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HomeMy WebLinkAbout0035 JOAN ROAD - Health 35 Joan Road, Centervile A= UPC 12534 No.2� 1__R •� NASTIN" UN t ��r FS • . ,per COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF.,ENVIRONMENTAL AFFAIRS 3 > DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617-292- 7 WILLIAM F.WELD ®!` TRUDY CORE Governor ^' I' ' 0 Secretary ARGEO PAUL CELLUCCI — ,V OV 2 S 1997 AVID B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INS ION �OPM, p Commissioner PART A HpF jjAB(f9 CERTIFICATION Property Address: 3 S J00fi ��• Ceh fe/V/�/�,/N�4 Address of Owner: rPti y Date of Inspection: /01aS' q 7 ,� (If different) %t 193=�� /�OW A7#I � kd. Name of Inspector: �Q�Qh 1k. NQ�"//sls CC'Alreville— MA- I am a DEP a proved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Ca(l SPocheck Mailing Address: /7 O, Si .�/.� S. PyAlS R9l9 02660 Telephone Number: _ 50.5- .38 S- ,SB 9/ CERTIFICATION STATEMENT 1 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 Evaluation By the Local Approving Authority Fails /!2 Inspector's Signature: Date: The System Inspector s all submit a copy of this inspection report to the Approving Authority 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 the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. V Any failure criteria not evaluated are indicated below. COMMENTS: ii BI' SYSTEM CONDITIONALLY PASSES: V 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. Csee suopleIr Ir om tV 11.) 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 conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:1twww.magnet.state.ma.usldep Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 35 j4"n Rd , Owner: 1�70/ph Date of Inspection: 1 D/d S1 7 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observe a distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribu ' ox. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s) are aced obstruction ' emoved dist ' ion box is levelled or replaced The syst equired pumping more than four times a year due to broken or obstructed pipe(s). The system will pass in ion 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or less ss]t(han 5 ppm. Method used to determifn distance (approximation not valid). 3) OTHER (rovimod 04/25/97) sago 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3 S JQ&n 6Y,1 Ce4 fpetldl<_ Owner: 127U✓jD 6 y Date of Inspection: /(q/a S/97 D) SYSTEM FAILS: You must indicate ei;,,er "Yes" or "No" as to each of the following: /V0 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 into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. N/ 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). Number of times pumped _. v 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. v 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 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. y� See s yppletnOy f 4 l P9 • /1 El 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 above: The system serves a facility with a design flow of 10,000 gpd or greater (Lar em) and the system is a significant threat to public health and safety and the environment because one or more o ollowing conditions exist: Yes No the system is within 400 feet surface drinking water supply the system is wi ' 00 feet of a tributary to a surface drinking water supply th tem is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) Th ner 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 04/25/97) Page 9 of 10 e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 3 J04V/I �q'.l �2f.?74,Pr✓i//r- Owner: �fV�p`jy Date of Inspection: ,0 S/97 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. !/ None of the system components have been pumped for at least two weeks and-hems T flA... FiuA4 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. v The site was inspected for signs of breakout. All system comoonerits, have been located on the site. Mom LPSSPGG r'"41 A C490014 f The- -gawk manholes were uncovered, opened, and the interior of the -ta_ 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: _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. 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) [15.302(3)(b)] (revived 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: .3 5 .loan ed� G`�q-her V/ Owner. /WL.'/-phy Date of Inspection: �D%S/97 FLOW CONDITIONS RESIDENTIAL: Design flow: N14 R.p.d./bedroom for S.A.S. Number of bedrooms: oZ Number of current residents: Garbage grinder (yes or no): VO Laundry connected to system (yes or no):Iyff-5 Seasonal use (yes or no): 'WS slpcel I4r Water meter readings, if available (last two (2) year usage (gpd): /996 /P'9S 000 — g.1 6.A D . Sump Pump (yes or no):_&O Last date of occupancy: 9r COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 syste • or no)_ Water meter readings, if available: Last date of occupan OTHE escribe) Last ate of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of infor ation: 'V'q "eece'-9� o ®amp/• on �' /�iP SIP•' System pumped as part of inspection: (yes or no)_&DV 41 /eQe4 P;,4 '&Ve*-e dry If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool ti" Overflow cesspool &Y.S60" Ca07SiSt/075 o F AJ4/n e ssloal and Aeochi 0.,/ Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contracts' Other APPROXIMATE AGE of all components, date installed (if known)and source of information: /fia V"Wrs•. 4-0 CAto, - 1nS41A-W 15,--;2'-7y leadS Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) Page 5 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 S J0q'r1 kd Ce'p V le- Owner: rpby Date of Inspection: 7 BUILDING SEWER: (Locate on site plan) Depth below grade: 2- material of construction: /cast iron _40 PVC_other (explain) Distance from�n�vate water supply well or suction line �P �o '�� wL1 � V14 S0$ O o✓ _1 Diameter .� / / /&`' -c /f2o L�.r2 C n Commertts: (condition of joints, venting, evidence of leakage, etc.) 7" � IA-e •,/oi�7`S a e o 0,7 O� V o S,,s,r3 o f Lev kqe ®r oho/'. TANK?SEPTIC Mal: ePssPo® l (locate on site plan) s Depth below grade:® Gram Material of construction: _✓concrete _metal —Fiberglass _Polyethylene —other(explain) R roc K If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 19,0P S'S' W. X i Eiieelive L')elA Sludge depth:4 per- /n Q/O/o Distance from top of sl d e to bottom of outlet tee or baffle; Scum thickness: &Z �p©� f cS dreg 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: 6��Dy/P'lL�® Sr/er Comments: (recommendation for pumping, condition of inlet and outlet to s or baffl s, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) /JO f Co �irJ �� oZ /11 /e PS ✓ lel— !S V C f4mr /4, el see- e o v foe— GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _other(ex Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outl or baffle: Date of last pumping: Comments: (recommendation fo mping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evid of leakage, etc.) (revised 04/25/97) page 6 o4 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 35 je-ok> Pd.., Cen-�PrVI 01 e Owner: u,r Ph'j Date of Inspection: � o1as- /g7 TIGHT OR HOLDING TANK: (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 o explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in ing order_Yes; _ No Date of previous pumping: Comments: (condition of inl e, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distri on is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) 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 cha r, condition of pumps and appurtenances, etc.) (revisad 04/25/97) page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3J� .loan Rd..) Owner: mV phy Date of Inspection: , /q 7 SOIL ABSORPTION SYSTEM (SAS): ✓ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: J— /X / W %oAt Grd�� Od- vOAOI" leaching chambers, number:_ leaching galleries, number: leaching trenches, number,Iength: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (note condition of soil, signs of Z h draulic failure level of ponding, condition of v gelation, etc.) /tea1 G v,, rye s/ '' o SLv G 6,0$ 74 /T n f' - No mertV426;h" cove.- as 4 CESSPOOLS: _ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool st be pumped as part of inspection) Coco nts: ote 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 draulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3 S ..lOQ►'1 �G>� Ce� "er v I le. M Owner: Date of Inspection: J 012s197 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) 1'ou�r 'Pkivc�t� Well Kyo LINE ( Services ouh;de SPIO ody) 3S Joan R� ��a�cF R 13 C ICI STOCE-S D Wlal�n C�sspoe I e �.cach �4C 3 � S pit-1 8C = Nq B 7t0 �e�S,1�80,c �yeeA �lj = 60•S i (revised 04/25/97) Pegs 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C K//���L n SYSTEM INFORMATION (continued) J Property Address: 3 Jew) •, cell fer V/l l f, Owner: m V r ahy Date of Inspection: lO ( zS 1R7 Depth to Groundwater�13 6Feet 6eL4Dt,v �eOCh P!t 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 ✓use USGS Data 4ari4 Map 11s'W he,lOVJ Describe in your own words how you established the High Groundwater Elevation. Must be completed) /�"-Pi /.S Jr'� � ✓} • S . L �SO�/✓C� Gl• S . G. S . /�yRA/!/ S ouact Grace Leoc: eif bot'tool s v 6-fraCj Cq?e Cod C0411W/59641 wc-tkp - contou r P max Vavl latf//wn In above MoP S u mraaR7 S SO I — <8• ` f c� 0 t a / . � (revised 04/25/97) Page 10 of 10 35 Joan Rd. Cew krvJ✓/e 72-e kare w Ge 4r� o4 . Pt IkA S/o� 5vf3 or��y . n .e- brj-eme,7� y ' AS o44 0 q/� U ry► ✓� dtJ�// 740OOR C aI�•r�a'Yl�s"I�('�tS�40/• ��r-C .tS � D,JS/�//� ✓/f?�Cl/ /%,ra�7'4 Al 07 970 f � �. �-/��� wed• id l s� �4S 1p7y �.P�o.� 71D S w�l IL ,V le ') r qs a ConWl hdv4 e/ ass . -7,;Llew1A Pue pwv1sD anr,( cG �Ve( de l+p1 �PC d•� l C' c sC,�rle � ®� ve�A-� • S THE COMMONWEALTH OF MASSACHUSETTS BOARD OF , HEALTH ..................Town-----------0F..........Barnatable.............................................. Appliration for Dispaii al Works Tonstrur#ion rrutit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at: ..55...Jo-an-.d..-s.-.� neryille ...... ................ Location-Address or Lot No. ..Mary-Q_._.Qlanay--------------------------------------------•----------- 35...JQan...Rd....,-....� t.ary.lIg............................ Owner Address a A.. -Ces ppp�,...Sep'ylp.e.....-•---•-----•---••--------- 1. 8..B sho ?s. Terraces Hyannis................ Installer Address Type of Building Size Lot............:...............Sq. feet U Dwelling—No. of Bedrooms.......3....................... .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons ................... Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures -----•------------------------------------------•-•-----•-•--•-----•••••......--•---... ............................................................. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic 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 ( ) aPercolation Test Results Performed by......................................................................... Date........................................ Test Pit No. 1................minutes per inch 'Depth of Test Pit.................... Depth to ground water......------.........--. 44 Test Pit No. 2................minutes per inch Depth of Test Pi't.................... Depth to ground water........................ 1:4 ..............------•-•••••..........••--••-•••-........--•-•••-••-.......--•-••---•---•--....---•---••---••---...-•----•---•-•---•...•...............•--•- 0 Description of Soil...........Sand.................................................................................................................................................. W ..-•---------------------------------------------•----------------------------------•--...................-•----------------.-----------------------------------------------------•......---•---•-..... V Nalure of Repai s o� A�terati ns—Inswer when applicable.-.----Ims tal.1-at-i-on....of---a---1.1-00-0---gall-o -. stone pa c e each F . ... -••••--•••-•---•••-•...---••--•••-•....-••-•••••••••••-•--••••-•-••-••--...•---•••----- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provis,ous of.-i�1 E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i issued b h �e boar Signed---- . •- .1 :.---. .......41_.. 1.79--•-- Date Application Approved By................................................................................................ 4 ...2,.7.9 Date Application Disapproved for the following reasons:------•-------••-•-----------------------------------•-•-----------------------------•-••-......•.._....--.._. ..--•-••-------------------------------•----•---------------•---.......----------------------.................-------------------••------------------•-------------------------------................... Date Permit No............. 79=............... ...... Issued .._2•••79----------------.....----- Date No.:79:_ ..... Figs. '.: 5..•.0.'0........ rd THE COMMONWEALTH OF MASSACHUSETTS f• BOA-.RD OF-HEALTH w ................_-Town... ...OF..... .°t3A-TIIUSTx` h. e..................--------••••••.........___.. :z lir t iaan for Uispo,sttl forks Tomitrurtion "permit Application is hereby made for a Permit to Construct ( ) or Repair (Zr ) an Individual Sewage Disposal Systetri�at - 3 .......................... -•----•-•••••----•••----------•---•----------•-•-------___. ...... _.: ......... ? s Location-Address or Lot No At=....................................................... 35..-�c€�xz... �........Cent�x�tr�13� � --............ i' Owner W Address ..._..... Z?9 B shoe...'der%MEe.:...i n s:... Installer Address U Type of'Buildin Size Lot.................. ----Sq. feet Dwelling=No ;of Bedrooms______ ___________________________________Expansion Attic ( ) Garbage Grinder ( ) aOther "'^ �Type'­°of-Building ............................ No. of persons......��...............__._ Showers ( ) —"Cafeteria ( ) ds>.: Other.fixtures •••••-••--•-•----•--••-•--•-•-.......--•- wDesign F Tow ........................; .:...............gallons per'person per day. Total daily flow............................................. gallons. WSeptic,,; „ Liquid capacity ..gallons Length................ Width................ Diameter__..._ ... Depth ............. x Disposal,*Txench77,No ............ ... Width..............:.__.: Total Length________...____.____ Total leaching area , ----- ft. Seepage'Pit`No'........ ........... Diameter............__:..... Depth below inlet.................... Total leaching area.....'.­__:....._.__sq. ft. Other DistriBiztio'iibox Dosing tank aPercol gion,Test, Results Performed bY ----------•------------------ ... Date----.... Test Pit No. I................minutes per inch Depth of Test Pit................_... Depth to ground water........................ Gt, Te's"t PiCN'0' 2: ........minutes per inch''Depth of Test Pit.........._......... Depth to ground water .................. GdI -------.................................................... Descripfron"'of Soil 58Ld Y3 x U •. . -- -•-• •---•- -----------•---•-•--••-•-•-•--•-•------••------•--------•---...--•----------•--••-•--••-•-•-----•-•---- ---- ------- U Nature''of Repatrsor Alterati ns—i nswer when applicable.....1"; gfi-rtrl--_ It... f6d t� aneak d l��c�.. a3 •---•--••...-•••--•---•- The ti' ersigried agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provsiQnoi,,'IT 5 of the State Sanitary Code The undersigned furt er agrees not to place the system in operation until a Certificate of Compliance has been issued he boarddZW6. Signed----• :._.`7 .._- ......... ate Application Approved: BY ------------•--------•..........................•----------- ..................... .....2 � .,5. .z,.i...,, . ., Date Application Disapproved for the following reasons_________________________________________________________________________ qtd v S�Q:j..y k 1 I)_ate .._..---•••-------_.... Issued ...................� ........._ ...... _.f..._.._....r�............. Date r w',y , .• THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , I T.01�-p............OF..........-BAftr�.c:c`i ........................................... .. . Tutifirate of Tompliana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or.Repaired (Y ) .......... �3c 1,so Installer - at 3 °: 1:. R _..*... x� ac�r _ x _._-�_�::_ ::c ._._ acw------------------------------- ---- ------------- has beery installed-in-accordance with the provisions of TIRE5 of The State Sanitary Code as'described in the application for Disposal Works Construction Permit No........................................... dated..........4.f` L2 . ............... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. CDATES _ Inspector_ - ........................G � ------------- THE COMMONWEALTH OF MASSACHUSETTS V f' BOARD ' OF HEALTH .................. ...........OF............... ..................................... No....19.=+............. FEE.......$.5A'.(X)... Diaposal Worho �on�#r iun ernti Permission is hereby grantedA..k.9...Cessw �1-•SI83"V' CEla _ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at No..35...Joan--- '..-#...Cen.�e$ 11.fii......!t....-- 1%--Clano�! Street 2/79 as shown on the application for Disposal Works Construction Pe _it N Dated.. .. ..... ......................... --------------------- Board of S r..� .....-----•---•.........................•••.. Healt� DATE...--•--•--------------------- FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS LOCATION SEWAGE PERMIT NO. VILLAGE ,,t INSTALLER'S NAM i AD R E S S Z�, <-• �-' R U I L D E R OR OWNER f 4, /117 DATE PERMIT ISSUED ZL L 32 DAT E COMPLIANCE ISSUED `- " � r � a �` � � � II