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Home My WebLink About0399 BISHOPS TERRACE - Health 399 Bishops Terrace Hyannis A=250 085 0 \ COMMONWEALTH OF MASSACHUSETTS i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 t U�51 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 399 Bishops Terrace Hyannis Owner's Name: Sonya A. Smith Owner's Address: 270 Fairwood Drive TiyPrtnn _ RT Date of Inspection: 6T S3W Name of Inspector:(please print) W i 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 pursuantVPeassies 'on 15340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority its Inspector's Signature: 1 Date: �A�5 Ste_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Bo of Hearth or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design ow of M000 6 gpd or greater,the inspector and the system owner shall submit the report to the appropriate region 1 office trfittte DEP.The original should be seat to the system owner and copies' ent to the buyer,if applicablez' d the apptoving� authority. � ..,t M Notes and Comments �. cep co r' t*t ****This report only describes conditions at the time of inspection and under the conditio s 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 1 Page 2 of 11 r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ 399 Bishops Terrace Hyannis Owner: Sonya A. Smith Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys m Passes: 1 have not found an information which indicates that any y 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. Syst Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tans:as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed p3ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval ofiBoard of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass`nspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is 1=ovod ND ex lain: I Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 399 Bishops Terrace Hyannis Owner: Sonya Sm t Date of inspection: (, �TConditions rther Evaluation is Required by the Board of Health: 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. I. 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 s tem 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 I 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 front 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 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. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 399 Bishops Terrace Hyannis Owner. Sonya mi Date of Inspection: <145 D. Sys em Failure Criteria applicable to all systems: You mus indicate yes"or"no"to each of the following for all inspections: Yes No — Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge 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 esspooi iquid depth in cesspool is less than 6"below invert or available volume is less than day flow equired 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 water supply well with no acceptable water quality analysis.(This system passes if lire 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 of the 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. E. Large Systems: To a considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 9Pd� You must indicate either"yes"or"no"to each of the following: (T'he following criteria apply to large systems in addition to the criteria above) yes o the system is within 400 feet of a surface dr'trtkirtg water supply the system is within 200 feet of a tributary to a smface drinking water supply _ T the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well red a significant t thrc or answered If a have answered es to any question in Section E the system is cnaside tgn at, Y Y "ye "in Section D above the large system has fined.The owner cr operator of arty large system considered a sig ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15 304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:_399 Bishops Terrace Hyannis Owner: Sonya A. Smith Date of Inspection: O Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? t/Have large volumes of water been introduced to the system recently or as part of this inspection?.. v Were as built plans of the system obtained and examined?(If they were not available note as N/A) v _ Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? v _ Were all system components,excluding the SAS,located on site? v _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? V/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. y _ 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: 399 Bishops Terrace Hyannis Owner: Sonya A. Smith Date of Inspection: 14 2 Z. FLOW CONDITIONS RESIDENTIAI. 3 Number of bedrooms(design):.�'� Number of bedrooms(actual): ` DESIGN flow based on 310 C 203(for example: 110 gpd x#of bedrooms): .3 G G Number of current residents: Does residence have a garbage ' der(yes or no): Is laundry on a separate sewage system(yes or no): if yes separate inspection required] Laundry system inspected(yes r no): %L 6 Seasonal use:(yes or no): �//� Water meter readings,if av tlablc(last 2 years usage(gpd)): 0 4/0 5 — 110, 250 ---,,Sump pump(yes or no): 03/04 — 65, 250 Last date of occupancy: COMMERCIAL/INDUST L Type of establishment: Design flow(based on 3 CUR 15.203): t;pd Basis of design flow(s is/persons/sgft,etc.): Grease trap present(y s or no): Industrial waste hol 'ng tank present(yes or no):_ Non-sanitary waste ischatged to the Title 5 system(yes or no):_ Water meter read' gs,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records gd 7 / ) , /�t ,, Source of information: Was system pumped as part of the inspection(yes of no):_ If yes,volume pumped: U gallons--How was quantity pumped determined? Reason for pumping: TYP)y6F SYSTEM 4eptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altcmative 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): Approximate age of all comp eAtsrdate installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 0 6 I'agc 7 of I 1 OFFICIAL INSPECTION FORM—NOT I'Olt VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PAItT C SYSTEM INF011A'IATION(continued) Property Address: 399 Bishops Terrace Hyannis Owner:Sonya A. Smith Date of Inspection: BUILDIN/SE ER(locate on site plan) Dcpdt bel : Materialsuction:_castiron 40 PVC other(explaut): Distance ate water supply well or suction foie: Commendition of joults,venting,evidence of leakage,etc.): SEPTIC TANK:/oocate on site plan) l Depth below grade: Material of construction: ✓cuncrete_metal fiberglass____polyethylene _odicr(explain) — If tank is metal list age: Is age confinned•by a Certificate of Compliance(yes or no):_(attach a copy of certificate) r r— 4 r r Dimensions: C G Sludge depth: ' Q ► 1 1 s Distance from top of sludge to bottom of outlet Ice or bafllc: — Scum thickness: Distance from top of scum to lop of outlet tee or baffle:Distance from bottom of scum to botton f outlet tenor bathe: I lo%v were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert,evidence of leakage etc.): GREASE TRAP: /oca(c on site plan) Depth below grade: Material of eonslru nion:_concrete_metal_fiberglass polyethylene__other (explain): Dimensions: Scum thickness: Distance front . p of scum to top of outlet tee or baffle: Distance fronYbottonl of scum to bottom of outlet tee or baffle: Dalc of last pumping: Continents(,on pumping recontntendations,inlet and outlet ice or baffle cunditio:t, structural integrity, liquid levels as relaledloloullet invert,evidence of leakage,etc.): I/ 7 Page g of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropertyAddress: 399 Bishops Terrace Hyannis Owner Date or Inspection:_`L—JLs'.—d TIGHT or HOLD 'G TANK: (twtk must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of eonstru lion: concrete_metal_fiberglass_polyethylene other(explaut): Dimensions: I Capacity:_ gallons Design Flow: / gallons/day Alarm present yes or no): Alarm level. Alann in working order(yes or no):— Date of last mping: Continents condition of alarm and float switches,ctc.): DISTIUBUTION BOX: ' (if present must be opcncd)(locaie on site plan) ) Depth of liquid level above outlet invert: Conunents(note if box is level and distribution to outlets c at,any evidence of solids carry-over,any evidence of leakage into or out of box,cic.): b PUMP CHAMBER._(localc�on site plan) Pumps in working order(yes or°no):_ Alarms in working order(ycs/or no): — Conunents(note condition df pump(hamber,condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 399 Bishops Terrace Hyannis Owner: Sonya A. Smith Date of Inspection: ��✓'�S SOIL ABSORPTION SYSTEM(SAS): (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/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): d n —!- CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and onfiguration: Depth—top f liquid to inlet invert: Depth of s lids layer: Depth of cum layer: Dimens' ns of cesspool: Materi s of construction: Indic tion of groundwater inflow(yes or no): C o ents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (ocate on site plan) Materials o construction: Dimensi0 s: Depth o solids: Co wents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 I Page 10 of 11 OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) I Property Address: 399 Bishops Terrace Hyannis Owner: Sonya A. Smith Date of Inspection: C, 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 a tens the building. fJ 1 I 1 t y L, 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: 399 Bishops Terrace Hyannis Owner. Sonya A. Smith Date of Inspection:f/ '-A f_G 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 ISO 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 ou stablished the high round water elevation: y� 3 g � 11 r- �\ I a / TOWN OF BARNSTABLE LOCATION S �/a�.� &SEWAGE # VILLAGE ASSESSOR'S MAP & LOaSd"' tff INSTALLER'S NAME & PHONE NO. P �� : 8- SEPTIC TANK CAPACITY k bodV LEACHING FACILITY:(type) / a D �' (size) I , NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:/ Z a VARIANCE GRANTED: Yes No /� �.^1�) lJ � M``vN�' � V •\ V ��/] �.i -7 �� '1FT r r-� �_ M i � V , No... Fxs......��,,r. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di-lipwial Wor1w Towitrnrtiun rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ?01 an Individual Sewage Disposal System at: .........--- -------- ............................... .... Location- Address \ddr ess or Lot No. . ................................... a •----•---------------------------'•-•--... ft Owner Address ` a �sa4 C ,J- " � ------------------------•---.......--- Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) aOther 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit...........--....... Depth to ground water--.----------------..... 44 Test Pit No. 2................minutes per inch Depth of Test Pit--..--.............. Depth to ground water.....--......--......... R; -------------------------------------------------------------------------------------•-.......------................................................... .----- ODescription of Soil..................................................................................................................................................... .................. x U ---------------------------------------------------•-----------------------------------.....------------------------------------------•-------------------•--•----••-----..........----------•-------. W UNature of Repairs or Alter ions—Answer when applicable.....�Z)'�.-.-.-.-.� --------�.�d.a°---..--`^�k-d'4?........ �•`�` -------e-'�------`-"t-----------�------------s -o, �,•-•--..:�..........._'�� ?? s.; ,........................................................... . Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. n � Signed ........... .p-. �. -^ 0------------------------------------- ------ Application Approved By ............... �. .. ........ ....... 1Gl.' j_e.:..g._ Application Disapproved for the ollowing reasons: . ..... .................................................................. . ................_...... ............................................................................................ Permit No- -------- ------ ----- ----- °�_-....�a.�- Issued ..................."`.` ` `- Date e - Date ../� os V No.._ Z FEs.... ., THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AVpli,d1i�an fnr Dhj ial,� fir (�nns rnr Ilan Permit Application is hereby made for a,Permit`to Construct ( ) or Repair ( -,4 an Individual Sewage Disposal System at: ..�� .........` l S o'�5....--•----�-=� . ...... ....... . Location-Address or Lot No. dfL......................................................................... .................................................................................................. Owner Address .-I 0 5�24 .. .��................................................-•--•--•••- ---- -••-. Installer Address PQ Q Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ----------------------------------------------------------------------------•---------- -----•---•------•••-•••-•-•--•••-•--•-••••-•----•...--------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. W Septic 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........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.-______-_-_-__------.. f? Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ....-•......................................................•-•-•---•-•----•---.........--------•-----•---•-•---............. ............................... ODescription of Soil......................................................................................................................................................... .... ......_.. rxj -••---••-------•-...•.. W , U Nature of Repairs or Alter tions—Answer when aCpplicable.-__. .�. - L.....................................1tr Y� ------ -------------�_1-_--_------ `.----.----------_-*-------------------------- -- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed -----------�.a. - ..................... �d///)z2 i . ....../ ......................... Application Approved By ........... ..., �.- --r..< -----�� - e ` A.�1. .. Application Disapproved for the following reasons: ... .... ....................... .... . ..................... .................. .............. . Permit No. - �.�/.--.._ �. -�,......... ........ Issued o�e. ...................................... Da THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TO��••WN OF BARNSTABLE 'ertifirate of umpliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ----------.._..---------- at1 1 i 5.... l� - - ..... 5 .� ---------------------------------------------------------------------------------_----------------------- has been installed in accordance with the provisions of TITLE 5c0 1 The State Environmental Code as described in the application for Disposal Works Construction Permit No. -----:1..4/P ...-_. .r�1 dated -------------............................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. FFi�rr /� ........ ----- Inspec`ter ................................. .. .�DATE... ---------------- --------------------------------------------------------- THE .'� COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... Gr ::_ ? ,�' FEE. - �.. .------ - r Disposal Workii Tons#rudilan Permit Permission is hereby granted.l`tl�-C �----. �d''V `....__.�-a�-- ... ........................................................ to Construct ( ) or Repair (f`/„)7an Individual Sewage Disposal System at No..." �t .......__..` �s\y_.. ....----•---�.�.�—rL-....----- ••---........ Street , , C as shown on the application for Disposal Works Construction Permit No. .. "_2__ ..__. Dated........ .................................., _;`-'1�)....................................................... 4 J Board of Health DATE............... 2=1_1.799 y--•••-••--•--••••-•-•----••-----••• VV FORM 3830E HOBBS h WARREN,INC..PUBLISHERS -