HomeMy WebLinkAbout0343 PRINCE HINCKLEY ROAD - Health 343 PRINCE HINCKLEY RD, CENTRVILL
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Commonwealth of Massachusetts
Executive Office of Envirolunental Affairs
Dept. of Environmental Protection
Jitl
One winter Street' D.E.P. Titlee V Septic i
Boston,Ma. 02108 Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
n� p izs c'0+1.9
Property Address: 343 Prince Hinkley Rd.Centerville Address of Owner:
Date of Inspection: 8/15/98 (If different)
Name of Inspector: John Graci Gamache
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name, Address and Telephone Number:
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 donned In Title V
Conditionall Passes code 310 CMR 16303.My findings are of how the system Is
performing at the time of the inspection.My Inspection does
— Needs Fur er valuation By the Local Approving Authority not Imply any Warranty or guarantee ofthelongevhyofthe
Fails
septic system and any of its components useful life.
Inspector's Signature: Date: 8121198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing thiiX
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector a9dd the system owner`shall su mit
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 approvjby authorit
W'fCOVEQ �®.
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INSPECTION SUMMARY: �390
" TOWN0F8ARNST
Check A. B, C,or D: ' HEALTHOfpr"�LE
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 systern 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 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
CoMnpliance(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 eAltration,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 04127)97)
One Winter Street • Boston,Massachusetts 02108 . FAX(617)556-1049 a Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Prince Hinkley Rd.Centerville
Owner: Camache
Date of Inspection:8115198
_ Sew.acie backup or hrealcout or hicih.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
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 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 IS 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 ppin. Method usedto determine distance (approximation not valid)
3)Other
D] 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 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.
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 343 Prince Hinkley Rd.Centerville
Owner: Gamache
Date of Inspection:8115f9s
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 112 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 1100 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 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 program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
343 Prince Hinkle
Property Address. y Rd.Centerville
P Y
Owner: Gamache
Date of Inspection:8115199
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.
_c_ — 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
P P P P
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 facilityowner and occupants, if different from owner were provided with information on the proper maintenance of
( p ) p p p
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
unacceptable)[15.302(3)(b)j
(revised O4r17197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 343 Prince Hinkley Rd.Centerville
Owner: Gamache
Date of Inspection:8115199
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g•P•d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: 3
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two(2)year usage(gpd):
n1a
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nfa
Design flow:U 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: nra
Last date of occupancy: nra
OTHER:(Describe) n1a
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System was last pumped 3 years ago.
System pumped as part of inspection: (yes or no)No
If yes,volume pumped: g 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:
$yetem Is 12 yema old,Infwwntlon hom ownoi.
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 343 Prince Hinkley Rd.Centerville
Owner: Gamache
Date of Inspection:8115198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 1'
Material of construction:x con create metal FRP Polyethylene—other(explain)
If tank is metal; list age nia . is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: Le•e"h5'7"w4'10"
Sludge depth:7"
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness:4"
Distance from top of scum to top of outlet tee or baffle:S"
Distance form bottom of scum to bottom of outlet tee or baffle:14"
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 functioning properly.Recommend pumping every two years for maintenance.
GREASE TRAP:
(locate on site plan)
Depth below grade: nfa
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rva
Scum thickness:nla
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle:rda
Date of last pumpingnt-
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.)
nfa
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_rs,-
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?o-
Diameter. nla
q,imments: (conditions of joints, venting,evidence of leakage, etc.)
(revised 04127187)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Prince Hinkley Rd.Centerville
Owner: Gamache
Date of Inspection:8115198
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rya
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: we
Capacity: rJa gallons
Design flow: rda 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.)
rVe
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
rVa
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_v�5
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Na
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 343 Prince Hinkley Rd.Centerville
Owner: Garnache
Date of Inspection:8115198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Na
Type:
leaching pits. number: 1000 gallon leach pit
leaching chambers, number:Na
leaching galleries, number: No
leaching trenches, number,length: rda
leaching fields, number, dimensions:n1a
overflow cesspool, number:nla
Alternate system: n1a Name of Technology:_rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
The leach pit Is structurally sound and functioning properly.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: nla
Depth of solids layer: Na
Depth of scum layer: Na
Dimensions of cesspool: Na
Materials of construction: n1a
Indication of groundwater: n1a
inflow(cesspool must be pumped as part of inspection)
n(a
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rtla
PRIVY:_
(locate on site plan)
Materials of construction: Na Dimensions: n1a
Depth of solids: n1a
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
n1a
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
343 Prince Hinkley Rd.Centerville
Gamache
8115198
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)
reC
. 7
E
OIL
403
a P
'AC3S �
� aNi
(revised04127197) Page ! of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
343 Prince Hinkley Rd.Centerville
Gamache
8l15l98
Depth of groundwater 12
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)
USGS Maps and Charts
(revised 04127197) page 10 of 10
C.[ TOWN F BARNSTAI3 E
LOCATION `2 9 SEWAGE #
VILLAGE m ✓ SSESSOR'S MAP & LOT�� 1 _ �►
INSTALLER'S NAME&PHONE NO.W
II SEPTIC TANK CAPACITY I 0
LEACHING FACILrrY: (type) Pl�-(size) [0® V
NO.OF BEDROOMS BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) 6CQ
Feet
Furnished by h C1 f"
e �
AA
35���
Cl
ASSESSOR'S MAP NO. 1 "71 PARCEL
l0 CAT 10 SEWAGE PERMIT NO.
VILLAGE
INSTALLER'S NAME i ADDRESS
e U I L D E R OR OWNER
,0_014 k) W �L. gKrrLS
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
r -� r
V► � .+
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'` '3ftC
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ASSESSORS MAP NO:
PARCEL ICU.: -I_�- Fps•••• •:......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................ ...._...........O F...........I............. ..........------........................................
Appliratiun for Uiipuiittl 10orkii Cnunitrnr#fun rprutit
Application is hereby made for a Permit to Construct (j,1) or Repair ( ) an Individual Sewage Disposal
System at:
• .._ ._
Location-Address or Lot No.
........... .....•--....----.............-•--•-•---•-•-----. ...........--••-••••••........................
Owner Address
......... a� /_'!�-d__fik"�7' ' ............
z
Installer / Address
Type of Building Size Lot.............................Sq. feet
U Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
(1, Other fixtures -------------------------------••--••-------•••... .._.. .. -.....•••--------------
W Design Flow............... ?.Za:............. per person per day. Total daily flow................t4.4..S_r......•......gallons.
WSeptic Tank—Liquid capacityS-- ".gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..............._....sq. ft.
Seepage Pit No........I........... Diameter.... Depth below inlet.................... Total leaching area..... ft.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by..13_!�_J_r�.!�._...._w.�.e:................................. Date...a.�_�_..�7+ ���-�
as Test Pit No. 1.......-1.....minutes per inch Depth of est Pit._....Ll ......_. Depth to ground water_._._e�
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' ...............
0 Description of Soil.......
x
V --•••---••--•••••••----••-•--•••---•--•--••-•••------•--•-••-••---•-•--•••••••--•-...-----••----•---•••-•••----••-•--••-•--•--••---•---•---••••--•-•-•-.......--•-•...................•-•---•-•-------•.
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 TIME 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a CP,11 cite of Compliance has been issued by the board of health.
c Signed
/fJ Dat e
A lication Approved B �-_�fG:�:.....�_! �'L--- •`'� N
Date
Application Disapproved for the following reasons---------------••---.....------------•-------------------------•----------------•---------.......----....._------
.........................•-•-•-•••...-••---•--•••--•••-•---•••----•••••--------•.............----••......•-•---•-•---•-----••-•••-••---••••••--••-•••••--•••••--•-•-••••----•--•-----•••--•-•-•-•-------
Date
PermitNo. ......................................... Issued-.......................................................
Date
J
F�s.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... .................. ............OF........................................
Appliration for Dioposal Works Tonotrurtiott rrrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: *t_ (/
...... .............................
c••J
Location-Address or Lot No.
.................... 1. •.. •-••-.....--•-------•-•_.........._......._.... .............._.......
?f ...... ............................
Owner dress
...:................... �'` �-••..__..._.._.__.. __._. _....__......� ......--------------------------------•--• ......._..----.........--••-•.................
Installer Address
Type of Building Size Lot............................Sq. feet
U� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...............................................................
Design Flow............._ 3:Q........t"s____gallons per person per day. Total daily flow............... .f.. ..................gallons.
WSeptic Tank—Liquid capacity ____ .__gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.......I............ Diameter.__t_►x__4__... Depth below inlet.................... Total leaching area....a:__�`�__....sq. ft.
Z Other Distribution box G•r'j Dosing tank ( )
Percolation Test Results Performed by13_p_rr! .'P.__tst
.y.L.................................. Date_.!_Ar...�7� ���,�
Test Pit No. 1_______ _______minutes per inch Depth of Pit____/_�.......... Depth to ground water.... ......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
D Description of Soil...... ._._--�___.. _
x
U •-----------------------------•---------.......•---•-----------------------•.....-------.....------•._....--------••------------•••--•-•-----•...-----.....--------------•......_..._.......------•----
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 TITLE 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Glte of Compliance has been issued by the board of health.
` Signed-----
' v ---•-•--•• -•-.....
........................................................... .............................
•� Date
Application Approved By.._.._._<__._��:: I..:` — .... - � •? :............. Date
Application Disapproved for the following reasons________________________________________________________________________________________________________________
----------•----------------------------------•-----------•-------------------------._....__..__.....---...---------------•----------------------------------------------------------------------.._....._
Date
�...
Permit No.�___-`- ..� ... .__ Issued____________________________
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1."Q1PIw................OF......................
...................
Trrtif iratr of Toutphatta
THIS Ii.10 CERTIFY That t Individual S wa
rDisposal System constructed ( ) or Repaired ( )
._._._.....!
by-•••--•-- -• - ........ -------- .........-..........................................................
.........
Instal
has been installed in accordance with the provisions of T" _ 5 The State Sanitary Code as des ribed in the
- application for Disposal Works Construction Permit No.-_C5-�'....' _ r-2 ..... dated_.... ,., ,_
THE ISSUANCE OF TH S CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUN N SATI FACTORY.
/ Lt.
DATE............................... ..................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
N�----_`�'�a2 ........................................... ...--•-•` FEZ.1_-_6_ ...
Diopos forks To trudion f amit
Permission is hereby granted.....-- .. .........
to Constct ( R -pair ( ) an I i idua Sewage Disposal System
atNo.. ��-''..__... ..�y: _e,.......... ....r ....l:! ......_._..---+---------..---------------....------•--A------..._....----- -
Street J
as shown on the application for Disposal Works Construction Permit No��_... a Dated.._ 1"7/- -------------
' .
DATE_ fJ-.k� Board of Health
FORM 1255 A. M. SULKIN, INC., BOSTON
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SEPTIC TANK E 1000 fS4L
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LAND SURVEYORS AND CIVIL ENGINEERS
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5077 3S-S
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SECTION THRU SEPTIC SYSTEM 08
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