HomeMy WebLinkAbout0909 PHINNEY'S LANE - Health 909 PHINNEY'S LANE, CENTERVILLE
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UPC 12534
No.2153LOR
HASTINGS.MN
COMMONWEALTH OF MASSACHUSETTS ..
�n EXECUTIVE OFFICE OF ENVIRONMENT:A-I-AFFAf1'R`S-1�]
DEPARTMENT OF ENVIRONMENTAL=PRO,attTIC5�
ONE �kI'�TER STREET. BOSTON. N1A 02108 61 7-2%2 >00 TO'NNOFBARNSTA81-E
HEAUH PFPT ,
W'ILLIAIv1 F \E L D TRUDY COXF.
Governor sl�T Secrew
ARGEO PAUL CELLUCCI DAVID B STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION r
Property Address: �05 ph�nn�yS L11. Canezrv�llc Address of Owner: 3){l C K I'� a-
Date of Inspection: d/4/, (If different) `S•-rR t,bKD eovr 0 017
Name of Inspector: R;-hard LQA L,
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Al� l' wtfc fncD.
Mailing Address: 7 "0!'78
Telephone Number: 2575--04-7
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
_ Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
� � �4 Inspector's Signature: $�z, ru; Date: 6
The System Inspector 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 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:
I have not found any Information which indicates that the system violates any of the failure criteria as defined in 310 CMR 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 ND). Describe basis of determination In all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a'conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
j DEP on the World Wide Web http Uwww magnet State ma uSroep
I <, Printed on Recycled Paper
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` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 909 P�inneys Ln•
Owner:
Date of Inspection: 6 6 98
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due.to broken or obstructed
pipets) or due to a 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 levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
Inspection if (with approval of the Board of Health)
broken pipets) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the systernis failing to protect the
public health, safety and the environment
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM fS 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and,the SAS is within 100 feet to a surface water supply or
tributary to a surface water supple
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9o9 Ph'twfey S Ln.
Owner: t9 . Fanjro
Date of Inspection: al Irl9g
DI SYSTEM FAILS:
Yo stndicate ewer "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
i
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 into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow,
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El 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 above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 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 6f 314 C-MR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9,09 ph;noeys Ln-
Owner: A F6,70-0
Date of Inspection: 1-11-6/,3 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following
Yes No
Y _ Pumping information was provided by the owner, occupant, or Board of Health.
_✓ L/ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates N.Q during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note ,f they are not available with N/A.
The facility or dwelling \,,as inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
•� _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part,C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 969 PA'AAE'yl Ln
Owner: .P , Oil 141"p
Date of Inspection: /�����
FLOW CONDITIONS
RESIDENTIAL:
Design flow: I/6_g p.d.,becroom for S.A.S
Number of bedrooms
Number of current residents b
Garbage grinder (yes or no) -p
Laundry connected to system (yes or no).4S•
Seasonal use (yes or no: -Ibb
Water meter readings, if available (last two (21 year usage (gpd, �—
Sump Pump (yes or no)
Last date of occupancy
COMMERCIAUINDUSTRIAI:
Type of establishment:
Design flow: gallon
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (ves or no)_
Non-sanitary waste discharged to the Title S system (ves or no;—
Water meter readings, if available
Last date- of occupancy
OTHER: (Describe)
Last date of occupancy
GENERAL INFORMATION
PUMPING RECORDS and source of information
lion&-
System pumped as pan of inspection, tves or no)--'N16
If yes, volume pumped gallons
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or not (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 of information: ITS, n S BV T'r
Sewage odors detected when arriving at the site: (yes or no)AO
(revised 04/25/97) Page 5 of 10
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 90 y r n{1lnneys LA
Owner:, FC,llt
Date of Inspection:
BUILDING SEWER: ,
(Locate on site plan)
t
Depth below grade �L
Material of construction cast iron PI-40 PVC _ other (explain)
Distance from private water supply well or suction line
Diameter _4=2
Comments (condition of joints, venting, evidence of leakage, etc.)
f
n�
SEPTIC TANK:
(locate on site plan)
¢i r
Depth below grade
Material of construction t-c-z5-n-crete _metal _Fiberglass _Polyethylene _other(explain;!
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: lOOG' act?
Sludge,depth _
n
Distance from top of sludge to bottom of outlet tee or baffle 3L
Scum thickness Z.to 4-
Distance from top of scum to top of outlet tee or baffle "
Distance from bottom of scum to bottom of outlet tee or baffle LZto O
How dimensions were determined rnrd�s ,,r,-
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.) nrFJ ta n +a _�Zti�C r^ ^� CdhG7nrcoLeg!
GREASE TRAP: A
(locate on site pla ;
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
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
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.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 909 Pbrr)ney L.n-
Owner: A, Fol)ito
Date of Inspection:
TIGHT OR HOLDING TANK:"(Tank must be pumped prior to. or at time, of inspection)
(locate on site plan)
Depth below grade
Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order _ 1 es, _ No
Date of previous pumping
Comments.
(condition of inlet tee, condition of alarm and float switches, etc )
DISTRIBUTION BOX: (/
(locate on site plan)
Depth of liquid level above outlet invert: CIO
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
level A 0VeC: Bc- lPl<<
PUMP CHAMBER:.
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: `909 PAinn-eVS (Jl.
Owner: Q. Fcoil-O
Date of Inspection:6�6/�8
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, J possible, excavation not required. but may be approximated by non-intrusive methods
If not determined to be present, explain r
Type: /
leaching pits, number (p X t!
leaching chambers, number
leaching galleries, number
leaching trenches, number,length,
leaching fields, number, dimensions t
overflow cesspool, number
Alternative system:
Name of Technology:
Comments
(note condition of soil, signs of hydraulic failure, level of ponding, condition oj)f vegetation, etc.)
SoRls dine —00 5 h Q� any prGbleMS — 5;-ef?t GO1clIrl.on
dirtSid in vv iZ"on
CESSPOOLS:
(locate on site an)
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 groundwater.
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.)
PRIVY:
(locate 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.)
(revised 04/25/97) Page 8 of 10 _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: Jo ph)n,)e S LI)
Owner: R, Fn pto
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)
3
z
A)- 12.5- 31 -381
A-z— z6 $z—41
g A3-- 3o,.s' 63-43,5
�al-aqe A4- 4-Z B4- —33
PRI NhICy S 04
(revised 04/25/97) Page 9 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 909 Phoj)j4&+S Ln
Owner: Fan i t-o
Date of Inspection: 6/6/fig
Depth to Groundwater 28 Feet ar »+o,-e
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
heck FEMA Maps
Check pumping records
Check local excavators, installers
-k::�-_-U-se USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
fiA, grac� t �c (eV 58
Waref- tvi44 t- -t7e✓. 30-l-
(revised 04/25/97) Page 10 of 10
3 L70q ` l . L
LOCATION � EWAGE PERMIT NO. '
VILLAGE G�
INS T ALLER'S N, ME & ADDRESS
0 U I L D E R OR Fo
DATE PERMIT ISSUED � � .o
D,AT E COMPLIANCE ISSUED
�p X",Ar (C4
T� -
l
21 -ZNo.- --- ` Fps,. ...°."........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..c.? ....... ........OF........1, ?'"A.! Via- - .....................
Appliratiou for Uhipusal Works Tonstrurtion rnmit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:,
................_. ......... •.........••.. .......................................................................
-------•---...... .. ....-----------------------------------•.
Location-Address or Lot N
.......... _C .e1.�ye�r_ .fed .+�s'...../ue..................... ' .._1, �.... ......... �� t -- .r 4x.41,-14G..............
Owner �Add�ess
W 1...f �.f�. - 1 � .�! --. � ._.._ ? ..
a Installer Address
d Type of Building Size Lot...,•%
..... feet
Dwelling—No. of Bedrooms.\ , --•--_____--______--___Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons--.-____________-_---__-_._. Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
W
Design Flow.............................e.S.a. _gallons per person per day. Total daily flow-_ ----------
WSeptic Tank—Liquid capacityl� ..gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit NoJr0_ 2?-__- Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( L-)-` Dosin to
'~ Percolation Test Results Performed by.. .. _k. : r................... Date.._ '� .`. :....._..
aTest Pit No. 1.._.....�...minutes per inch De h of Test Pit.................... Depth to ground water.._._..._...............
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-•--•-•-•-•-••---------•...............•-•....._....._.......• - ---------- - .........................................................
ODescription of Soil....... 'a:.ry a.x......�r r .---• .!1,% �Q,��sJ,._---- a a �----------------------------------- ------
x t.
W
UNature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iI"iE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b is ue by the�,,b'a.iV1 of health.
.g
t ned -1 _�► ---•-------
r ��l<<f�' E�rJ�-- � •-•-------- ate
Application Approved By_.... f,........... -- ��
Date
Application Disapproved for the following reasons:.................................................................................................................
•....................................................-.............................................................................................................. ...............................
�/f Date
Permit No--------------------•... '� Issued.
1 Gv. �. `7 �/
�
Date
Ad
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF SHEALTH
..........OF........ .,.-----•.................................
Appliration for Diipotia1 Workri Tonvtrnrtion ramit
Application is hereby made'for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
!1 /ice 1$ r / --•-•---
Location-Address or Lot
7 -d~ ra�:_. � � - t".-.-1.�' .................... i .. �t tr1' 431A.6. •• --
Owner /Ad ess
............................................ ........i� .e� ..: ,d� -.. 1 1 ._..
Installer Address
d Type of Building Size -----Sq. feet
U Dwelling—No. of Bedrooms.. �-.,10.......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ...... No. of persons............................. Showers — Cafeteria
Q' Other fixtures ..................................
-•---•-------•-------------
Design Flow................ "�"x"'~..gallons per person per day. Total daily flow_...4 ___'".4A�0.............gallons.
WSeptic Tank—Liquid capacityrif0P.gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width........._---------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.1 'C.___- Diameter........... ....... Dep 1 below inlet_ ............... Total leaching area..................sq. ft.
Z Other/Distribution box (�^'" Dos ir t 0 R
'~ Percolation Test Results Performed by. -..__.___ •__..._.. �.. �.__ ................. Date...��� ....._....._......._..
aTest At No. 1........7....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........................
•----------•-•-----------------••-_••... ... -•-•----------------.--_.._ .... ..........................................................
xDescription of Soil...... -----92a�-W'--•0 "1-----
(� ----------f----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
W .,,
UT Nature of Repairs or Alterations—Answer when applicable................._................................ s
Aglreement: :err>•,_•
The undersigned agrees to install the aforedescribed ,Individual Sewage Disposal .System in accordance with
the provisions of TITLL
p 5 of the State Sanitary Code—The undersigned ftirtl en.agrees riot to place the system in
o eration until a Certificate of Compliance has bW i sue b the ba of Zealth' 1`
�,/$.,""} � �a>� � �n
P P �7 ✓ dt� �iI� A r�Xr
igne • ----••..--. ....... •.
. -
11-1
r
,7. Or.7.10
ApplicationApproved By--••-------r-------•-------•---•--••-----•-------------•---•----- ........................
Date
Application Disapproved for the following reasons:-------••------•-•-----•---.....----•-------------------•--•------------------•-----•---------•-----------_.....
----•--••----------------------•----•---•-----------••-•---------•---•--------------------•---------------------•---------------------------- --------------------------
Date
M
Permit hJo----------------•---------------------------------------- Issued---• - - ��
Date
:., THE COMMONWEALTH OF MASSACHUSETTS
BOARD Oy HEALTH
rdifiratr of Tout liana
T I the Individual Sewage Disposal SystenA constructed ( or Repaired ( )
.3 .%�..... ...........................................................------ .s been install; in accordance with the provisions of T _ `�bjMe State Sanitary Coo e. a�y'd�s760 'in the
application for' is ,I Works Construction Permit No. .......... da.ted....................... <.........................
THE ISSUANCE OF THIS CERTIFICATE-SHALL NOT'BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......---••-•--••..............^S.....2 7,�................. Inspector-•-•--. ...#.. ..! .. �..L.._,
THE COMMONWEALTH OF MASSACHUSETTS
i BOARD O H d-
7. .....OF............................................. S
No......................... FEE..,.....................
i o tt r if
nrtion �f amit
Permission h reby granted.... .................. ... -------- -----•. • `•.
=
to Constzitctr R '( ' ei'`,�lalsp°s ?*
atNo. ••---------------------•----•-----•---•-----•----•---:----•••---•----••-------•....-------------•------•-•--•----•--------------...---•----+ry----
Street p'C ..
as shown on the application for Disposal Works Construction Permit No..................... Dated...........................................
---- ...........................................................................
Board of Health
DATE------.�...................1...........:..................
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