HomeMy WebLinkAbout0121 GREENWOOD AVENUE - Health 121 GREENWOOD AVE., HYANNIS
A=289.102
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Town of Barnstable
Inspectional Services Department
• BARMASM - Public Health Division
16 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
Leonid and Tatyana Sukennik March 2021'
121 Greenwood Ave
Hyannis, MA 02601
RE: SEWER CONNECTION:DEADLINE EXPIRED
121 Greenwoodenu Ave; Hyannis,e F' A= 289=102
Dear Property Owner,
Your sewer connection deadline has passed.
Please contact the Public Health Division Office to provide an update relative to the
status of property's connection to. public sewer (i.e. contractor name, DPW sewer
connection permit number, anticipated connection date.)
If you would like to request an extension, such request must be in writing addressed.to
the Board of Health (200 Main Street Hyannis, Massachusetts) or e-mail Sharon Crocker
at: sharon.crockerktown.Barnstable.ma.us within fourteen(14) days.
Sincerely yours,
Karen Malkus-Benjamin
Town of Barnstable Health Division
Coastal Health Resource Coordinator
karen.malkus(c)-town.barn stable.ma.us
Lc.� 1 -- U�`�
Town of Barnstable
Inspectional Services Department
• BAIMST"M s Public Health Division
KASS
1639. 1�
�" 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
October 21, 2019
Leonid and Tatyana.Sukennik
206 Burgess Ave
Westwood, Ma 02090
I2E: SEWER CONNECTIONPIA IN -EXPIRED !
121 Greenwood Ave.; Hyannis A-„289 102 p
Dear Property Owner,
Your August 30, 2019 sewer connection deadline has passed.
Please contact the Public Health Division Office to provide an update relative to the
status of property's connection to public sewer (i.e. contractor name, DPW sewer
connection permit number, anticipated connection date).
If you would like to request an extension, such request must be in writing addressed to
the Board of Health(200 Main Street Hyannis Massachusetts) within fourteen(14) days.
Sincerely yours,
Karen Malkus-Benjamin
Town of Barnstable Health.Division
Coastal Health Resource Coordinator
karen.malkus(o)town.barnstable.ma.us
phone: (508) 862-4641
FtKE r�,,
Town of Barnstable Barnstable
Regulatory Services Department U4Ww'caCftY
1 '
IARNSfABLE.
9 ��� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scali,Interim Director
FAX: 508-790-6304 Thomas A.McKean,CHO
1,
CERTIFIED MAIL# 7012 1010 0000 2851
January 13, 2014
Leonid & Tatyana Sukennik
206 Burgess Ave
Westwood, MA 02090
IMPORTANT NOTIC
Map & Parcel 289-102
The Department of Public Works informed us that public sewer lines are now available
• in your neighborhood. According to our records, your property has a septic system.
This letter directs you to connect your dwelling, at 121 Greenwood Avenue, Hyannis,
• MA, to public sewer on or before 8/30/2019.
The old septic system must be either removed or filled in due to future safety concerns.
This may be done by the same contractor who connects you to the sewer. Septic
Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street,
Hyannis.
Failure to comply with this Board of Health Order may result in a complaint against you,
in a court of law.
For additional information pertaining to the sewer connection, please see enclosure.
PER ORDER OF BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
• Enc.
Q:\SEWER connect\Sample order letters for sewer connection\121 Greenwood Ave Hy Jan 2014.doc
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i
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No.
`� ��Y � Fee $J 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Z(pprication for Milpogal *pftem Construction Vermit
Application for a Permit to Construct( )Repair(X )Upgrade( )Abandon( ) O Complete System El Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
121 Greenwood. Ave , Hyannis, MA Dave Baker/ Marilyn Baker
Ass e r' arce
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E , Robinson Septic Service
P 0 Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 3 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 Type of S.A.S.
Description of Soil Sand.
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system- tank,
D-box and. 2 leach chambers .
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 theonvironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss. ed b of Hea // q
Signed -y✓" Date (a r d
Application Approved by �' Date101�Q�[
Application Disapproved for the following reasons
Permit No. o- Date Issued r
i $50
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
w
Application for Mi!5pool *p!tem Construction Permit
Application for a Permit to Construct"( )Repair(X )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
121 Greenwood. Ave,' Hyannis, MA Dave Baker/ Marilyn Baker
Asse r' /Parcel
6
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E, Robinson Septic Service
P 0 Box 1089, Centerville , MA
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 r
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system- tank,
D-box and. 2 leach chambers .
E
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 thefifivironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss ed b t o of Hea / C�
Signed - 4 - Date
APpli�horn'Appro,,v.eA�by �' ... � M Date xol�°
Application Disapproved for the following reasons
Permit N �- Date Issued 6
----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Baker (tertificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( )
Abandoned( )by Wm. E . Robinson Septic Service ry
at 121 Giie%nwood. Ave . , Hyannis has been constructed in accordance
with the provisio,�s of Title 5 and the for Disposal System Construction Permit No. "'" dated --
Installer Wm. R• Rob ins orb S r. Designer
The issuance ofthis permit shall not be construed as a guarantee that the system will function as d'vsl,gned.r� 1
Date 1' !�! Inspector % 1�?% 1 v.)
No. "� 47� --------------------------Fee $50
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Baker
Mwi5po5a[ *p0tem Construction Permif'
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon
System located at 121 Greenwood Ave . , Hyannis
and as described in the above Applicayon fe-Di'spo al System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the followingg-kcal prf 'sio r�flecial c nditions. �y r
Provided:Construction must be completed within three years of the date of thi�rmit.
Date: /40 Approved b
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)
I, Wm, E . Robinson Sr. , hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 121 Greenwood. Ave . , Hyannis , MA meets all of the
following criteria:
w•
The failed system is connected to a residential dwelling only. There are no commercial or business
es associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
L/There are no private wells within 150 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]
/ the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
LLL� leaching facility will not be located less than fourteen(14) feet above the maxcimum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
I.
B) G.W. Elevation +the MAX. High G.W. Adjustment .
DIFFERENCE BETWEEN A and B
SIGNED : L 1 DATE:
[Sketch proposed plan of system on'back]. _
q:health folder.cen
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HYANNIS FIRE DEPARTMENT
95 HIGH SCHOOL ROAD EXTENSION
HYANNIS, MASS. 02601
Harold S. Brunelle
RMUMMUMEMEM S�sZv�2e �eteetvz� Sage ,L'ic-ed BUSINESS: 775-1300
CHIEF EMERGENCY: 775-2323
DATErr
TO I' s MAW I TI rV fc-p'
Z4 &rwwtAl& A L,,E'-
o'7,6ai
-In agcordance: w' S27CAiR 9 ,21 1) abelo ] the folivwiiit� .
tank (s) % (��� 1�►e �zs�fJ5r
Located tat
Have been approved to be abandoned in .place. : The. tank (s) -.have
been properly cleaned by ;
1V✓FjAeeb t yiaAme4tio j e�Vic'
PG gOk y(��-
and-have been-f.i1.1.e.d-.wi-th--an-.approve.d-iner-t_ma.ter�ial of;
_ L/ 11J--Fb Fii-�-
Each step in thi0j.? �iess has been inspected and was found to
be in compliance with th aFd
,.. �
y"/
Y r P I
For; Harold S. Brunelle �G26Q1
,Chief
Hyannis Fire Department
CC.
Town of Barnstable Board of Health
527CMR 9 .21 (1) If the owner decides to abandon a tank which is either located under a
building and, cannot be removed from the ground without first removing the
building or which is so located that it cannot be rernoved from the ground
without endangering the structural integrity of another tank, [lie owner shall
promptly notify the head of the local fire department of this condition. After
verification that such condition so exists, the owner shall have all product
removed from the tank, by hand pump if necessary, under the direction of the
head of the fire department, and shall have the tank filled with a concrete
slurry mix or any other inert material approved by the Marshal for this purpose.
1
Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permit.
Vj_ �ie��e%r,�2Ca�-�'r�e C��rscced— ✓c�aaixda��re �x�e�cCca�rc
APPLICATION. and PERMIT I Fee:
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
•
Tank Owner Name(please print) iMV�`
Signature( aplirng
forpennI
Address f�� 6� w lqU � ,��s 1• 4 a-Z601
Street city Stare Zip
Removal • • • •
Company Name Advanced Enviro. Spry: Tnc. Co.or Individual
Print Print
Address PO 'BdX 472 So. Dennis, Mg - Address .s`_:
Print 02660
Prot -
Signat (' ap g,for pe Signature(if applying':for permit)
.O IFCI.Certified Other_ O lFCl Certified O LSP:# Other'
Tank Locations
Sreet Address c:. .. Crty� ——
.,
Tank Capacity(gallons) �• S / Substance,Last Stored
Tank Dimensions(diameter x length). �< 60
Remarks:
Firm transporting waste Advanced Enviro. Serv. State Lic.# MV5083856100
Hazardous waste manifest# E.P.A.#
Approved tank disposal yard James Grant Co. Inc.Tank yard# QQR
Type of inert gas Tank yard address Wa 1 cci St. RPa dyi.1 7 e fMa
City or Town FDID#_ oz Permit# 9 9? ? q
Date of issue Y / Date of expiration
Dig safe approval number: a Dig Safe Toll Free Tel. Number-800-322-4844
Signature/Title of Officer granting permit
After removal(s)send Form FP-29OR signed by Local Fire Dept.to LIST R ne Ashburton Place,
Room 1310,Boston, MA 02108-1619. AP�tr/S 40j �� I
r 414 Gf� e�1r
FP-292(revised 9/96)
of Bs� BARNSTABLE COUNTY
9� DEPARTMENT OF HEALTH AND THE ENVIRONMENT
U SUPERIOR COURT HOUSE
* F POST OFFICE BOX 427
BARNSTABLE,MASSACHUSETTS 02630
7�ssACHIJS Public Health 08)362-2511 Ext.330
333
Environmental Health 383
Water Quality Analysis 337
FAX(508)362-4136
TDD(508)362-5885
UNDERGROUND TANK TEST RESULTS
NAME: DAVID BAKER DATE: 4/l/99
TANK LOCATION: 121 GREENWOOD AVENUE, HYANNIS
TAG#NONE YEAR INSTALLED: UNKNOWN CAPACITY: 275
The recent check of the vapor monitoring well(s) near your underground storage tank (UST) did not detect any
significant contamination. Because the use of soil vapor monitoring for UST leak detection is a limited technology
we cannot,however,guarantee that.your tank has not leaked. You should also realize that a "good"result from our
test is no indication of how long the tank will remain sound.
Due to fiscal constraints,the Barnstable County Department of Health and the Environment has instituted a nominal
test fee of$30 for one well and$10 for each additional well at a site. Accordingly, would you please send a check
for$ NC made payable to R RN4TABE COUNTY to: .
Charlotte Stiefel
Barnstable County Department of Health&the Environment
P.O. BOX 427
Barnstable, MA 02630
The following items, if checked,also apply to your UST:
X We encourage the removal of older tanks before the expected leak(s) develop.
X We encourage the removal of tanks under 300 gallons as they were not made for underground use.
X Your UST doesn't appear to be registered and tagged as required by your Board of Health.
It would be advisable to mark your monitoring well to prevent accidental usage.
The soil conditions surrounding your tank are not ideal and may accelerate tank leakage.
TANK IS BEING PERMANENTLY ABANDONED.
A copy of this letter has been sent to your Board of Health and the records reflect the results of this tank test. If you
have any questions please contact Charlotte Stiefel at(508)-375-6620.
cc: Board of Health: BARNSTABLE
Whereas,the escape of fuel from an underground storage tank may result in civil and/or criminal liability of the owner,lessee,licensee,
licensor, and/or other persons in control of the premises;
Whereas,the use of vapor monitoring procedures is only one of several procedures that may be used to detect leaking or escaping fuel;
Whereas,the reliability and experience of the testing procedure is limited; and
Whereas,from location to location and soil to soil test results may vary due to a number of factors;
The County of Barnstable and the Barnstable County Department of Health&the Environment represent that while the test results give
a fairly accurate reading of the vapor content in the well sites at the place and time of the testing,the soil conditions and condition of the tank
and connections may be such that leaks could occur at the time of testing or shortly thereafter without detection. Similarly,the equipment
is sufficiently sensitive as to detect fumes when, in fact,no actual tank or piping leaks have occurred at all. Therefore,no party shall rely
exclusively on the results of the vapor monitoring test. Neither the County of Barnstable nor the Barnstable County Department of Health
&the Environment shall be liable to any person either for the failure of the test to detect a leak when such a leak has,in fact,occurred or for
the detection of readings which may indicate that vapors are present in the soil when,in fact,no leak has occurred. Neither the County nor
any department thereof shall be liable for any faulty or overly sensitive readings resulting from the taking of such test.
TOWN OF BARNSTABLE 14,1
LOCATION /A,1 62c-,12�cl ~ fit/ SEWAGE # f"-& .
VILLAGE &VAIf s ASSESSOR'S MAP & LOT
INSTALLER'SdNAME&PHONE NO. S a z_, `Z ��•" `� ,_.
SEPTIC TANK CAPACITY lSI
LEACHING FACILITY: (type) — ��7 `� dL (size)
NO. OF BEDROOMS -`�
BUILDER OR OWNER 0640
PERMIT DATE: e 0 = �9 COMPLIANCE DATE: ��'J:'•
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Botto f Leaching Facility Feet
Private Water Supply Well and Leaching Facili (If any wells exist
on site or within 200 feet of leaching faci ' Feet
Edge of Wetland and Leaching Facility( y wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH
.......... OF.:. ......... -.............................
Appliration -for Uhipoottl Oorkii Tonotrnrtion Puniit
Application is herebymade for a Permit to. Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
............ !...... ........ ------------ ------------------------------------------------------------
Location.Address or-� ...... Lot o.
�i1��.. ... ..... .........h'Yfti .1,S !Lf ....
Owner Address
a ......... 4.7-(d !�-® ! s----------- " L.� /ihit -S>�} � ...... ---------.
Installer Address
d Type of Building Size Lot............................Sq. :feet
U Dwelling—No. of Bedrooms------------------------------- - -Expansion Attic ( ) Garbage Grinder ( )
P., Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ........•
d ------------------------------------------- -------------
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---------------------------------------
a Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water.-..----.__._..._.._---.
�,A Test Pit No. 2................minutes per inch Depth of Test Pit.____-___.._________ Depth to ground water--.-.._-_-__----__-----.
9 ------------------------------------------------------------------------------------------------------------------------------------------------------------
ODescription of Soil-------------------------------------------------------------------•------------------------------------------------------------------------- ---------- --------------
x
x ----=------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -----------------------
U Nature of Repairs or Alterations—Answer when applicable............Avo----____.-/.'..Lp..J g.aQ._._.. 7�y _ 9G?�iJ
---------T v-------- ,Te�------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been i u by e yrd o health.
ned.- . . I. � "'= .................... -••-------- ----•---------------------------
Application Approved By----------- ---------- - ----------•---•----•-----•- e
Date
Application Disapproved for the following reasons:........ ---••----------------------------•................................................
-----------•---•--•---•-••--•..............................•----------------•------------------------------•---•--------------------••-------------------...-•-•----------------------...--------------
Date
PermitNo......................................................... Issued........... --------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,9F HEALTH
�........ --.. OF....... �liPir�L ............... . .........................--
. pphration -for Diiipoiiat Morks Tomitrurtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
1
Location-Address or Lot No.
Owner _ Address
------•-- -- ----C -------•-•--•--• -----••••-• .......................................................
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
a4 Other—Type of Building ............................ No. of persons.........------------------- Showers ( ) — Cafeteria ( )
a' Other 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. 1................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--.-----.-___--.--_-.___
IYi •---------•----------- ------------------------------------------------------............................................................._.................
ODescription of Soil------------------------------------------------------------------------------------------------------------------------------------------------------------------------
x
W
----------- 1 �/� (!O✓----- r_ ��['%��
U Nature of Repairs or Alterations—Answer when applicable._._....___.%/.?l1
t-- I
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has beenisisgued by the oo rd of health.
Si Tied_ '� l/Y� e�.... —�U,'�.,
/ •-•-•-•--•------------------------------------- --------------------------------
Application Approved By..................1.. -"1 '�
V Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------•-------•-------------------
..........••-•-------------------•-----------------------•-•-------------•--•••-•-------•-----•------•-•-I-------------------------•-------------------------------------•----•------•-------------------
Date
PermitNo--------------------------------------------------------- Issued...................... ..................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF......................................................................................
` - CUrdifirate of f�11mVIiatta
T ,T `T-0 CERTIF' , iat the Individual Sewage Disposal System constructed ( ) or Repaired (�
by (�t� 1. ' �`
1 Z Inst. le ��
...
has been installed in ccordance with the provisions of A eXI of Th State Sanitary C/ode as described in the
application for Disposal Works Construction Permit No.............z:G___'�........---.- dated..._S�a_-__'�S ..'..� ...............
THE ISSUANCE OF THIS CERTIFICATE SHALE, NOT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEM W1 FUN ATISF CTO Y.
�
DATE---- C
------------------------••-•-- -----�-- ----•------------•----.... Inspector :.--•-•-= ---- •--- —c—�;`---------
THE COMMONWEALTH OF MASSACHUSETTS
2G BOARD OF HEALTH
1 ..... ......OF............ .... --+- .--........------:..............._.
No..................... FEE----- --------•--...
r
.
Permission is hereby granted '-•_l- a-/ic-- -------1, ���- f ----------------------•---- ••-•------..............
to Construct ( ) Repair ( an Individual ,Sewage Disposal Syst J
at No.!rr,�fltil- t "................�.z....�I./-�l��s''--t_� !. -�Z\_.C�t �..._.
v Street /
as shown on the application for Disposal Works Construction Per
------------
/DATE----- ..-�---------�—' -r-�/ Board of Health �
---- ---(---------------------------.-------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS