HomeMy WebLinkAbout0035 PINE TREE DRIVE - Health -35'Pine Tree Drive,Centerville
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HASTINGS, MN
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection ,Jolui Grad
• One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector
P.O. Box2119
Teatieket, MA 02536
(508)564-6813
WILLIAM RWELD
99vemor 1�.
ARGEO PAUL CELLUCCI �N . �"' ! 7 :
Lt.Governor �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A e 9
CERTIFICATION
Property Address: 35 Pine Tree; Centerville ;`\ g Address of Owner:
Date of Inspection: 2/26198 � (if different)
Name of Inspector: John Graci William Griswald
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) 1P oo
Company Name,Address and Telephone Number:
g
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
code 310 CMR 16203.My findings are of how the system is
_ Conditionally Passe performing atthe time ofthe Inspection.My Inspection does
— Needs Furt r Ev at)on By the Local Approving Authority sepicsyystemaand nyorlb ompon ntsuseff the ullife.
y of the
Fails
Inspector's Signature: Date: 2125198
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 NO). 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 exhitration, 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 OWD97)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 0 Telephone(617)292-5500
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 35 Pine Tree Rd.Centerville
Owner: Wiliam Griswald
Date of Inspection:2126199
_ Sewaae backup or.hreakout or high.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
Cl 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 15 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 watersupply 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 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate elther"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.
(revived 007197)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 35 Pine Tree Rd.Centerville
Owner: Wiliam Griswald
Date of Inspection:2126199
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 It 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.
pevlaedelrl7l87)
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART 8
CHECLIST
Property Address: 35 Pine Tree Rd.Centerville
Owner: Williamcrtswald
Date of Inspection:2126199
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.
Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
x
unacceptable)115.302(3)(b)J
(mleed 00707)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 35 Pine Tree Rd.Centerville
Owner: WiliamCrtswald
Date of Inspection:2126199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g•p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of current residents: o
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yea
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: Na
COMMERCIAL/INDUSTRIAL:
Type of establishment: rda
Design flow:o 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: n(e .
Last date of occupancy: nla
OTHER:(Describe) ria
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rya
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nla
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:
epproxImNiy:19T7.19T9
Sewage odors detected when arriving at the site: (yes or no) No
(reylsed 04717197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Pine Tree Rd.Centerville
Owner: WIIIiamGriswald
Date of Inspection:2126199
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 16"
Material of construction:x concreate_metal_FRp_Polyethylene—other(explain)
If tank is metal, list age nie . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: 1_816" +5'7"W490"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 24"
Scum thickness:0
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0
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.)
Septic tank and all components are structurally sound and Nnctioning property.Recommend pumping every one to two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: Na
Material of construction: _concrete_metal_FRP_Polyethylene_other(explaln)
Dimensions: nla
Scum thickness:Na
Distance from top of scum to top of outlet tee or baffle:nla
Distance from bottom of scum to bottom of outlet tee or baffle: Na
Date of last pumping;d.
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.)
Na I
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 2'
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction linOovm
Diameter: 4
(v,Imments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04117)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 35 Pine Tree Rd.Centerville
Owner: WIIIIamGrlswald
Date of Inspection:V261911
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nta
Capacity: nla gallons
Design flow: Na gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: liquid level wlth bottom ofpipe
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
-Box Is strueturslly sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised 61127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 35 Pine Tree Rd.Centerville
Owner: WiliamGriswald
Date of Inspection:212619E
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nfa
Type:
leaching pits,number: nfa
leaching chambers,number:nia
leaching galleries,number: nfa
leaching trenches,number,length: L30'W10'D3'
leaching fields,number,dimensions:nia
overflow cesspool,number:rva
Alternate system: nfa Name of Technology:_wa
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
System and all components are structurally sound and Functioning properly.
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: nra
Depth of scum layer: nia
Dimensions of cesspool: nia
Materials of construction: Ma
Indication of groundwater: Na
inflow(cesspool must be pumped as part of inspection)
nfa
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nia
PRIVY:
(locate on site plan)
Materials of construction: nia Dimensions: nia
Depth of solids: We
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nfa
(revised 01127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
35 Pine Tree Rd.Centerville
William Grlswald
MGM
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)
Prod
6
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(rovLed04W197 Page ! of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION(continued)
35 Pine Tree Rd.Centerville
William Griswald
2126199
Depth of groundwater 6.
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)
USG9 maps and charts
(revm•d04WIDT) Page 10 of 10
Name Sewer Permit No..... .__.__.......
C e`vrem? 0) /)' ......./77 .__._._.....
Installer's Name and Address _ C�1llv '1...C ;?.,c�.�► 1 ..... a',:
,l ...y... .%.�1 al.......,r�.(1 -.......... .... .. .. w.. s.........1 ?. ?................................... ...__.............
Builder's Name and Address.. ilir/.U....e., ..... ...��o.S ..._ _S'c /.................................
. I( r S.V !.,/� ......��s �......... 0 _/_.._..../c' 91p.v .. .._ '!Ya.<........... ....................................
Date Permit Issued: ( 1. .,,.....:... .
Date Compliance Issued:.......... ....~ ...
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
^ U --------------OF......... -------.....
Appliratioo -for Bhipooal Workii Towitrortioo Vamit
Application is hereby made for a Permit to Construct ( iol"or Repair ( ) an Individual Sewage Disposal
System at 6-�
i..�.�. = = .-- �_�-6 -----------------------------�--�-=. ..--- -
Location ddress or Lot No.
94
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W ? ---- n�+c ..Address 7
Installer Address
Type of Building Size Lot._.._14.5- 0----Sq. feet
U Dwelling—No. of Bedrooms------------ _ .....Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) Cafeteria ( )
Pr Other fixtures ------------------------------ - -
W Design Flow_______________-56....................gallons per person per day. Total daily
` fow---------------_5®P---------------gallo-
ns.
P4 Septic T J- -0� allons Length_8.:-C. Width.� ."C r.....I uid ca acit .- _.. ..... . Depth-- _1- -�.
Disposa No.--__-__-•----__--__- Width-_-_-._----.....
D�
Total Length._.....5 �o14abe area-. ft.
Seepage Pit No--------------------- Diameter.........._......... Depth below inlet____ ,... of area._ ------ ----- -sq. ft.
Z ( ( ) 6�, R RT
Other Distribution box Dosintank
a Percolation Test Results Performed by--- 14ALI�t _�:1,�. � _I_- jtwt �
Test Pit No. 1---Jzl------minutes per inch Depth of Test it--- _... e��h1��� i� ii21 ater_. ��__Q°i.____
f1 Test Pit No. 2................minutes per inch Depth of Test Pit...............°1...... �th t%�Y } I water-..---------------------
a ,s..r PST
O De cri tion of Soil. �� 2j5-.a" 1
1 ....... .?_& ----J�i/J_D----- i- �P ii.1 CS-Z------g_Ak.& _o
MAU -------------------------- -----------------•- -----------------------------------------------------
UNature of Repairs or Alterations—Answer when appli le.---------------------------------------------- -------------------------------------------.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' sued by the board ealt
ti �-
igned z 1t� ---� �----- --------- - ----
45 .; ---
Date
APPlication Approved By---
Date
Application Disapproved for the following reasons--------------------------•----------------------------------------- ......................................
............................... -•---------------------------•--•-----....•------•--.._..----••--•••••---------••-------------------------------- -----------------------------------------------------
Date
PermitNo.......................................................... Issued---------------------- ............................
Date
N0....7..................... � F��..."�U...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
rc .� �,t.. ..OF .....� ..t .t�.E. ..i !
Applirtttiun -fur Binpuotti Marko TunMrurtiun Vanift
Application is hereby made for a Permit to Construct (4<or Repair ( ) an Individual Sewage Disposal
-`-•-system at
g ('�_ Locatio ddress or Lot No
C Owner/� � Address
W t_ t / �_
a •-•-•. .. ..... S feet
Installer Address r
Q Type of Building Size Lot_..____�.�_..� _._ _ q.
U Dwelling—No. of Bedrooms------------ -----_-----------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
Other fixtures .............................................
W Design Flow...............�.�''__.. .-_._�:._'�___.___gallons per person per day. Total daily fiow_:____________.�>.�F�___.._._...__.-_gallors.f
Septic T.�u„,I.I iquid capacity____ _gallons Length _ ___ Width.�::`�._-- r_-..---._---__-
x Disposal� —No_ ____________________ Width----- ------------ Total Length-----: -'s @sob� rea--- `---S-----sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below i e ------- tal area------- ----------sq. ft.
z Other Distribution box (dsj Dos in tank ( ) � OBE
aPercolation Test Results Performed by.! t4 -i* R ' �7
�. �= minutes per inch Depth of Test Pit. _.• `--� D* W ater <4 '.a. _._..._..
Test Pit No. 1______ _______
f=, Test Pit No. 2------------_---minutesper inch Depth of Test Pit--------------- s � water._._..____-_ _.._.__ ---
�+ ------------------- - - - ---•-••---• ar �° a�,S� iAC \� ••. ----•-----
D Description,of Soil J ` " -1--------- .7 `_ .r� t a i ....._.. _ �" .• . s' iC. .t-----��=
V _ "-----•----------------•----••--•---•---•--••• . ...
U
U Nature of Repairs or Alterations—Answer when applicable..____--_______________________________________
Z
--------------------------------------------- --------------------------------------------------------------------------------------------------------'-------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI 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 ,,-d/f/_heal/� J��
Signed.........� 11�/� C __A _ t------
---•lam- ---------•---------•--•---------
Date
ApplicationApproved By.................................................................................................. .......--------------------------------
Date
Application Disapproved for the following reasons:................................................................................................................
--.......--•-•-••-••-----••-••-•••-•--------•-------------------•--..._....-•-••-------------------•------------•...----•------•-----•-••-------•-------.........------....._-------•---....-------•----
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
: ?.......................OF. .. t , € , ,.....................
Cnrartifirate of Tompiittnrr
THIS IS TO CERTIFY, That the Individual,,Sewage Disposal System constructed �or Repaired ( )
by-------------------------------------------------------------------------------------- ------- ' ------- ------------------------------------•-...........................
Installer
at----------------------------------------------------------------------------------------------------- ---------------------------•---------------------------•---•------•-----•-••-•----•--•---------
has been installed in accordance with the provisions of - r 'cle XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit +,,�.��_. .................. dated.�.__e.--`_'__7,-----_-._.-_----_--•---
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM rL FUNCTION SATISFACTORY.
DATE---- .................. 7Y-----------------•-------•-•----------- Ins ector. ------------------------------------------------------
7�-------------
THE F G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:u: .:�...............OF.. ` .�} ..T.... _ �.. ..-....
No. FEET ................
urtiun A rmit
Permission is hereby granted........ -----
to Constr'�ytG�� or Rep 'r-( ) a mdivid Sewa D, isosal Syste
at No. %�t�t.Z(1----- 1 � L�`�C - I <= � '` --�r---�
Street C /
as shown on the application for Disposal Works Construction Permie No...... ..___.✓___ "ated'___1'-._-_y'_7_! -______--..-
Board of Health
DATE-------------------------------------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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NORMAN GROSSMAN
REGISTERED LAND SURVEYOR/REGISTERED PROPESSIONAL ENGINEER s
226 HOLLY POINT ROAD
CENTERVIIJ, MASS. 771-0362
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