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0030 WILCOX LANE - Health
30 Wilcox Lane Centerville A= 190— -165 0 I N SMEAD No.2-153LOR UPC 12534 emead.aom • Made in USA eDocYc% TOWN OF BARNLE LOCATION ���a/'�9� �dQ/�f SEWAGE l' VILLAGE L /t;.rQl�l4�� ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Q�' SEPTIC TANK CAPACITY Z LEACHING FACILITY:(type) ����1 'sd� /"/� (size) A NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER /D& BUILDER OR OWNER IA rj44Z ?rZ DATE PERMIT ISSUED: DATE CO?.LPLIANCE ISSUED: VARIANCE GRANTED: Yes No X 7 T 3C� 1/ � �3 � /� �, �� � "� � � ® —� e t, TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Z 0 1 2— Time: In Out Owner �-��L>iPJi<1 f �- C�S Tenant 2`—(3- Address Rig p" C2" c�T. Address so O 'L-cu �/ p L OC3 1 LA)©o � . AAA O�T -QI u.C, 1AA Fl Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities J 6. Heating Facilities 7. Lighting and Electrical Facilities — U -0 pj 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural . Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17. Temporary Housing pJi° 18. Driveway Width 19. Number of Tenants Observed /\.)A PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles lowed (axe Number of Persons Allowed (max), Persons) Interviewed ilI)KA — Inspecto If Public Building such as Store or Hotel/Motel specify here a ` TOWN OF BARNSTABLE BOARD OF HEALTH Y1\ ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION p '. 3 0 Date a3` ( Time: In— Out Owner ��-�`�j �.O1C��S 5"!i - l�rj Tenant Vv&,i4y,� Address 814a CoP� SlrLEtT Address 3-0 W i C-w �-- �� wc�oti,� ;WIA vA�,x 1MA O,o3,3- Complia a Remarks or Regulation# Yes XN0 Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 3- f 4. Water Supply 5. Hot Water Facilities l 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use _ 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal �j — k3036fL 17. Temporary Housing 18. Driveway Width 19. Number of Tenants Observed //0 //d �CY/ PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) ---- Person(s) Interviewed Inspector If Public Building such as Store or Hotel/Motel specify here t TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date I ' cyS Time: In [O{ Ob Out Owner -� ���atif`A QR 01 Tenant V4t - Address A o i!b Address )9�-c.�1- Os1 f VVIA C�a C��6 1 Complia a Remarks or Regulation# Yes VNO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities Annmved: 4. Water Supply rib out ;- a 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities 10. Curtailment of Service 11. Space and Use 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal 17.Temporary Housing Ap 18. Driveway Width i o 19. Number of Tenants Observed 7, �j C-f PART II 37. Placarding of Condemned Dwelling; ^- Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles Allowed (max) Number of Persons Allowed (max) Persons Interviewed Inspector If Public Buildingsuch as Store or Hotel/Motel specify here P fY �� L�, -tz- Certified Mail#7007 0710 0005 5818 8535 P�0*1HE Towti Town of Barnstable Regulatory Services M ' + BARNSTABLE, MM. Thomas F. Geiler, Director i6gq• �� ArFO MAC Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 26, 2007 Helena Prokes 814A Gay Street Westwood, MA 02090 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE CODE CHAPTER 170. The property owned by you located at 30 Wilcox Lane Centerville, was inspected on October 26, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable. This inspection was conducted on the basis of the rental registration in accordance with Chapter 170 of the Town of Barnstable Code. The following violations of the Town of Barnstable Code were observed: 170-10—Smoke Detectors and Carbon Monoxide Alarms. No CO alarm or smoke detector in basement. You are directed to correct the violations listed above within ten (10) days of your receipt of this notice by installing CO alarm and smoke detector in basement. You may request a hearing before the Board of Health if written petition requesting same is received within ten (10) days after the date the order is served. Non-compliance will result in a fine.of $100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Q;\Order letters\Housing violations\Rental ordinance\30 Wilcox Lane.doc J t Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. PER ORDER OF THE BOARD OF HEALTH o as A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Meredith Morgan, Health Inspector Q:\Order letters\Housing violations\Rental ordinance\30 Wilcox Lane.doc FORM30 CAW HOBBS&WARREN TM THE COMMONWEALTH OF MASSACHUSETTS BO D OF HEALTH CITY/TOWN DEPARTMENT 1 , M DDRESS //'� Lf LEP ONE Address, )Cox Occupa ►u Floor Apartme o. No.of Occu nts No. of Habitable Rooms No.Sleeping Room No.dwelling or rooming units N Storjes Nam a d addres of owner _� ;+ QW6Remarks Reg. Vio. YARD Out Id s.: Fences: Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains.- Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Lighting: STRUCTURE INT. Hall,Stairway: Obst'n.: Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: ._ PLUMBING: Supply Line: ❑ MS ❑ ST ❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRICAL Panels, Meters,Cir.: ❑ 110 ❑ 220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 Bedroom 2 Bedroom 3 Bedroom 4 Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.: Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.: Wash Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS IN P CTI EPO IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTI E ' INSPECTOR TITLE A.M. j�DATE '—y 10,61037 TIME P.M. A.M. THE NEXT SCHEDULED REINSPECTION �_ �+��1� P.M. i 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall.failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24,hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). I (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. io a q2 l Parcel Detail Page 1 of 3 7;/ I w �Mry1lG C ✓'•'fL rl�� �k+biftia! Logged In As: Parcel Detail Friday, Octob Parcel Lookup Parcellnfo Parcel ID 190-165 Developer!LOT 3 -- Lot ----- ------- --- -- -- Location 30 WILCOX LANE I Pri Frontage 86 Sec Road INDIAN TRAIL I Sec 150 -- -- ---- Frontage` -- - - village CENTERVILLE I Fire District�C-O-MM Sewer Acct 1 Road Index 1839 Asbuilt Septic Scan: Interactive i l h 190165_1 Map Owner Info - - - owner PROKES, JIRI & HELENA - - Co-Owner, Streetl 814 GAY ST Street2 i City WESTWOOD State MA zip 02090 Country SUS Land Info Acres 0.46 use ,S-in- le Fam MDL 01 Zoning tR D1 � Nghbd �010�6 � -- -- _ Topography Level -�;) Road ,Payed Utilities Public Water,Gas,Septic ;� Location Construction Info Building 1 of 1 Year Roof - -�- Ext Built Struct P Wall 1985 Gable/Hi Stucco on Wood � --- --- ----'I --------- ----�I Effect 2540 I Roof Asph/F GIs/Cmp-� AC!Central Area _-._ Cover Type ---- - -- - --- style Modern/Contemp, Int wall Drywall Rooms _ - Bed 13 Bedrooms II _ '---- -- ----- - - Int Bath Model Residential J) Floor Hardwood _ R oms 42 Full +-1 H -AI Grade Custom 'I Type 'Hot Air __-_-1 Rooms it http://issql/intranet/propdata/PareelDetail.aspx?ID=13245 10/26/2007 Parcel Detail Page 2 of 3 -?l .32 { SFB< 5 ff FCIS BA S ll"32 BMl' 3 Heat --_ I Fuel '.Gas ------- Found ation IPoured Conc. Stories 2 Stories 32 Permit History Issue Date Purpose Permit# Amount Insp Date Comm 10/2/1984 B27092 $60,000 1/15/1987 12:00:00 AM CE 10/1/1984 B27092A $60,000 1/15/1996 12:00:00 AM CE 2 Visit History Date Who Purpose 1/26/2007 12:00:00 AM Paul Talbot Cyclical Inspection 1/16/2004 12:00:00 AM Gary Brennan Meas/Listed 11/29/2000 12:00:00 AM Paul Talbot Meas/Listed 1/15/1990 12:00:00 AM M Sales History Line Sale Date Owner Book/Page Sale P 1 2/10/2003 PROKES, JIRI & HELENA 16368/239 2 3/7/1997 FILL, KAJETAN 10640/296 3 7/15/1982 FILL, KAJETAN & SHERRY 3515/126 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parce 1 2007 $223,500 $8,400 $0 $171,900 2 2006 $201,600 $8,400 $0 $200,100 3 2005 $184,400 $8,400 $0 $142,800 4 2004 $183,100 $8,400 $0 $121,400 ; 5 2003 $159,800 $8,400 $0 $36,700 ; 6 2002 $159,800 $8,400 $0 $36,700 7 2001 $159,800 $8,600 $0 $36,700 8 2000 $125,000 $8,300 $0 $36,300 9 1999 $125,000 $8,300 $0 $36,300 10 1998 $125,000 $8,300 $0 $36,300 11 1997 $127,500 $0 $0 $32,700 http://issql/intranet/propdata/ParcelDetail.aspx?ID=13245 10/26/2007 Parcel Detail Page 3 of 3 12 1996' $127,500 $0 $0 $32,700 13 1995 $105,800 $0 $0 $32,700 14 1994 $96,600 $0 $0 $26,200 15 1993 $75,900 $0 $0 $26,200 16 1992 $44,700 $0 $0 $29,100 17 1991 $41,600 $0 $0 $58,100 18 1990 $41,600 $0 $0 $58,100 19 1989 $104,100 $0 $0 $58,100 20 1988 $31,500 $0 $0 $26,900 21 1987 $84,700 $0 $0 $26,900 22 1986 $21,200 $0 $0 $22,800 Photos 1 http://issql/intranet/propdata/ParcelDetail.aspx?ID=13245 10/26/2007 � r IM f s 40 d-•r- W • �� q� at ,r- , Y` .fib� _ - .V 1 4L �_�e � _ ,.iq �.k _.. 1. �. _ � _, z "1'" •e � r.. r` 'F •,. ----. � ` a��4 ` � ;� _. ��.,. _ rv� ... y No�::...� .C Fxs... THE COMMONWEALTH OF MASSACHUSETTS BOARD .OF HEALTH ------..... !/ I: ...OF....�f � � -�?, ,1------------------------ Appliration for Disposal Works Tonstrnrtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• , F f ............... l9 . = 0= •='•...•-----......•........................ - ..,._. Location-Addre s or Lot No. Owner Address ---------------4;;w---------- ....------------------•--------------------------Addreses ler .s....---------------•------------------------ � Instal d Type of Building Size Lot............................Sq. feet Dwelling6_= o. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------•----------------- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid"capacity------------gallons Length_........*.... Width................ Diameter---------------- Depth................ xDisposal 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........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ......--•----•-•------•--------------•---...................•••---•-•-•--••-••........................................................ 0 Description of Soil.......... . -....................................................................................... V •-••••-••••-•-•--••---•••••-•--•••--••-•-••••••-•-••-•--•---•••-••------••-•--••----------•----•---•......-••----•------•--•••--------••-----•••--••-•--••-•••-•-•---•-•-----•-•••---•--•............... V. Nature of Repairs or Alterations—Answer when applicable---------------- ......._..__..___ ....?.'-! __ __ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with T'1�;• the provisions of l I:'IT j 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 th bd f hlh' _. %J Y S_igned'�t�L�i _/ ,..;�� (',/-/F /.------------ • -. ^"•,,,,_«..rac--' ` .--- 1 Pate Application Approved By...`�_= = ..=_. ------ - ,......----•-•----•--••-------•. ......•...--• ••-•-••-••-•-•-•....... Date Application Disapproved for the following reasons:---••----•-•--------------------•--•-------------•-----•-•-•-----•------------------•--•---•-•-••-------•------ ------•-----•-••---••---.....----•--•.........................................•--•--...............-•---•---•....--•••-------•••-----•----•-••--•----•-••--••••-•••--•---••-------------------•--------- Date Permit No....... - cL `-- Issued Date THE COMMONWEALTH OF MASSACHUSETTS -- BOARD OF HEALTH t :. (Irrtif iratr of Tuntpliattrr TH,-S IS TO,CERTIFY, Thdt the Individual Sewage Disposal System constructed or Repaired (by } --•.................... ---- ....... --✓ Installer / / ..................................... has been instailed in accordance with the provisions of T I TIE 7 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...................................c:?_. dated---------- ._�_._..__�..........•_.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................' � �-�.� ---------------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS ,. �._ BOARD OF HEALTH ./ i��!F! _. ........OF..... 4,../.f,.s....>....:�. {i............ ......................... ..�-. .. . O.'. ..............�� i FEE.......••-••••-•---..... Permissiondreby granted......`� v... ," to Construct—,(- or Repair ( ) Imdivir3/ual S : rage Disposal�stems at No..... rt �1'. �1 .... � ' ![�.. �.__...h' . '__ s r,//........ ....................................................... d. Street - p // as shown on the application for Disposal.Works Construction Permit No......:......:'..... Dated-------------------- -� c Board of Health ` DATE ........... ,i'= ` ' ...........•-----------•---•---- ` e r� FORM 1255 HOBBS & WARREN. INC., PUBLISHERS ' ASSESSORS MAP NO: C. PARCEL NO.: o S NFlz$...../......p.,,c.co THE COMMONWEALTH OF MASSACHUSETTS BOAR® 9F HEA TH .......O F...... .... _---------_-----_---- L� Appliratiou for Bh4p sal Work,5 Toustrurtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst�t: ".-- pw Ile ----- ------------- ..............9.. ocation ` •----------------•--•••-........ Lot_No- Owner Address a F7. -:._...... - _ Installer Address U Type of Building i Size Lot............................Sq. feet Dwelling o. of Bedrooms.....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) = Cafeteria ( ) aOther fixtures ...................................................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._.-_-___---_- Depth................ 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......................................... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2----------------minu � Description of Soil---------- tes per inch Depth of Test Pit.................... Depth to ground water........................ w --- --------------•---------•------------.---------•.----.-------•-------•-•-------•-•-•---•••-•----------•---------•-•---..--••----.- -- -- =--•- ----=--�--------------.....---•-•-••----------------------------------------------------------------------------------•-----..........._. x U --------•••--•---•---------,..•---•••-•....----•----•--•••-•--•--•------------------------------------•••-•••----------...•••-••-•-•--•-•••--•-•••-----...-------•-••-------------------•--------------- W -------------------------------------------------------------------------------------------------------------------------------------------�. x Nature of Re airs or Alterations—Answer when applicable �� lr��! l/ e ---•---------------------------------------------------------------- U —Answer P PP / ---- , i --------•--------------------------------------------------•------------•--•--...................... •---�-------•----------•-•-------------..................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i'ii,^ p 5 of the State Sanitary Co e—The undersigned further grees not to place the system in operation until a Certificate of Compliance has bee ssue the oar health Si --•- • Application Approved y---------- --- - ..........................=......------......---•-. -------- Date Application Disapproved for the following reasons:----•----------•-----------------------•----------------------•-------------------------------------------••---• r .............................•---..--............-•-•----•------••-----.............-------•----•----••----------------•------------------------••-------------•-------------------------------.----•--- �__ Date PermitNo .... ....... Issued....................................................... 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