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HomeMy WebLinkAbout0047 VINE AVENUE - Health 47 Vine Avenue Centerville P 226 030 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS , DEPARTMENT OF ENVIRONMENTAL PROTECTION if RE - 0C o cUo4 1-� TOWN O r�r,:. .�f ABLE TIT LE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 47 Vine Avenue Centerville Owner's Name: Gail Lyon Owner's Address: ' Date of Inspection: -- Name of inspector:(please print) Wi 11 i am E_ •Robinson sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number:_(508) 775-8776 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 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 pursuanZeasses tion 15.340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Dute: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh•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 appro.ving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 ' r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 Vine Avenue Centerville Owner.• Gail L on Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: I 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass.'section need to be replaced or reps ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please expla _ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsou 3d,ekhibits substantial infiltration or exftltration or tank failure is imminent_System will pass inspection if the existh ig tank is replaced with a complying septic tank as approved by the Board of Health. •A m tal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance Indic ting that the tank is less than 20 years old is available. ND xplain: Observation of sewage backup or break out or high static water level in Ithe distribution box due to-broken or ob tructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pas inspection if(with approval of the Board of Health): broken pipes)are replaced obstruction is rcmovcd N explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 Vine Avenue Centerville Owner: Gail Lyon 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 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 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 froul 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 coliform bacteria and volatile organic compounds indicates that the well is Gee from pollution from that facility 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: 3 Page 4 or 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 47 Vine Avenue Centerville Owner: Gail L on Dale of Inspection: —/ ! D. System Failure Criteria applicable to all systems: You mu t indicate"ycs".or"no"to each of the following for all inspections: Yes N 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 Liquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ Any portion of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private v►atrr supply well with no acceptable water quality analysis.(This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.) (Yes/No)The system fails.1 have determined that one or more ofthe 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. Large Systems: o be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 g d. u must indicate either"yes"or"no"to each of the following: le following criteria apply to large systems in addition to the criteria above) ye 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—1WPA)or a mapped Zone 11 of a public water supply well If yu u have answered"yes"to any question in Sectim E the system is considered a significant threat,or answered "ye ,in Section D above the large system has failed.The owner or operator of wry large system considered a sign ficant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PropertyAddress:47 Vine Avenue Centerville Owner: Gail L on Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No PP mping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? P P P Has the system received normal flows in the previous two week period? _ j//Have large volumes of water been introduced to the system recently or as part of this inspection?.. — t/Were as built plans of the system obtained and examined?(If they were not available note as NIA) Was the facility or dwelling inspected for signs of sewage back up 7 j� 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, nco red opened,and the interior for of the tank inspected for the condition P P of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? s/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: Yes no Existing information.For example,a plan at the Board of Health. _ 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(3)(b)] 5 Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 47 Vine Avenue Centerville Owner: Gail L n Date of Inspection: 'O FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): L� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): d Number of current residents: 3— Does residence have a garbage grinder(yes or no):.Vz�5 Is laundry on a separate sewage system(yes or no)�CU [if yes separate inspection required] Laundry system inspected(yes or no):N v Seasonal use:(yes or no):)L-5 Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 3-1 1 9 ,0 0 0 Sump pump(yes or no):/i., v - I T3-,T-90 Last date of occupancy: COMMERCIAL/IrDUSTRIAL Type of establis nt: Design flow(bas on 310 CMR 15.203): gpd Basis of design ow(seats/persons/sgft,etc.): Grease trap pr ent(yes or no):_ Industrial wa a holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water met r readings,if available: Last date f occupancy/use: C R(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped asp of the inspection(yes or no):_ If yes,volume pumped:_gallons--How as quantity pumped determined? Reason for pumping: / �/'�+� F �e I P F SYSTEM e tic tank,distribution box,soil absorption 'system P rP _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): f 9 5-2-Q Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):/G U 6 • Page 7 of 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Vine Avenue Centerville Owner: Gail L on Date of Inspection: L--O BUILDING SEWER(locate site plan) Depth below grade: Materials of construction/_cast iron _40 PVC_other(explain): Distance Gorr private ater supply well or suction line: Comments(on condition ofjoints,venting,evidence of leakage,etc.): SEPTIC TANK:Zaocatc on site plan) Depth below grade: �✓ Material of construction: oncrete metal fiberglass_polyethylene _othcr(explain) If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):—(attach a copy of certificate) ` ,Dimensions: K cb 4 a. J t>s Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: -0 Distance from top of scum to top of outlet tee or baffle:. Distance from bottom of scum to bottom of tlet tee or bafi]e: �� How were dimensions detcmiined:- 6 ---�- TAB•JC Comments(on pumping recommendations,inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of Ieakagg,etc GREASE TRAP:_(locate on s'c plan) Depth below grade:_ Material of construction:_c ncrete metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum o top of outlet tee or baffle: Distance from bottom of um to bottom-of outlet tee or baffle: Date of last pumping: Comments(on pumpin recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet inv ,evidence of leakage,etc.): 7 Page 8 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA'I PART C SYSTEM INFORMATION(continued) Property Address: 47 Vine Avenue CPntPrvi11e Owner: Dale of Inspection: — L TIGHT or HOLD G TANK: (tank must be pumped at time of inspection)(locate on site plan) ) Depth below gra : Material of const ction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity. gallons Design Flow: allons/day Alarm prese (yes or no): Alarm level Alarm in working order(yes or no): Date of las pumping: Comment (condition of alarm and float switches,etc.): DISTRIBUTION BOX: (/(if present must be opened)(locate on site plan) Depth of liquid level above outict invert: 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.): PUMP CHAMB R: (locate on site plan) Pumps in wor• g order(yes or no): Alarms in�� king order(yes or no): Comments note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Vine Avenue Centerville Owner: pail Lyon Date of Inspection: t SOIL ABSORPTION SYSTEM(SAS): L' locate on site plan,excavation'not required) If SAS not located explain why: Type ' leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): _ CESSPOOLS: (cesspool must be umped 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 i ow(yes or no): Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site pl Materials of construction: Dimensions: Depth of solids: Comments(note conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Vine Avenue Centervi e Owner: Gail Lyon Date of Inspection: —0 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Ll --------------- 1 a 3l l b0- i 3 2 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 47 Vine Avenue Centerville Owner. Gail L on Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: (9l f 2. 11 LSJCC TION _ SEWAGE PERMIT NO. VILLAGE .01 A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER - L �� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i a J Q M Doll- CtNfrl�3rn i LOCATION SEWAGE PERMIT. NO. VILLAGE A & B CESSPOOL SERVICE 128 BISHOPS TERRACE, HYANNIS, MA 02601 BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED o.of� CtN6-,��rn 6. No.. �: Yus 15-00 ............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town pF Barnstable ........................................................••--------........................ Appliratiun for Disposal Works Toustrnrtiun rruti# Application is hereby made for'a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ` ' v��e Hyannispo tl� Ma. C.onXmmcs--laentex....---�,n =- .Ave..------------------- -------------------•---------------------------------------------------------------------------•-- Ed,1yons Location ess Conference Cente3er Lot NoOcean Ave. HyannispoftfMA er Address aSe37vice............................................ 12R_.Bishops..Tjerrace..;+Hyanni ,--Mai.-•----••---... M Installer Address Type of Building Size Lot----------------------------Sq. feet U ' �., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures ......................................... :'Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic'Tank—Liquid capacity............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..................sq. ft. z Other Distribution box ( ) Dosing tank ( .) . aPercolation Test Results Performed by.......................................................................... Date........................................ ,4 Test Pit No. 1................minutes per inch Depth of Test Pit...--............... Depth to ground water------.--__-_--_--_-... GT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -••••-••-•-•----....----••............•--•-•....:...................••----------------•.............................................................. 0 Description of Soil....................................................................................................................................................................... W U w x ••••-•-----------------------------•-••-••••••••-•-••--•••-•-•••••••••--•-------------•---••--••......--•--•..........--••••-- •••---••---••-•-••......•-••--•-•-••-•--•-••. ......••-•-••---••---•-•. U Nature of Rgpairs or Alterations—Answer when applicable.-1500..Gal-xstone..Rac�Ced__t ---•••two..(2).1000..&a1__Pits---•----•••-•- 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 Certificate of Compliance has been issued b board ea /e Signed••• • -,.. !,11.. i n / Date Application Approved By........... .... .: -. — S ......-- ................................. ---•---•-••• ................ Date Application Disapproved for the following reasons----------------•------------•--------------------•-----------------•-------------.............................. ...........-•••••••••----•---• -•--••....•-•--•-•-••••-•--...---••-••----•--•---••---........••--•--------•-•••••-••----•--•-•- -------------------------------------------------------------- Permit No......���_---.- �- Ll� Date -•------------ Issued-------••-----------------------•---...._. ------ Date No..�.�7 fir' FEs.......... �, THE COMMONWEALTH ,©F MASSACHUSETTS BOARD OF HEALTH ......Town....................0F..............13ar stable------------._-_____--------____-__---_--•--•--__ . pplirFatiun for DiipnsFal Works Tonitrurtion Famit � Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: • }. •�. ----------- .... 13��ct_.Ma...................•••-----------•--•--•-------•------•-.....__....---•- �en�%e LC3tion-Addre �$ e s or Lot No. ........11d.Lyrnns----------------------------------------------------•--••-••-••-•---•- ......... onfarenoa..Cjmtex---------..9oojn- jKe •-.Ify,o sDoft, Owner Address W a A- B Ee �pcs�3"5�1��------------------------------------- ...........g28-Btnharps--Te gss_-14 f-s..--Na:-------- Type of Building Size Lot..................... .....Sq. feet �-� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of ersons____________________________ Showers a YP g --------------------------- -----•---...---P--- ( )--- Cafeteria ( ) dOther fixtures -----------------------•--•---•-- -••---------••-•---••-•••----•-----------•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............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..................sq. ft. Z Other`•Distribution box ( ) Dosing tank Percolation Test Results Performed by........................................................................... Date............ 14 Test Pit No. 1............._ minutes per inch Depth of Test Pit..................__ Depth to ground water........................ r-. Test Pit-No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water:'....................... ----•--------------------------•----....--•----------....-------..._..-----•---.....---•----••-•......................................................... 0 Description ofSoil........°._____ U U -Nature.-of Repairs or Alterations—Answer when applicable 450a.Iga3:1-:-stone• ked--+a�rtkD-Bogie--ama _..__.__ ' =--------- Ca` _4004--@dal-pttg-------------------------------------------------------------•-------------------•------------------------------------ ...-----.....--- Agreement`: E The/undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provk'sionstof TITLE 5 of the State Sanitary Code— The u dersigneslpfuqlper agrees not to place the system in operation until a Certificate-of Compliance has been i •ssued e b r h h. i ned___ ------• •------ ................................................. .......................... Application. Approved By--- -- �-- .. - e ........ Date W APPli eatiori Disapproved for the following reasons----- -----------------------•---------------------------------•----------------------••••...--•---- Date qb Permit No........... Issued_. ` 7 Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (9rrtifirate of TuntvItFatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )X by..........4--&•-B-Qe sspool...Sexy.oe..--•-•-•-•------------•-••-------•-•...--•--------------------•••...-----=--------••-....----._.....-------•-•-----•-._...---•---•••- Installer oxt �x'aX�ce_Ctr....Ocean_.Aye.___W. Hyarinisport,� Ma.•------------------•-••-------------------------....--------------- has?been installed in accordance with the provisions of TITL 5f TtSte Sanitary Cd � escb in the application for Disposal Works Construction Permit No___________________________ .......... dated-------_-_.___-_____________________-__________- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUN TIO SATISFACTORY. DA TE......................�.. •�S-•••------ ............ Inspector......... .�.. 1.. THE COMMONWEALTH OF MASSACHUSETTSs BOARD OF HEALTH . v ..............ToxM..................OF.........terns#gable......................... I --- FEE........................ Rsviis4LEvrkii Tnnotrud on rrntit Permission is hereby granted.......... ........._.'....' to Constr ( YNr Repair ( �( an vidual gage Dispos� ysten{,>.t4, 4 MP at No_-== e n G ern ` P ._...------•---------------------•--•----..._..---..._..._......_..__••..._..------•-•--•- Street as=shown on the application for Disposal Works Construction Permit No.... /�,J)attey7d __. ---_._:.___ ________________..... _________________________________________ - g Board of Health DATE FORM 1255 A. M. SULKIN, INC., BOSTON