HomeMy WebLinkAbout0222 PRINCE HINCKLEY ROAD - Health 222 PRINCE HINCKLEY RD, CENTRVILL
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Commonwealth of Massachusetts I7Z/-/��Z
_ Inspection Form
Title 5 Official spe
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
- c
r< 222 Prince Hinkley Road -4
Property Address
Priscilla Lane
Owner Owner's Name /
information is required for every Centerville t/ Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection 1-"
a.
.a
07
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information pQ
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key.
Cape Septic Inspections
�y Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
Cityrrown State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
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 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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
09/07/2016
Inspector's Signature Date
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.
****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.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
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I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 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:
13) 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.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.'° 222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed' ❑ Y ❑ N ❑ ND (Explain below):
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 system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°r 222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
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
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
0 ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I 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 facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is
required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
C. Checklist
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 part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the 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 maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
Existing information. For example, I n® ❑ a a at the Board of Health.
9P
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): >330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 6
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
In 2016 17,000 gallons were used so far and in 2015 177,000 gallons were used and in 2014 168,000
gallons were used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•'' 222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® 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) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
-- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information,(cont.)
Approximate age of all components, date installed (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 25"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 15"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: standard H-10 1000 gallon
Sludge depth:
3"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle apx. 35"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle apx. 5"
Distance from bottom of scum to bottom of outlet tee or baffle apx. 12"
How were dimensions determined?
sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.
based on the future use of the home.The Barnstable Health Dept. has a list of local pumping co.
Grease Trap (locate on site plan):
Depth below grade: feet
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: Date
t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped 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 per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ .Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
' Depth of liquid level above outlet invert of,
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.):
At the time of the inspection there no signs of solids carryover or evidence of hydraulic failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is
required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: One
❑ 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.):
At the time of the inspection there was appx. two feet of ponding water.
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 groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition 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 condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owners Name
information is required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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 enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
/3 �
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
TOWN OF BARNSTABL,E
LOCATION CI tv I SEWA/',B d
'MUG&Cokes s.4 ya 1k PASSE SOR'S MAP A
INSTAUEWS NAME&PHONE NO.
SEPTIC TANK CAPACrIY 10W 2&1
LEACHING FACI2.TTY:(typo) Q +.�_ (sire) 4 wo! t
NO.OF BEDROOMS
BUII.DER OR OWNER W(& Wl t tf
PeNffPDATE: S��t,21 COMPLIANCE DATE:
Separation Distance Bo weer the:
Maximum Adjusted Groundwater Table and 0. Z.r Fen
Private Water Supply Well and Leachial;Facility (if any wells exist
on site or within 2W feet of lcachinS Lcility) Fen
Edp of Weiland and[.aching Facility(if any wetlands exist F.
within 300 feet is ry)
Fttrnishcd by
i
A AS
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t fir,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•" 222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is
required for every Centerville Ma. 02632 09/07/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® 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 how you established the high ground water elevation:
I augered a hole to 15 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
222 Prince Hinkley Road
Property Address
Priscilla Lane
Owner Owner's Name
information is
required for every Centerville Ma. 02632 09/07/2016
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
CrcjA e
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t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
• \ .y COMMONWEALTH OF M4SS?►CHt SETTS
EXECL-TIVE OFFICE OF EIN VIRONME�T4L AFF A �
r DEPARTMENT OF ENVIRONNE\TAL PROT N
ONE WINTER STREET. BOSTON. NIA 0.2105 FI?•:9:-�:OG .� J(j !��
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GEO P AL1 CELLI'CCI �� D`V STRL'F-_
t,Gavi:rnor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM^•• ' 6 CornMissiorr_.
PART A
CERTIFICATION
Lor
tfu.�Q; tttNClfz, U4� ddress of Owner. r-tN�
- , t mt
roperty Address; NC R
.lc3
ate of Inspection: tip Zof different) l
Ine of Inspector: a el CE7-- orC,
1 am a DEP ap roved system inspector pursuant to Section 13.34/0 of Title S (310 CMR 13.000)
ompany Name: 957,1 Yi ceiM0-64 PN ! i
ailing Address: *P O oS cm x P ?a I`T v 2E'4.cl
elephone Number: rSe?N 4-L. 242
ERTINCATiON STATEMENT
I cer:iN that I have pe•sonall mspeeed the sewase d!sposa' system at this address and tha: the iniormation resorted be'o,- is true. accurate
and complete as o:the time of inspec:,o-. The inspect.on %as pe^ermer base: on my training and experience in the proper funcicr, and
maintenance of on-site sewage disposa;-!vsterns. .1he systen:
Payes - .. .. . . .
_ Concno-aci. Fasses
_ 1Eecs Furthe- Evatuatio- Ey the local Approving Authorirt
Inspector's Signature: Y w�/ " i' Cti Date:
T;ie Svs-.e-r lr,s're^o• shai' submit a ccpv of this inspec.cri recce, to the Approving Autheriry within thirty f301 days of completing this
inspection_ It the sv!iern is a share: s\•stern c- has a de:,gn flow of 10.000 Z:d or greater, the inspector and the systr,e• owner shall submit
the repo-: is the a-,oropriate regional o ice of the Depan.ment of Envimnmenta' Frotecior.. The original should be sent to the syste^ c ne-
and copies to the buyer. if applicable. and the approving authority
INSPECTION SUMMARY: Check A, 'E, ,C, or D.
Al SYSTEM PASSES:
I have not found any information which indicates that the system viciates any of the failure criteria as define' in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below. .
COMMENT5:
BI SYSTEM CONDITIONALLY PASSES: -
One cr,mere System components as described in the 'Conditional Pass' section need to be replaced or repaired. The syste
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes:no• or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined', explair
_ The septic tank is metal, unless the owner or opeator has provided the system,inspector with a copy of a r
Compliance (anachedi indicating that the tank was installed within twenty (201 years prior to the date of r'
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a con(, i
as approved by the Board of Health, j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
- ; CERTIFIUTiOh (continued)
Property Addws: :' . . _ I
Owner:
Date of Inspection: I
B1 SYSTEM CONDITIONALLY PASSE5 tcontinu _
_ 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, sealed cr uneven distribution box. The syste.�rt will pass inspection if(with approva! of the
Board of Healthl., Describe observations:
broken pipes) ale replaced
_ obstruction is removed
_ distribution box is levelled or replaced
� _• The system required pumping more than four times a year due to brokers or obstructed pipesL:7he system will pars
inspection ii twith approval of the Board of Health):
broken pipetsi are replace' -
obstruction is removed _....._.
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:~ i
Conditions exist which recuire iurthe•evaluation by the Board of.Health in order to determine if.the systern is failing to prote the i
public health, saie:y'and the environment 1
i
1) SYSTEM WILL PASS UNLESS BOARD OF HE.,kLTH DEiEiLMINE5 THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER 1
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFiETy AND THE ENVIRONMENT:
_ Cess000i or pna is within 50 fee, of a surface water
_ Cesspool or pn.1- is ithin 50 fe--t of a bordering vegetated wetland or a sail marsh. -
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEkILTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETER.MINE5 THAT
THE SYSTEM IS FUNCTIO',ItiG'IN A MANNER THAT PROTECTS THE PUBLIC HF-kLTH AND SAF Mi AND THE
t
ENVIRONMENT:
_ The systern has a septic tank and soil absorption system (S 51 And the SA< is within 100 fee; to a surface water supply a
tributary to a surface water supoly.
_ The system has a septic tank and soil absorption systern and the SAS is within a Zone 1 of a public water supoly well.
_ The syste^n has a septic tank and soil absorption system and the SAS is within 50 feet of a private water suppty well
_ The syste^n has a septic tank and soil absorption systern and the SAS is less than. 100 feet but 50 fe--t or more from a r
private water supply we!1• uniess a we!I water analysis for coliform bacteria and volatile organic compounds indicates thz-
the we!l 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 a4;2s/9') ?age 2 of 10
4 ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
DJ SYSTEM FAILS: ,
You must indicate either "Yes' or 'No" as to each of the following;
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea j
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.
_- Stanc liquid levei in the distribution boa 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 tlov.
Reruired pumping more char, 4 times in the last year NOT due to clogged or obstructer pipes.
Number of times pumped_.
An%- portion of the So:l Aosorption'Svstem, cesspool or privy is below the high,groundw•ate% eieyatior.
Am poi :on of a cesspool or privy is within. 100 feet of a surface water.suppiv or tributary to a surface water supply.
Any portion of a cesspoo: or.prnti is'within a Zone I of a public-well."
An\. pc—ion o:a cesspool or pmti is within 50 feet of a private water supply well
Am• por,,or. o' a cesspool or privy is less than 100 feet but greater than 50 fee: from a private water supply well with no
acceo;able Ovate, quart, anak-sis. If the well has been analyzed to be acceptable. attach copy of well water analysis for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
1rou must indicate either 'Yes" or "No" as to each of the following,
The ioliow:ng criteria app;l to large systems in addition to the criteria above:
The system serves a facilin with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and saferr 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 ict a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment prc
requirements of 314 CMR 3.00 and 6.00. Please consult the local regional office of the Department for further information. 1
J
(revised o4/2s/91) Page 3 of 20
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CHECKLIST,
Property Address:
Owner: Wi
Date of Inspection: �Z� V4
Check if the following have been done: You must indicate either 'Yes"or'No"as to each of the following:
e No
_ Pumping information was provided by the owner,occupant. or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flowrates during that period. Large volumes of water have not been introduced into the system recently or .
as pan of this inspection.
plans have been obtained and examined. Note if they are not available with N:A.
The fac:lin or dwelling was inspected for signs of sewage back-up. -
2( _ The system does not receive non-sanitary or industrial waste flow. - --
The site was inspected for signs of breakout.
_ All sv- tern component-, excluding the So:1 Aosorption System, have been located on the site. -
^C _ The septic tank manholes were uncovered. opened. and the interior of the septic tank was inspected for condition of
baffies or tees. materia'. o'construction. dimensions, deptn 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 fat lit. o�.ne ,ano occupants. tf difteren: from ow•nert were provided with information on the proper maintenance of t
_ !
Sub-Surface Disposal Svsterr..
Existing information. Ex. Plan at B.O.H.
_ De;ermined in the field !ift am of the failure criteria related to Part C is at issue, approximation of distance is i
unacceotabie 115.302:3);bl!
(rwined 04/25/97) Pag• 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C i
SYSTEM INFORMATION
Properts Address:
Owner:
Date of Ih p ction�:�
FLOW CONDITION'S .
RESIDENTIAL:
Design ilo% p.d./bedroom for S.4�S
Number of bedrooms�Z j
Number o*current residents
Garbage g•::der (yes or no!
Laundry co-•-ected to system (yes or no). -
Seasonal use ryes or no!:
Water meter readings, if av T gpd
able (last two i2i year usage tt:
Sump Pump lees or not
Lai: date o`occupancy
JJJ
COMMERC tAL'INDUSTRIAL-
Type of establishment
Design fio%% _galionsida,.
Grease trap present Ives or no
Indusma! 1Naste Holding Tani: present. Ives or no
':on.sanitan Haste d-scnargec: to the Tit,e 5 system. Ives or no
1later meter readings. if availabie
Las:pate o: o c,panc,
OTHER: .Deicribe
Last care of occuoanc-.
GENERAL INFORMATION
PUMPING REC S and sou ce of ormanor.
System pumped as par, of ins cti0 : wes or no.
If yes, volume pumped- eallons•
Reason for pumpmF ,
TY�F,OF SYSTEM
Y Septic tank/distribution box'soil absorption system
Single cesspool
Overflow cesspool
Prn�'
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site. (yes or no)
r
r
1
(revised 04/25/9'7) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTE.Ni INFORMATION (continued)
Property Address: '-
Owner:
Date of Inspection:
BUILDING SEWER: :. . ..
(Locate on site plan)
Depth below grade.
Material of construction. _cast iron _40 P`'C _other (explain)
Distance from private water supply well or suction li-e
Diameter _
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:z
(locate on site p an
Depth below grade-
_.[_
i
Material of constrUL110n.: ,concrete _me-.a _F!oergla5s _Polyethylene _othertexplam
If tank is metal. hs: age _ Is age conf;rmec o\ Cen;fica:e of Compuarice _('res.-No
Dimensions
Sludge depth �.5 t(
D!siance from top o- sl!u dee to bororn of ou:,e: tee o• ba�;e 1
Scum thickness t L
Distance from top o: scum to top or outlet tee or bade Z r
Distance from bosom of scum to bo-o-n o,outlet tee e• bah.e
Now dimensions v,'ere determined 1u i a11A k 2 '
I
Comments.
trecommendat;on for pumping. condition o; inset and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural f
integrity, .idence of le •age. tc.t `�
W '
GREASE TRAP:
(locate on site plan!
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 i!ilet and outlet tees or baffles, depth of liquid level in.relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(reV3.20d 04/25.17) Page 6 of 10
•S , V M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATIOti (continued)
Propert% Address: Z (1 � ►�C �-� -
Owner: mDate of Inspection: 4.
TIGHT OR HOLDING TAN K:'�` ?ank must be pumped prior to,or at time, of inspection)
(locate on site plan,
Depth below
Material of construction.-- concrete -_metal -- Fiberglass _Polyethylene _other(explain)
t
Dimensions: --- -
Capacm v gallons --
Design floN' gahons.`da, —------ - -
Alarm level Alarm in H orking order_Yes _ No
Date of previous pu-nping —
Comments - -
(condition of inlet tee. condition o' a'a,m and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan —
r i
Depth of Iiouid level aoove outle: m%e,:
Comments
mote if level and distribunor e u '. evidenee of solids carrvover, ev ence of leakage into or o t of box, etc.)
PUMP CHAMBER:
_(locate on site plan."--
Pumps _..._.
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.) --�- - -
f
{
treviaad 04/25/97) Dag. 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Addr,ss: OL22_% C-
Owner:
Date of Inspection:�{u'�
SOIL ABSORPTION SYSTEM (5AS):
(locate on site plan, if possible; exca� utn not required, but may be approximated by non-intrusive methods.
If not determined to be present, explain: -
TYPe
_ m leaching Arts:-number.
leaching chambers, number:_
leaching galleries, number.
leaching trenches. number,length: - -
leaching fields, number, dimensions
overflow cesspool, number -- -
Alternative system -
name of Tecnnolop-
Comments.
to to co dition of . _ . . _ _ .soli. signs of hydraulic failure, level of ponds cron. dit n o' egetation, et
. � I
( — .C= .. . 1
I
CESSPOOLS: `
(locate on site plan
i
Numbef and configura:-on
Depth-top of liquid to inlet Inver,
Depth of solids Jaye•
Depth of scum layer.
'Dimensions of cesspooE -
Materials of construction
Indication of groundwate - -
inflow tcesspool must ce pumpeC as par, of inspection,"
Comments:
(note condition 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 condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page ! of 10
i 4/•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued;
Property Address: aa-)- � ( •.
Owner:��
Date of In3pection: ji7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reverences landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Ls
7
K
a
7
z
3 �1 G)
y
A)— 36! � —
�1Z
r,
(revised 04'25/57) Page 5 o: 10
r
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address
Owner: ��B�C� �ZJ�• t
Date of Inspectwn�
i
Depth to Groundwater 't-feet
Please indicate all the methods used to determine High Groundwater Elevation: 1
1
Obtained from Design Plans on record
f_
Observation of Site (Abutting property-, observation hale, basement sump etc.)
Determine it from local conditions
Cnec� %+rth Iota! Board o• nea!tr
Chec� FE.MA neaps
Check pumping records
Check Iota! e;ca•:ato,s installe,s
t_se LSCS Da--a
0
Describe in voi, o%%,• v.oros r.o•.• %o:: es:abLshed the high Groundwater Elevation. (Must be completed:
Tutt T�SI loci 0j
(zay.aad ;4;25'9-. page 10 of 10
i
� V
THE COMMONWEALTH OF MASSACHUSETTS i
`. BOARD F H EALTH � �I
...............OF........ .... . . ... --- .........................
Ap, ptiration for Disposal Nurks Tonstrnrtwi n Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys ei at: - /�f� - .r
Location-A flress �� or
....../ _ .....•........ ....... .... tit..._ -P��, !-:»::..... .� G� Trv."�:;�:............
ner Address
.---.a .: .._ - -----•--------------------------------- -----------.... ^-r...... ------------------------------------
Installer Address
UType of Building Size Lot.21.7.070....Sq. feet
.. Dwelling—No. of Bedrooms...............................:......................Expansion Attic ( ) Garbage Grinder ( -0
Other—T e of Building No. of persons............................ Showers — Cafeteria
Otherfixtures -----•--•-------••--------------------------------•---.------ ..----------
W Design Flow_._..-�— ._..___.gallons per person per day. Total daily flow.......7.4
�t...................gallons.
x Septic Tank—Liquid caacity...........gallons Length................ Width................ Diameter.:. ......_... Depth...............
W Disposal Trench �_ _.'.K. iameter
. _. Width................... Total Length............_.__.... Total leachingarea.........._.........s . ft.
Seepage Pit No.. .................... Depth below`inlet ...... ......-_. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) ;J G 42
Percolation Test Results Performed b Date Date....�- _ '.7�..'...-_-.
aTest Pit No. I................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........................
--------------------- .---------•-----•••......--••------ .....
Description of Soil------ _^Vre' •. ---------. --
x ��` --- Ze.
V .-----------------------------•-------•-------•----------•------•-----------------•--•---------------•---••-------------•--•-----------------------•----••---------•..........----......---•-----•----•-
W ---------------------------------------•-•-•----------------------•------------•--------••-...---------....---•------••---•-•--•••--------•----------•--•----•-•--•--•--------------•--
VNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigne,})further agrees not to - ce the system in
operation until a Certificate of Compliance has been issued by the board o"'health. s
Sign . • --•- =--- --- .............•-•---
Date
Application Approved By.... 144. _- .................... a—Z-, .......
/ ......................................................Date
Application Disapproved for the following reasons:.:........................................................
................................................................................•--•-•-......------•-•---•--•-•--•••-.....-•----....--•-----•-------------............................................
Date
PermitNo......................................................... Issued...... • .......................
Date
�'�..... ....... Fps......JV .
..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
j 1 ywr:rr..r
rf.
r
.:.�°.. ..a::.................OF.......��' !7.?�{.� j`' /��`
Applirathin for Disposal Works Tonstrnrtiun Fermit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at. 'e
4,11
�•� l eftI f IIr 74r1. /• 11
.._-••••••••----i-.. ...................................,.......::.:..................------. ......_...... I
Location-Address t f or Lot No.•• ••�
f /.J.. /.(...
} Owner Address ..............
Installer r Address
UType of Building Size Lot.... %.....%._...�....Sq. feet
a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( 14)c
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures . :...:.......................
W Design Flow............................................gallons per person per day. Total daily flow.....' ----- ?-------------------gallons.
WSeptic Tank—Liquid'ca.pacity......_.....gallons Length_............. Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq.,ft.
Seepage Pit No................. Diameter.................... Depth below inlet_.__.._ ......._. Total leaching area.................. ft.
Z Other Distribution box ( ) Dosing tank ( ) + P
aPercolation Test Results Performed by....................................._,. ..____-___ _..____......._. Date..... " .' .7.._...`.......
Test Pit No. I................minutes per inch Depth of Test Pit............ ..... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground
water........................
a '
D -_ -
iescrtionofSoil...............:
V ---------------•-----•-------------------------------••------------•--••-----..-----•--•--•----
W
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.• • -••--------•-••--•--•-••-•------...---••----------•-•---•-•---••-•--•-•....-•-•--............................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual.,Sewage Disposal System in accordance with
i the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.. �J
Sign /... ................................................!f { __..... or -r ...:.. ..
Date
Application Approved By..... - r 4_ '
..............
Date
-!Application Disapproved for the following reasons:................................................................................................................
•i;
...............................,......................................................._..................................................................................................................
Date
Permit No...............................-........... '. .... Issued_....1.__1l.' ?Ir.--•----•-..........----••--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
�........O F....... ..:!.........................................
(9rrtif irate ,af TomptiFanrle
THIS I T CE I hat the Individual Sewage Disposal System constructed ( or Repaired ( )
by_•.`" t = ....................................
...... -...--------....�... ..........................................
allei"�
has been installed in accordance_,with the provisions of 5 otate Sanitar de,as described in the
application for Disposal Work"s Construction Permit N .. _..__� __________________ da.ted_..
THE ISSUANCE OF THIS CERTIFICATE SHA OT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEM 'WILL FUNCTION SATISFACTORY. Y.
DATE----.....I_... ...... .1-------------------•-•-----.................... Inspector...:•A - 1/�t�1....._. ._.._....._._....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF7 HEALTH
9 ...... ......OF........... .... �.�'��... .................
N ........... ......... FEE...+ ...............
Disposal NOr nrtilan rrntit
Permission is,hereby granted...!........ -- --....-• . .. •...............................•-------••-----....----..................•--•--.
to Construct ( or Re ( ) a In 'vidual Sew e�ispo yst+em
at No.......� .. .
treet
application for Disposal Works Construction Per > No.. __.... Dated.....__' ____ .." � "�
as shown on the .............
�/ ��L
DATE.'::°,.n! .. _ ��. _... 7 Board of Health i
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
E
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
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��'P i�eCsi.. GcktrlPL�lS W {TI•a T'i-.!L?,� •j 1 U� t..1►..�Es -____-._....____. _-..
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