPREmism)C
4
'EcE IVE
DEC 0 5 2001
TOW HEALTH DEPT.BLE
9
i
Ric f�
commonwealth of mossachusetts MAY 3
1996
Executive office of Environmental Affairs 1996
CP
Department of
Environmental Protection
WUltarn F.Wald Trudy Cox*
s.u.ay
Gooemof David B.Struhs
Argoo Paul Celluccl CorwrJ"Io ec
LL Govrmor
oa
SUBSURFACE SEWAGE DI9POSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address; 21/+ Park Ave Centerville MA Address of Owner. 639 Seaview Ave
Date of Inepoot(on: (If different) Osterville,Mass.
Name of Inspector. 02655
Company Na-ze,Address and Telephone Numb-cr.
J.P.Macomber & Son Inc . Box 66 Centerville ,Mass , 02632 508-775-3338
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurata
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:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's slynat
The System Lispoct'r shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inspection. If the system is a sharod system or has a desig'i flow of 10,000 gpd or greater, the inspoctor and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protoction.
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 PA99E9:
I have not found any information which indicates that the system violates any of the failure criteria as definod in 310 CMR 15.303.
Any failure criteria not evaluated are iudisat.od below.
B) SYSTEM CONDITIONALLY PAS 9ES:
One or more system components Hood 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)
/j,t) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or esfrltratioa,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
�J by the Board of Health.
(revised 11/03/95) 1
One Wlntor Stroet 0 Boston, Massachusetts 02108 0 FAX(617) 556-1049 9 Telephone (617)292.5500
SUB9URFACE SEWAOF,DISPOSAL/SYSTEM INSPECTION FORM
PART
CERTIFICATION (oontinuod)
ProportyAdd"= 214 Park Ave Centerville': Mass . 02632
Owner. Joseph P. Keller
Date of Lupeotion: 4/19/9 6
BI SYSTEM CONDITIONALLY PASSES (continued)
Bawo.ga backup or breakout or static water level observed inmt>�p����n due to�(with
�pop=,�al of the Boai'di�j)
or due to a broken.,settled or uneven distributioa box. The syste
Health):
broken plpe(s)are replaced
obstruction is removed
distribution bo:i is Imlled or rep
laced
� sys m pumping more than four times a�year duo to broken or obstructed pipe(s). The system will Y&U
inspoction if(with approval of the Board of Health):
_ broken pipe(s)are replaced
obstruction is removed
CI ETHER 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
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENTS
M CTIONING IN A
ANNER WHICH WILL PROTECT
Cesspool or privy is wither 60 foot of a surface water
Cesspool or privy is within 60 foot of a borderiag vegetated wetland or a salt marsh.
Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERb11NE9 THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH
AND
SAFETY AND THE ENVIRONMENTS
• :t_:r? The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
rurUca water supply.
�C�T The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. .
The system has a septic tank and&oil absorption system and is within 60 feet of a private water supply well.
(� The system has a septic trek and soil absorption system and is less than 100 feet but 60 foot or more from a private water
apply 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 6 pp=
3) OTHER
(revised ii/03/95) .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Proporty/lddrass /.,. Park Ave Centerville ,Mass . 02632
Owner. J(,Dr}eph P. Keller
Data atlusp"Uon• Z,/19/96
D) SYSTEM FAJIL: •
/�L I hav deter 'ra1 that
the
system violates one or more of the following failure criteria as daflned in S10 CbdIi 16.303. Tb•but for
this datern.!nsLion L identified below. The Board of Health should be contacted to dat.ermin•what will be necessary to correct the
failure. ;
,1 D t,-jj;p or sawa{e into facility or system component due to an overloaded or clogged SAS or cesspool.
Di }sr-Vv or pondi.ng of effluent to the surface of the tround or surface waters due to an overloaded or clogged SAS or
�� S:etic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or c"spool.
y, T'jq,iA depth in cesspool it less than 6"below invert or available volume is leas than W day flow.
pumping more than 4 times in the last year NOT due to clogged or obstructed pip•(s).
i r of times pumped_
(-f.�'> ,er Yo :ion of the Soli Absorption Systein,cesspool or privy U below the high groundwater elevation.
t of a surface water supply or tributary to a surface water supply.
of a cesspool or privy u within 100 foe •
j r. y ;Nrt:oa of a cesspool or privy U within a Zone I of a public well
< fin, c t! ❑ of a cesspool or privy U within 60 foa.t of a private water supply well.
fir- s i^n of a cesspool or privy is loss than 100 feet but granter than 60 feet from a private water supply well with no
� : water quality analysis. If the well has boon analyzed to be acceptable,attach copy of well water analyst for
cteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E)LARGE 9Y91':-.M :.t iLS'
The fclio5:i:: aria apply to largv systems in addition to the criteria above:
/V() The r)•!t,e;', ;;,.c< a facility`with a design flow of 10,000 gpd or greater(Large System)and the system is a siguiA=t threat to public
4^d the environment because one or more of the following conditions exit:
it within 400 foot of a surface drinking water supply
!/_I/i ,.,., tsm is within 200 f.Qt of a tributary to a surface drinking water supply
t�:i U located in a altrogen sonsitive area(Interim Wellhead Protection Mee(MA)or a mapped Zone II of a public
x2 .. .spp`y wall)
The owner or o : ,:cr oI ssay such system sha.l brL'g the system and facility into 4i:11 COmpltnCe with the mundwatr tr"Uunt proQt0.1ri
requlremeac r,; •' 6k-)•and 6.00. Plow:a corwult the local regional office of the Department for Anther information.,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PropertyAd1,c,e_a. 214 Park Ave Centerville ,Mass . 02632
Owner- Joseph P. Keller.
Date of c . */19/96
Check if the T t' =::i^. have been done:
Y:mpiiig information was requested of the owner,occupant, and Board of Health.
' ?'.ona of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
.�.: !h,a period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
nl-i-na have been obtained and examined. Note if they are not available with N/A
z +.';.Tl y or dwelling was inspected for signs of sewage back-up.
s._.
?,,n does not receive non-sanitary or industrial waste flow
A,,u inspected for signs of breakout.
�-
components,Ax luding the Soil Absorption System, have been located on the site.
tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or
of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
nad location of the Soil Absorption System on the site has been determined based on existing information or
_a:-_nted by non-intrusive methods.
_ ty owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub.
r irpoaal System.
(revised ? 9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAddr.-uz: ?` l; Park Ave Centerville ,Mass . 02632
Owner. -;;::-yph P. Keller
Date of Inapocti...r 10%96
FLOW CONDITIONS
RESIDENTIAL:
Design flow:_._ .S,iloea •
Number of beds-aom-_
Number of currant
Garbage grinder(.: cr no):_
Laundry coanoct-..d to y:tecn (yes or no):Seasonal
Water meter r: �dilrsble: � � _ / Q �`, 7
01
Last date of �::_.cr. .__:'f',•
COMME?"-
Type of ac,__,
Design flo%::__..
Grease tr;i, na) 9
Indust ri-i --n'z present: (yes or no)Itt
Non-ag':i: to the Title 5 system: (yes or no)A&
Water me' able: Jti fT
Last date of
OTHER-
Last
GENERAL INFORMATION
PUMP' ' source gf' ormation:
f/ y p;
of inspection: (yes or ao)1-1
r;
zd: ons ) -
c7� _ -�". �,lQL�`i C•GL�i:y2 L �c'�9/.= S �.l�yQ-J"S
TYPE Ot . .
ution box/soil absorption system
Ay
or no) (if yea, attach previous inspection records, if any)
APPRQ;'i... .+ components, date installed(if known) and source of information:
Sewage arriving at the site: (yes or no)
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 214 Park Ave Centerville ,Mass . 02632
Owner. Joseph P. Keller -
Date of Iaspeotion:4/19/96
SEPTIQ TANK„
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP_other(ezplain)
Dimensions:
Sludge depth:
Distance firm top of sludge to bottom of outlet tee or baffle:_
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
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.)'
GREASE TRAP:A/t�
(locate on site plan)
Depth below grader
Material of construction:42&oncrete_metal_FRP_other(esplain)
Dimensions fo A
SCUM thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baIDes, depth of liquid level in relation to outlet invert,structural integrity,
evidence f leakage,etc.)
A)o ,yf,dI¢IV
,
(revised 11/03/95) 6
~ SUBSURFACE SEWAGE DIS P T CSYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
Property Addre" 214 Park Ave Centerville ,Mass . 02632
Owner. Joseph P. Keller
Date of Inspe0tl0n:4/19/9 6
TIGHT OR HOLDING TANK4,140C, e.
(locate on site plan)
Depth below grads: _metal_F}U' _other(esPlain> '
Material of construction:�°0
I
�j ILA
Dimensions:_
Capacity:_____ �—jrall°z
Design flow'-
Alarm level: >1,
Comments:
(00 ditio of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:,
(locate on site plan)
Depth of liquid level above outlet invert:
Comments: over, evidence of leakage into or out of box,etc.)
(note if level and distribution is equal,evidence of solids carry
PUMP CHAMBM*!'Lwc
(locate on site plan)
Pumps in working order:(yes or no)A/)�
Comments: and appurtenances, etc.)
(ao�e condi' n of pumnp chamber,condition of pumps
r
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
PropertyAddr•e" 214 Park Ave Centerville ,Mass . 02632
Owner. Joseph P. Kel:l.er
Date of Inspection:4/1 9/96
SOIL ABSORPTION SYSTEM (SAS):_
(locata on sits plan, if possible;excavation not required,but mNy be approximated by non-intrusive mathods)
•
It not datarmined to be present,explain:
Type: leaching pits,number:
leaching chambers number:
leaching galleries, number: y
leaching trenches, number,length:_ ,
leaching fields, number, dim nsions:overflow cesspool, number:
Comments: (rote condition of soil, a4w of hydraulic failure, level of ponding,condition of ve tatio etc.)
Loamy- sand; to medium sand; No signs of hyfdraulic �failure or pon ing
All vegetation is normal- Q6.1 l i AQ are dry No rPpai r4 nPPr3P(3 at the
Drac^n+ +imp
CESSPOOLS:,)TrfJt,
(locate on site plan)
Number and configuration: _--�__--
Depth-top of liquid to inlet invert:
Depth of solids layer: m
Depth of scum layer. N��
Dime— ns of cesspool: 11)A
Materials of construction:
Indication of groundwater:
Alp—
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
Alr r -1
PRIVY: I)OV ..
(locate on site plan)
Materials of construction ti� — Dimensions
Depth of solids: /
Comments:(note condition of soil, signs of hydraulic lailur•e, level of ponding, condition of vegetation,etc.) �J/Q
(revised 11/03/95)• 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddreaa: 214 Park Ave Centerville,Mass . 02632
Owner. Joseph P. Keller
Date of Inspection:4/19/9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all we1L within 100'
Centerville Osterville
Marstons Mills
Water Company
� I
II 428-669:.
1 �
1 0 �.
1 C) j
�
DEPTH TO GROUNDWATER
Depth to groundwater. 1 2' + feet
method of determination or approximation: No water encountered at 121 when system was installed.
Plan On file at—E l�e�oa�rd Or He al-t� .
(revised 11/03/95) 9
4
GV -�
16
• f{TI♦—ri•fT.TT�{��.T.'riT1—i'R�.�.T:-:f TTT:`.Ta•:'e.'if'L'T'�iLP:.��
I,•.I•q. .... T.':CTt'RT CTT-S:mil• TT...•••.I—•
5 TOWN OF Barnstable BOARD OF HEALTH
SUBSURFACE SEHAGF DISPOSAL SYSTEM INSI'F.CTION FORM - PART D •- CERTIFICATION
-`.._.� �-..�..s�r••. ::♦—T.t1'-._T•r•I.r.-n•r.:er1—r.—r.:��Z_.�.... r...:rnrr—rr-t'---�
::.---r ._._.... .....-F�rrsrsrrs7r.�racrlrsras:�:.r�rrtrrrsT.srr.rrr..•..:rrr•r.--I.•—..
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 214 Park Ave Centerville,Mass . 02632
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME Joseph P.' Keller
PART D - CERTIFICATION T
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADDRESS Box 66 Centerville,Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 775 3338 FAX ( 508 ) 790 - 1578
_>Q
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage dispostij system at
this address and that the information reported is true , accurate , and
complete as of the time . of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one:
XXXXXXXX]Gystern PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection whiclr. I have conducted has found that the system fails to
Protect the ptiblic health and the environment in accordance with Title
5 , 3.10 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
4/29/96
Inspector Signature Date
One copy of this ert.ific4tion must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEAL1'il.
* If the inspection FAILED, the owner r"0 o e p rator shall upgrade ' tha sYste
within one year of the date of the inspection , unless allowed or requiredm
otherwise as provided in 310 CHR 15 . 305 .
0D �w G
L
Y
-C OMMONVWEALTH- OF A IAS SACHUSETT
THE
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
F
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
'as rovided in -3"10 �CMR
p 15.340 and Section 13 of. Chapter.21A of the
General Laws. Issued by The Department of Environmental Protection.
June 8, 1995
Acting Director of the '-ion of Water Pollution Control
e.
ASSESSORS MAP NO:
PARCEL NO.: Fes$....... :..".......
No.. --....._.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
�..� .Yl.................OF......! .rk!s 1C......................................................
Apptiration for UhipwiFal Workii Tomitrnrtinn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (*) an Individual Sewage Disposal
System at:
-• 1!�__aclr .. :. �Xli _1���.0:........................ .•---...........----.............--•------- ---•-----------------------------------..
--- -------------
Location-Address or Lot No.
n 1 n
----•--•-•-•----•------------------------- ..rQrt_LFu ,n ....................................
/��j/� Owner A Address
►W-a 446 CC 360 _�Cilh %4--,L4. -- O
-----------. cars- -------------------------- --------- -- ----.. .tRaa�,� tar,�c_.w ..............
Installer Address
UType of Building Size Lot____•__--_--_-•-•-__-____-_Sq. feet
Dwelling—No. of Bedrooms...................................3.....Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures .........................---••- .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
G� Septic Tank—Liquid"capacity............gallons Length................ Width................ Diameter---------------- Depth................
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---___-_---____--_-_--.
a' ••••-••••••--------------------------••--•--•-•--------•-..........------•--•--.....----------..............................................................
0 Description of Soil........................................................................................................................................................................
W
U .......................................................-,.....................................................................................................................................----••----
W ••---•--••-•-------•----------------------------•-•---------------.................................................. ..................................................
U. Naturx of Repairs or Alte rations—A swer when applicable. n O
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i I:11: }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 he board of ealth.
Signed !3 f'� ....
Application Approved By....... ................. ---------1
r Date
Date
Application Disapproved for the following re ons:-------••-•---•---•------••----••--•--•-•-••----•-••-•••••••---•---••-----•-•------•-••-----•••----••--•--•-----
•-------•--••--•---•--•--•---•••---••--•----•------•--•--•--••------••-••--•----•-••-----------•--------------•---•---•--•••-•••--•••••••-•••--••-•-••••-••-•--------•---------••--•--------•-•••••••-•-
Date
03
Permit No.
-
Date
103�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliration for Disposal Works Tonstrudion rumit
Application is hereby made for a Permit to Construct ( ) or Repair (4) an Individual Sewage Disposal
System at:
.... a... .
f Location-Address ( r orb Lot No
...�l 1 r 1 i C.C{f!C_ ...... f l U.. ....✓+:i�S�A
Owner 1 r Q Address
Inst ail er........•.........•................... .: �I r�--y-----�.��---•••:.r-_I:�t -__.�.tn_.
Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.................................t9__-__-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixtures .............•--•-------•--------------•---.....•--_..._
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—NTo..................... 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........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --------------------•----•-------•...._.....--•---•------•-••......•--•--...........•----._...----•-.....................................................
----
0 Description of Soil........................................................................................................................................................................
W
V --••--------•------•----•-•-----------•--•------------------------------•----•----•---------•-----•-•------•----------•-•-•-----------•-------------•-------...-••••--•-.......-----------------•.-----
W
UNatu e of Repairs or/Alterations—Answer when applicable T„�_�!� --- - r.-../'so, ..." .... .... r..,•.
r our' ht\ r;;,!!•r+1� On,/ �t lx1a2 CC°a lot:rp��-,r� .... f
V-------------------•--------------------- - ---- ----•- ._...,... ••-••-------------------------------------------------------
Agreement: i
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TiT�p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certincate of Compliance has been issued by the board of health.
Signed......... -= 9 ,
........................................................ ..........................-....
Date
ApplicationApproved By............ --------------..*�............... ................................................
Date
Application Disapproved for the following reasons-------------•----------------------------------------------------------------------------------•-----...-•-••••.
--•-------••--------•---.....•-------•-----••---••-•••--•---••...._.....--•--------•----•---•-...............................•--•----------•-----•......................................................
Date
Permit No. ...�C13 Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...................OF.... Y,In_
..........
01.1rrufiratr of f ompltanrr
THIS,IS TO CERTIFY, That the.Inu vidual Sewage Disposal System constructed ( ) or Repaired (L.)
Installer
----
has been instailed in accordance with the provisions of TI TIE j of The State Sanitary Code, as described in the
application for Disposal Works Construction Permit No._'').(a__
....................... dated_""..�-€�-�-1
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNC14ON SATISFACTORY. ��,
DATE...........)-o .-.1.7 _ P--------••---•-•---••-...-•-••--_._.. Inspector--••-- A4..................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
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No.:....................... FEE...r.. _.�..........
Dispersal rks Toltstrwtion.rprutit
Permission is hereby granted.. ==��--- -----------------------' a +- -----
to Construct ( ) or Repair ( ) an Individual Se ge Disposal System
at No.-------4................................................(A � �cRaf C-l�l"�
.... ... ............••-•-----------...-------••-••----•----•---•----•-----•-----------............-•--•-------••-•--
Street 11
as shown on the application for Disposal Works Construction Permit NOS 5---- Dated----- ..�_d�._-"_. ._..........._.
Board of Health
TAT ....-------l---l- ....-----••... ------•---•--•---------•-•----.-•--••---•---• ti
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS