HomeMy WebLinkAbout0158 SETH PARKER ROAD - Health 158 SETH PARKER RD., CENTERVILLE
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UPC 12543 0 ��
No.
HASTINQS,MN
TOWN OF BARNSTABLE �l
LOCATION i S 6 CSC\\Y--, QC� SEWAGE #
VILLAGE Q%A&-he2V l ASSESSOR'S MAP& LOT t�l
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY WOC7
LEACHING FACILITY: (type) (size) \O C7b W
NO.OF BEDROOMS_s�
BUILDER OR OWNER
PERM DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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) �`14 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by ���
(4-cx4,
2 6
RI_ 516' �
hZ- so' 6Z- 301
l 3- 3p` 63_ 41 o 6 N
_ S®'
C0NjMO\-\VE.A.LTH OF NL-%SSACHtiSETTS
EXECUTIVE OFFICE OF E.NVIR0NIMENTAL AFFAIRS
,t= F DEPARTMENT OF ENV]RONMENTAL PROTECTION
ONE nZNTER ST?=RT. BOSTO\ 1L4 02108 (617) 29'?•i:�c1U
1- TRUDY COX-r
Secretary
ARGEO PALL CELLL;CCI DAt'ID B. STR HS
Governor Cornmissic;er
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
m or 1 PART A
LOT 0151 CERTIFICATION
Property Address: \Sco `3s:t�% \�vwvcQA- Name of Owner
C.Z4��M.UtI``Q_ Address of Owner: 1'
Date of Inspection: u � T
Name of Inspector: (Please Print) 11A\L �21 O, `"5 4' CA X k
I am a DEP approved system inspector pursuant to Section 15.340 of True 5 (310 CMR 15.000)
Company Name: J
Marling Address: r -A3 (D�C X C.Z(„4C'
Telephone Number: SCOT- '-� j '- t Z�
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further alua n t Local Approving Authority
F Ise�AA nn G
Inspector's Signature: ' "W' i Date: ? F
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to tfre
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
�91
A
8 199:8
revised 9/2/98 rjl:VIof11
L • rr.r_cd o�Reac ird Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
(� CERTIFICATION (continued)
'roperty Address:
Jwner: R
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with ap
proval pproval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 PagclofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 syste is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CM 15.303 (1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT.
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt mars
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC W TER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEAL AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption syste (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 soil absorption s tem and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption stem and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorptio system and the SAS is Tess than 100 feet but 50 feet or more from a
private water supply well, unless a well water nalysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility d the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine d' lance (approximation not valid).
3) OTHER
revised 9/2/96 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properr Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 C 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what w' be necessary to correct the failure.
Yes No
Backup of sewage into facility-or system component due to an overloaded or clog ed SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface water due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an ov oaded or clogged SAS.or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volu a is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to ogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or priv is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I f a public well.
Any portion of a cesspool or privy is within 50 fe t of a private water supply well.
_ Any portion of a cesspool or privy is less-than 00 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the we has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compou s, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the Ilowing:
The following criteria apply to large systems n addition to the criteria above:
The system serves a facility with a desig flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment cause one or more of the following conditions exist:
Yes No
the system is within 40 feet of a surface drinking water supply
the system is within 00 feet of a tributary to a surface drinking water supply
the system is loca ed in a nitrogen sensitive area(Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public
water supply we
The owner or operator of any su system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for fu er information.
revised 9/2/98 Pagc4ofl]
f
a '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: S UQ S`-I 1J�_
Date of Inspection:
kZkzl�,�
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
x _ 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-recehhng normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with N;A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
�yC _ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)1
The facility owner land occupants, if different from owner) were provided with information on the proper xnainteltaacs of
SubSurface Disposal Systems.
revised 9/2/98 pag,5ortl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
_ C- SYSTEM INFORMATION
'roperty Address: In G V
owner: S��vua
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:FI�7:�50 g.p.d.lbedroom.
Number of bedrooms (design):(aj Number of bedrooms (actual):_o 3
Total DESIGN flow
Number of current residents:
Garbage grinder(yes or no):�
Laundry (separate system) ( es or nO):_; If yes, separate inspection required
Laundry system inspected es or no)
Seasonal use (yes or no):—h=?
Water meter readings. if available (last two year's usage (gpd):
Sump Pump (yes or no):J
Last date of occupancy: S�:vn Jv�� lw-<l Uok,dS
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box'soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I;A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known) and source of information: t-{__�()I.NLry
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/9E Pag,c6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEINER: kk� 2<
(Locate on site plan)
i
Depth below grade: 3
Material of construction: _cast iron_k40 PVC_other (explain)
Distance from private water supply well or suction line TO tkj
Diameter 4 _
Comments: (Londitior) of joints, venting, evidence of leakage, etc.)
T tom, < \�r TT�c���wt'.� Ica
SEPTIC TANK:. Q,^J
(locate on site plan)
t�
Depth below grade: Z13
Material of construction: 4concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: ccCo .AA
Sludge depth: 01-�
Distance from top of sludge to bottom of outlet tee or baffle:31 4
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:
How dimensions were determined: X��\SL�
'omments:
(recommendation for pumping, condition of inl t and outlet tees or baffles. depth of liquid level in relation outlet i ert tructur irate ity,
evidence of leakage, etc.) .f Sri r-k ~ a �O
S`—X, \ G`
GREASE TRAP:��A )
(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 inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
revised 9/2/98 Ilige7oru
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
,roperty Address:--�S� -'
Owner: ' yUaNt0.K.
Date of Inspection:
TIGHT OR HOLDING TANK:_nL—�Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_Vy,.S
(locate on site plan)
Depth of liquid level above outlet invert: V '
Comments:
(note if I vel and di tributi i e al, evidence of solids carryover, evi nce of leaka into or out of box, etc.)
c
PUMP CHAMBER:
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,-condition of pumps and appurtenances, etc.)
revised 9/2/98 I'agcNorII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner: t
Date of Gispection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible: excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number: 1 talo+f'
leaching chambers, number:_
leaching galleries. number:_
leaching trenches. number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, igns of hydraulic failure, level of ponding, darg spil, co ition f vegetation, et .)
� ldv
n
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate 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 9/2/76 Page 9ofII
r
SusSultFACR BEWA1aE IMPUSA6 SYStT6M INSPCMON FORM
PART C
SYMM tWORMATION lCOfrtrwedl
•tt+c�vtY�Ao¢c�I��esas:
Dane o4� �Z� o
ir+eluAA 4e6 to AT 104st two 0e9manent relw4 as landmarks cr hanabr DIRS
/9Ct11e aN walm wlQlri,%1011'honor*whaft 4%"e water 6UGaf'40MCS IMIQ hovsel
c;
fA4
L�
revised 9/2/98 a„u tnocw
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address: 'v�U g�
Owner:GL'zt',v .
Date of Inspection:
NRCS Report name L
„1 Soil Type_
(VV Typical depth to groundwater
USGS Date website visited
RR.. Observation Wells checked
IV� Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope tleS
Surface water (�J
Check Cellar
Shallow wells
Estimated Depth to Groundwater--k4*eet
Please indicate all the methods used to determine High Groundwater.Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you.established the igh Groundwater Elevation. (Must be completed)
Tcc,
revised 9/2/98 Prl;ctlurII
N5�# 15� TOWN OF BARNSTABLE
LOCATIONL cri,4 l ,S P"/SEWAGE
VILLAGE G� � R.�p, //�= ASSESSOR'S MAP & LOT/���-
WNSTALLER'S NAME & PHONE N 06/�c
:SEPTIC TANK CAPACITY
et
LEACHING FACILITYAtype)? (size) G
),NO. OF BEDROOMS PRIVATE WELL OR PUBLIC W``R
BUILDER OR OWNER .�1/,��0 , rA,056 �
DATE PERMIT ISSUED: 9 ®c
DATE COMPLIANCE ISSUED: $
VARIANCE GRANTED: Yes No �^
�4V
��
� ��
�� a�
*�;� '�
�y�
,�� ���
tl N dt: ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® I-I EA T 1-I
f4.......OF........ ...::............................................ ..........................
App#tation, is hereby made for a 9Permit to Construct (rl"or Repair ( ) an Individual Sewage Disposal
syst t: _..� �i1...._..
------------t-1^ 7.................................................................
10;!" ocation_Addr ss Lot No.
...•. ................ .--•••-------••-••--•-•---------•---....-----
ner Address
W
..................................... ............. .• ................................................
Installer Address
Type of Building .� Size Lot_ - ---. a..Sq. feet
a Dwelling—No. of Bedrooms............................................Expansion Attic ( /y6 Garbage Grinder ( -0'P b
p-, Other—Type of Building ............................ No. of persons___-________--_.--_--------- Showers ( ) — Cafeteria ( )
P., Other fixtures ,e--------------------------- -
---------------------------
DesignW Flow........ ...... -.�---__._....___gallons per person per day. Total daily flow........... gallons.
- -g P P P Y• Y �----------------------------
1:4 Septic Tank—Liquid capacity.I�_ llons Length................ Width................ Diameter---------------- Depth..............._
Disposal Trench—No. .............. Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No.----
6Diameter.................... Depth below inlet.................... Total leaching area............_.....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-, Percolation Test Results Performed by.......................................................................... Date.......................................
Test Pit No. 1................mmutes per inch Depth of Test Pit.................... Depth to ground water----_--______._----_--_.
G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................______.
9 ----------••------------------••-•--•-------------••---•••-•------........-•---•----•--•••-----••---.........................................................
0 Description of Soil........................................................................................................................................................................
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
the provisions of TT T E 5 of the State Sanitary Code— The undersigned fuvier agrees not to place the system in
operation until a Certificate of Compliance has been i e y the of heAffh.
Signed ...... .....................................•. .- ....... ..l
ate
Application Approved BY....: 7�...... ... .................... �.
1 Date
Application Disapproved for the following reasons:..................................................................................
.............................
...........................................=•...........................................................................................................................................................
Date
Permit No.........Fs.�V'.............. /^ Issued-........ f 2_ .L/
�?-------------
Date
1
r,
w
a
Fps..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
.�. ra 4 w
`-- -. - .....OF... ....
- -
Applira#ion for Uiipoi�al Works Tonitrurtion Permit
Applik,"66n is hereby made for a Permit to Construct ( `) or Repair ( ) an Individual Sewage Disposal
Systeaiat .O 4{
...................... .........
• f Location Ad
�
e �r,pp or Lot No - -
/ --s------------••-----------•-•-------- ----------------••---••---'--— ----� t _ k'__• id"rG�
Address
........ ...................................
caner Ad
W ...,. /
dre ss
Installer
� Address
Type of Building Size Lot,./ ...Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (XL)'G Garbage Grinder
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixturesm'"......................................................................................
;--------- --------------- --------
W Design Flow....... _ __ _________________gallons per person per day. Total daily flow . .... ...............gallons.
WSeptic Tank—Liquid capacityll"="_ allons Length................ Width................ Diameter................ Depth................
xDisposal Trench..\To. __.H�.____.._____ Wid1th.................... Total Length................. Total leaching area....................sq. ft.
3 Seepage Pit No...x€`l _K2 Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --••----•-••-----------------••••-•••---•-•--•------••••-...-•-------.._..------•-----...-•-•--••---.........................................................
0 Description of Soil.......................................................................................................................................................................
W
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 T TLE j of the State Sanitary Code—The undersigned furiler agrees not to place the system in
operation until a Certificate of Compliance has been i ue'by the.b�oa�rd of h4lth. ;< e—
Signed ............... -----------•--• • •--•'••---- ..
Application Approved By...... ......................... -•---•c''"' '
Date
Application Disapproved for the following reasons:--------•-•-------------------------------------------•-----------------------•------------••---•--•---..._..._
----------------•-•----•--------------------••-----...--••--•-------....----•----•---------------........._......---.._...-----•--------•-------....--••••-•-••--••-•--•-•-----•-• --•--••••-•--•-•-_---
Date
Permit No. ----------
Date
._......=�/;? i�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... O F........ . .. �---.
� ..D.. .... r- .............................
%'-pPrtifirair of TautpliFanrr
THi IS TO C�R'TIFY, That the div•du 1 Sewage Disposal System constructed ( ) or Repaired ( }
by............. ---------_Lk
:
/� �'-•'"" Install --"'
atS ✓ ......f ..ems r---..._.. ...................................
has been installed in accordance with the provisions of T i T IE j of The State Sanitary Code 46. described in the
application for Disposal Works Construction Permit To...-
datedC
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT HE
SYSTEM WILL FUNCTIO�Nj SATISFACTORY.
DATE (� ..G--...'._ .. ............ Inspector........... ...... ............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
hu'eJ OF.............. N '...._......._..........._..
FEE_ _-___ ^'--
Diapooa� orb i n itra ioat rrntit
Permission is hereby granted.......... �--�...Z)._.-"-- ....... ...........
6 -
to Constru ( ) or Repair ( Individual Sewag D._i osal System
--� t
at No........ .......(.---•-------- i d 4 R ��._ ..-�. .................................�
v_
Street _
as shown on the application for Disposal Works Construction Permit Dated �l-.�.� -_________
--------..==---=--'--...... ---- / =-----------------------
G .rl.of Health
z ,
_ r�--•,, s � Boa
DATE 1 d._- ?---------------•-
FORM 255 HOBBS & WARREN, INC., PUBLISHERS I a
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