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HomeMy WebLinkAbout0218 ARROWHEAD DRIVE - Health 218 ArrowheadDri�e 77('Hyasl eo !` u ❑ e II o � i� o u q tl u o N o d r w . n A o . -6. .. Fee No. � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migotaf *pgtem Construction Permit Application for a Perinit to Construct( )Repair(AUpgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. of 1 � 1_��` n Owner's Name,Address and Tel.No. Assessor's Map/Parcel �y , Installer's We,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: `UT' Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building TT No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank X JCZ d Type of S.A.S. Description of Soil Nature of Repairk or Alt rations(Answ r when applicable) 51� 1 �o X X a- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the re d)cribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental o and n to a the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signe Date Application Approved by Date 9 7/a 11 Application Disapproved for a following reasons Y Permit No. y s S Date Issued (P o 1 ——— ————————————————————————————————— l ' Nd. � � Fee 79 THE COMM12NWE!ALTH OF MASSACHUSETTS. Entered in computer: Yes. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYication for Zi!5po!9ar,*p.5tem Construction Permit ( , p pg Y ( ( ) O Complete System ❑Individual Components Application for a Pemut to Construct )Repair(air( U rage�'`�`.)Abandon Location Address or Lot No. a n ' ' Owner's Name,Address and Tel.No. j Assessor's Map/Parcel �7 y ` • i, �© ''rS ` b S� 0L 7C.1) Installer's'N ,A dress,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling Nd of Bedrooms _ Lot Size sq. ft. Garbage-Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. -� Plan Date Number of sheets ( Revision Date Yr Title � Size of Septic Tank Type of S.A.S. Description of Soil Nat a of Repai or Alt ration (Answ r when applicable) rs11 O` `T0 3 — _,... �aG cSS Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the ore d cribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental o and n f to ce the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signe Date ` Application Approved by Date Application Disapproved for the following reasons Permit No. —y 5 S Date Issued 2$ o fj R -*- --------- ------------------- THE COMMONWEALTH OF MASSACHUSETTS 'BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIF=e Se age Di.posal System Constructed ( ) Repaired X) Upgraded( ) Abandoned( )by I at has been constructed in acc9rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. — `�1/�ated �p �-$/U / Installer Designer The issuance of t is ert '/hall not be construed as a guarantee that e system ct'on s designed. Date �L(}�j Inspector " — r�—— ——————— —— — ——————————————— ——— No. PU`O l—�`jj — — -— Fee S C-> � THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE., MASSACHUSETTS lwigogal *pztem Construction Permit Permission is hereby led o Cgpsstruct Re 'r( (Jpgfade( )Abandon( ) System located at or //�� ��// O and as described in the above Application-for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date o this pe it. Date:_ ` G Approved by I No. B „r.. ' �\' Fee ✓ r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Mgonl 6pgtem Congtruction Permit Application for a Permit to Construct( )Repair(V)1151pgrade( )Abandon( ) D Complete System ❑Individual Components Location Address or Lot No. 1 g /T rI-o(j n r. Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��� — � D�j ou Installer's Narne,Address,and Tel.No. Designer's Name,Address and Tel.No. A& 8 CANC® 350 Main Street Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1007) Xis ,_ Type of S.A.S. Description of Soil e Nature of Repairs or Alte ation (Answer when applicable) 1 S'�A-1 C' ' SOS 7� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ued by this Board of ealtILI , SigneDate 60 Application Approved by Date Application Disapproved for the following reaso s Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS, Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( upgraded( ) Abandoned( )by eogq G 0 at J 16 Atto&) T, h! h b , nstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pen-nit No. ted Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector I�-- —e — -- - - ——————————————--——— �•„ ♦..i..r.u.s¢ . ,\,�. t. .> -^ •.. ,,.,�.`I. �.� •\1.,.Cr�.�... y . ♦ .. 5tn" ..�„tf.fh r(� r ...._♦ .t,r.yw .+. .,,Yr .... ... ..: ..- ., �r.^rr• .r'L r! ' t G Sid '-No.` _ . 'era?, ,_, Fee Entered in computer: THE COMMONW EALTH OF MASSACHUSETTS • Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS `2 0(pprication for Migpogaf 6pgtem Corigtrucfio_n- ,ermit Application for a Permit to Construct( )Repair 9vy6pgrade( )Abandon( ) ❑Complete System El Individual°Components Loca ion Address or Lot No.Q ( U A t rot,J h c a d I 1-. Owner's Name,Address and Tel.No. n u , c Y I.�j �vusi,t f/`F Assessor's Map/Parcel ��� — f7 a f j Gct(15fA Installer's Name,Address,and Tel.No. Designer's!Name,Address and Tel.No.\L I Type of Building: w ,r�• Dwelling No.of Bedrooms�_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day.,,Calculated daily flow gallons. f^' Plan Date Number of sheets Revision Date ` Title �� i .. Size of Septic Tank 4001) ext; Type of S.A.S. Description of Soil i f 5i44 / Nature of Repairs or Alteration (Answer when applicable) .L h 54 a Date last inspected: a � rq+ Agreement: ;. The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system i in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of ealt . Signe rf, 1, .1 '/ Date Application Approved by r U y Date Application Disapproved for the following reaso s r 7— Permit No. Date Issued tat �6q U I ` THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS ,�w�• tF� Certificate of (Compliance THIS IS TO CERTIFY; that the On-site Sewage Disposal System'Constructed( )Repaired u pgraded -Abandoned( ),by at P 40 4J A e a "1 1�. /-1�f'!i 5 h b a-constructed in accordance- ` with the provisions of Title 5 and the for Disposal System Construction Permit No. �'' ated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will'fun tibn is designed-,..-.. Datet Inspector No. V `�I ���----- ---------------•------Fee ...�(�—� . .. .. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1wigo0al 6pgtem Congtruction Vertu Permission is hereby granted to Construct( )Rep 'r ade( Abandon System located at (./ �P and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:C ns �tio P) A completed within three years of the date of this � t. Date: I —Approved b PP Y r V y 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL .WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS). hereby certify that the application for disposal works construction permit signed by me dated 1 e 1 , concerning the property located at Q5 v1,11n Zc�cQ meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business �ses associated with the dwelling. • he soil is classified as CLASS I and the percolation rate is less than ore equal to�T` p q 5 minutes per inch. /• There are no wetlands within 100 feet of the proposed septic system • There are no private-wells within 15Q feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: c A) Top of Ground Surface Elevation(using G1S information) `S o B) G.W. Elevation +the MAX. High G.W.Adjustment. DIFFERENCE BETWEEN A and B- 020 SIGNED : DATE: [Please Sketch proposed plan of s stem on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert '��� r _ - �., ��� >> ` (" �i � „ . � .. v _ . . U� ?�� } �,, �- �' %J� 1, �. � - � � v . _ . � � . c r -�� C TOWN OF B,A,R�INSTABLE LOCA;i1ON �/✓tt�i�e� _ rc SEWAGE # VILLAGE �/�/ ASSESSOR' 8c LOT Z.� b (p INSTALLER'S NAME&PHONE NO. 4,90r SEPTIC TANK CAPACITY LEACHING FACILITY: (type? (2/6 w�4 Ae✓S (size) NO.OF BEDROOMS BUILDER OR OWNER u9(l.� �a --r���4 n:i PERMUDATE: 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) Feet o Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �- m t" �`^,, _ �, ,� � � � °`�, f, 1 a g TOWN OF BARNSTABLE LOCATION l��iD u�.le� o -- SEWAGE # VILLAG ASSESSOR' & LOT INSTALLER'S NAME&PHONE NO. c SEPTIC TANK CAPACITY LEACHING FACILITY:._Cty_p �� k,_-,S (size). NO.OF BEDROOMS \ � ' BUILDER OR OWNER PERMITDATE: 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by i I �D (a) The maximum number of occupants in a residential dwelling shall be determined by the number of bedrooms contained therein. A maximum number of two occupants are } permitted for each of the first two bedroom ,,for_each additional bedroom a maximum number of one occupant is permute s be a violation of this Ordinance for any person in excess of that provided herein to occupy any residential dwelling. t , Ff(b ) The maximum number of motor vehicles that are permittedto be parked overnight, ther than in a building, at any residential dwelling shall be equal to two motor vehicles or the first bedroom in a residential dwelling and oneinotor vehicle per bedroom thereafter. / § 59-4. Exemptions. Children under the age of twenty-two (22) shall be exempt from these provisions. t/ § 59-5. Enforcement and Penalty. (a) This chapter may be enforced by the Building Commissioner, or his designee, the Board of Health and/or its designees or the police. ` (b) The owner, lessee or person in a position of control of any dwelling unit found in violation of this ordinance shall be subject to a fine not to exceed three hundred dollars ($300.00). Each day of continued violation may be deemed to be a separate offense. (c) This chapter may be enforced under the provisions of MGL Chapter 40, §21 D. The fine for any violation under the provisions of MGL Chapter 40, § 21.1) shall be one hundred dollars ($100.00). Each day of continued violation may be deemed to be a separate offense. §59-6. Severability. (a), Each provision of this chapter shall be construed as separate. If any part of this chapter shall be held invalid for any reason,the remainder shall continue in full force and effect. (b) Nothing herein shall be construed as allowing for more bedrooms in any residential Idwelling than is otherwise permitted by any state or local law or regulation governing health and safety. SECTION 2: The subject matter of this ordinance shall be examined by a committee appointed by the President of the council before October 1, 2007, to report to'the council by February 1, 2008 with respect to any changes which may be deemed necessary or advisable. 46 DATE ACTION TAKEN /C) ' 45 � S 07/23/2010 09:35 5087789312 BARNSHOUSAUTHORITY PAGE 06/11 F 6 rA s• . 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"� ►-3...5�_. .. . ._ . ........... ....... ........ ----..._._...,_. r� r _. _..._.......... _..._ ..... . 07/23/2010 09:46 5087789312 BARNSHOUSAUTHORITY PAGE 01/03 Bamstable Telephone(508) 771-7222 0� Fax(508)778-931.2 nnn��a� Leascd Housing Dept. 508 77)-7292 Housing Authority 146 South Street Hyannis,Mass. 026()1. FAX TRANSMITTAL SEIEET DATE: TO: fiU�Ir.e�,�t� ATTN: Cy FAX We are faxing you the following: Letter ^Lease.Amendment/Addendum _Release of Information Verification DOCUmentation Other: ]Regarding: --a' - Comments" Name of Sender: �to A71 P P- j Number of nclu.di�,Cover Sheet) Confidentiality Notice The documents accompanying this_fax Transmission contain information from the Offices-Rf Barnstable Housing Authority and are conridential and privileged This information is intended for the use of individual or e„tiAy named on this transmission Sheet. if you are the intended recipient, be aware that any disclosure, copying, distribution or use of the contents of this u:formation is prohibited If you have received this fax in error,please notify us by telephone immediately so that we mqv arrange for retrieval of the original Equal Housinz Opportunity Agency 07/23/2010 09:35 5087789312 BARNSHOUSAUTHORITY PAGE 01/11 x Barnstable Telepbonc(508) 771-7222 ,,,,VW i I Fax(508)778-9312 + a"& 7�cHscd Hausin.g DcPt. (.SOb)77]-7292 u o. ®using Authority 146 Soutb Street•Hyannis,Mass.02601. FAX TRANS1MrTT.AL SHEET DATE: /j A TO: A..TTN: FAX We are faxing you the following: _.Letter Lease Amendment/Addendum _Release of Information Verification Documentation Other: Regarding: Comment: Name of. Sender: Number Af'j Inclutd?t0.g•Cover Sheet) Confidentiality Notice .The documents accompanying this fax transmission contain information from the Officeswof Barnstable Housing Authority and are confidential and privileged. This informa4on is intended.for.the use of individual or entity named on this transmission .sheet Iff you are the intended recipient• he aware that,any disclosure, copying, distribution or use of the contents of this information is prohibited. .If you have received this fax in error,please notify us by telephone immediately so that we may arrange for retrieval of the originaG Equal Hous.i.n.g Opportunity Agency j1p wpm WMA cure t,;d I' If yrII ,I �I��l�lY M gC f Wk'' 7 1 ,el } GM A51 ITA gA"o Mr ......... Yj IN IM, i'411 "d HF R, 112 ills 41- vtw �J=It IN p Rf� "AM uf:�K 115 NS I IN r"d Pe tar " "Il, t ,MINIra 'lgg yN i �ls 'n .M ,m vyMv p oa Ohl 1 7 It7d A. t�w No guf, tv pw ?f lit pggm jT ."JON",kp" I (I�Rp I ,.i R11, , ' ' it Tn t IR)( 10t ;i , '11 21iP9 ! N 1 t RM.Irv— fQj ,ggt %at kit P 10. ta. 64 .^VIA aw wl th V ,�tj L704 -V� Nt 07/23/2010 09:46 5087789312 BARNSHOUSAUTHORITY PAGE 03/03 ITTT7—TOW"'Raw R11 9 L/ p .3 T .CdL1ti: ' I �l 07/23/2010 09:35 5087789312 BARNSHOUSAUTHORITY PAGE 07/11 ah ,�",.if. ':N i�1' i•�. ?i%i r;v. ..1?',+;;�hl.d,:F. .� W Q; ��'t ��'i��S:yk'J��•. �:^.4�:•"'M�: �l" r a ��'t*v'�:�r•:�+nic" l� P STA /11 -7 ' yj 3' Health Complaints 15-Jun-01 Time: 3:45:00 AM Date: 6/11/2001 Complaint Number: 2894 Referred To: GLEN HARRINGTON Taken By: DANIELLE ST.PETER Complaint Type: TITLE V SEWAGE Article X Detail: Business Name: Number: 218 Street: Arrowhead Dr. Village: HYANNIS Assessors Map-Parcel: Complaint Description: Their property is overflowing onto Julie's yard, she has children and has talked with the tenants on the problem property, and they said the landlord isnot doing anything. Actions Taken/Results: I spoke w/tenant and called David Hart at Barnstable Housing Authority. BHA will pump j for maintenance. The system lasted approx. 10 months from last pumping. More details in file. Investigation Date: . 6/13/2001 Investigation Time: 10:15:00 AM I i I 1 i pi r,31010JIaL Try wf� ve � ��� qL Health Complaints 11-Jun-01 Time: 3:45:00 AM Date: 6/11/2001 Complaint Number: 2894 Referred To: GLEN HARRINGTON Taken By: DANIELLE ST:PETER Complaint Type: TITLE V SEWAGE Article X Detail: Business Name: Number: 218 Street: Arrowhead Dr. Village: HYANNIS Assessors Map_Parcel: Complaint Description: Their property is overflowing onto Julie's yard, she has children and has talked with the tenants on the problem property, and they said the landlord isnot doing anything.. Actions Taken/Results: Investigation Date: G�/3��/ Investigation Time: zv ,pv 4- C c.rC Lw�0 1 I . L O CATION SEWAGE PERMIT NO. VILLAGE LLER'S NA E a ADDRESS .� ; 8 UU II L-DD I R OR OWNER BSc.",[ U,s`< ��-� dy�`��-ty��f i DATE PERMIT ISSUED ' i DATE COMPLIANCE ISSUED �.� _iA _�S I � (� `� ,��� � � � �. .-� C�. �' � ��.. � c. �� 4 �=- ,L. - ._ � 1� I- � � ` .- . :, � s � ` � 4 i P, No...(?-15..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF....... ................................. Appliration for Uhipooal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ............................................ ..................................................................... ............................ L cat*o ,Add s or Lot No, o .......... ... .............................................. C—oP I Address .......... .................. . ......... ....a.....a... ....... . ............... Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.......k4---------------------------------Expansion Attic Garbage. Grinder PL4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria 04 Other fi t es ....................................................................................................................................................... Design Flow.._...._ �4.\A..Q.................gallons. >..............................gallons per person per day. Total dail flow........ 9 Septic Tank—Liquid"capacityYaQ�allons Length------....... Width...__........_-. . Diameter................ Depth................ Disposal Trench—No. .................... Width....:�............. Total Length..............,...... Total leaching area....................sq. ft. > Seepage Pit No.......�.*�....... Diameter...K,)......... Depth below inlet.....q.......... Total leaching area..................sq. ft. Z Other Distribution box Dosing tank 1-4 1 4 Percolation Test Results Performed by...............................................:.........*...............1. Date........................................ 1-.4 Test Pit No. I................minutes per inch Depth of Test Pit.............-..--_- Depth to ground water.......................... 0-4 44 Test Pit No. 2................minutes per inch Depth of Test Pit................__.. Depth to ground water---..................... P4I......................... ........... ........................................................................................................... o on o escr Diptif Soil........... 0 ......................S ............................................................................................................ W .......................................................................................................................................................................................................... U ....................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable.......V ...... . ........7D., ............ .............................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of TITLE TILE 5 of the State Sanitary Code—.The undersigned further agree's not to place the system in operation until a Certificate of Complianc,, s��' ed by the Abo Signed...................... ............... ...................................... D t ...... ..... ... .. Application Approved By.... ....... ..... :�Y...... Date Application Disapproved for the following reasons:............................................................................................................. ......................................................................................................................................................................................................... Date PermitNo.... ..................... Issued....................................................... Date No... ...... F4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------40 .............OF...... . ..... ................................ .. Appliration for Dhipasal Workii Tomitrurtion Permit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ...... ............................................................. ................. ............................................. ocation or Lot No. ... ......... ........................................ Address ............ ..................... .......... ................ Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............q.............................Expansion Attic Garbage Grinder ( ) P4 Other—Type of Building ............................. No. of persons............................ Showers Cafeteria ( ) A4Other fixtures ............................................................................................................................... Design Flow_...._...: - - ......................gallons per person per day. Total daily flow.........Q.-K.—N_0.................gallons. 1:4 Septic Tank—Liquid'capacity�15�..gallons Length-__--.--...... Width._..---........ Diameter............... Depth.............._. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. f t. Seepage Pit No........(;2...... Diameter.....\_2;�....... Depth below inlet.............. Total leaching area...................sq. f t. Z Other Distribution box ( ) Dosing tank ( ) �_l 4 Percolation Test Results Performed by.......................................................................... Date_...__.__............................... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water......._.............._. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.___................_... ............................................. . -------------*--------------- -----------**-------- .......... 0 Description of Soil................. ............................................................................................................. U ......................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable._A:6 -.0.....::2_� ......... .................................................................. 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 d by the b rd QL_health, 0 Signed.......7. ............ ..... ......... ............ ............ Application Approved By...... ......... .... ....... ........................................ Date Application Disapproved for the following reasons:.......................................................................................................... ......................................................................................................................................................................................................... Date PermitNo.---..d ................. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......�'....:.OF.... ........................................... .... .......................... Tatifiratr of Tompliatta TJHS-I-S-Z 0 C TIFY, That !�5(diyidual Sew.ge Disposal System constructed or Repaired by............... . .......... <..... ........ ......................................................................................... Installer c3L Q_ at.... A .......1��6\A.- k ------------*---------**... .......................a..i?t!nD..... has been installed in accordance with the provisions of TIT State COA_ - d *b d in the Codes es p e i Yt' Sanitary application for Disposal Works Construction Permit No.-__-. ..:_...... . ...... dated... --------------------­_' ...(.---�7/1....... ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................... ......... 5................................. Inspector...............H.. ..... ... *. ................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH c.............OF....... ............................ No.... FEE........................ iu Nor ii Toth Wit Permit ..................................................... Permission is hereby granted......... I to Construct nstruct or Repair ( �an Individual Sewage Disposal System atNo... -X P z�..... . ..................................................................... Street *-r— IN 11 / -Z // — as shown on the application for Disposal Works Construction Permit No..................... Dat9d ...... icat ------ .............................................................. Board of Health DATE......./,%-. .......lf-S........................................ FORM 1255 A. M. SULKIN, INC., BOSTON i3r — -�' O 4' s3� o 1SoC) SE PT�c 7ANk � . ,- - ®0 , o � Li RCoyy\