HomeMy WebLinkAbout0047 GROUSE LANE - Health 47 GROUSE LANE,W. HYANNISPORT
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SEWAGE#
V LLAGE. 6.6t, , v ®o�C% ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACrrY
LEACHING FACIL=: (type) (size)
NO.OF BEDROOMS
K
BUILDER OR OWNER
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
within 300 feet of leaching facility) Feet
Furnished by iyl A c 0,^I1c�
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Report 11
LEAD INSPECTIONS
William Fl .n�
P.O. Box 123
�. .. Dennis,� '�'e�1; D � IY.�.�.. 02670
L> D PAINT
TESTING 508-398-3632 , 508-;3J8-3J04
OF
Lead poisoning CAPE COD
LETTER OF INITIAL LEA C P
.�NYYYuu[[1wYwiww h..r..1ww.-sam
Maeeachusotte State Certified Inspector 11 11783
Alemlrr Member of MasenchuRotla Association of Lend Testors
Date: " /Y
Dear�.t3 Gl� �'O/�/J�y/V • .
This letter is to'certify that I inspected your property located at_'-�_ (14,04( e .44.
,
and relevant common areas, in the City or Town of4;a- ; y1041W- APR
for dangerous levels of lead according to 105 CMR 460.730(A) through (G): Procedures for Initial
ecti n, Regulations for Lead Poisoning Prevention and Control, and determined that there were no
violations. The inspection was conducted on _ /y
Please be advised that Massachusetts law requires that only certain residential surfaces be free of
lead paint. Thus, this letter does not mean that your property contains no lead paint. The premises or
dwelling unit and relevant common areas shall remain in compliance only as long as there continues to
be no peeling, chipping, or flaking lead paint or other accessible materials and as long as coverings
forming an effective barrier over such paint and materials remain in place.
Sincerely '
lk w
�J� Many
Inspector DPH License No. '
Should you have any question about this letter, call the Department of Public Health's Childhood Lead
Poisoning Prevention Program at (617)522-3700, ext. 188, (after 6932) or 1-800-532-9571. April 14, 1995, (617)983-6900, ext.
IZepoi
�.Y$
I.rEAD INSPECTIONS' William Fl nii
P B --.— Box 123
`V�7'est.Denni.s,, 11IA, 02670
LEADTESTING 508-398-36 32 5084398-3904
.UF .
Lend poisoning CAPE COD '
LETTER QF INI ALLEAR-001 \1 c I E
r .
Moseachusette BtAto Cerlitlod Inapoclor 11 11783
Mernbor of Mosenchtiaottn Aesoclatlou,or Lend Testors
Date: 3^ .
Dear��,�G1�• l"O/�'/li9/V
This letter is to'certify that I inspected your property located at '-,(-'7 la 4Q4/5C ,
awe• and relevant common areas, in the City or Town ofWE ANq/if�O�P j'
for dangerous levels of lead according to 105 CMR 460.730(A) through (G): Proced—ures for Initial
Inspection, Regulations for Lead Poisoning Prevention and Control,'and determined that there were no
violations. The inspection was conducted on 1K
Please be advised that Massachusetts law requires that only certain residential surfaces be free of
lead paint. Thus, this letter does not mean that your property contains no lead paint. The premises or,
dwelling unit and relevant common areas shall remain in compliance only as long as-there continues.to
be no peeling, chipping, or flaking lead paint or other accessible materials and as long as coverings
forming an effective barrier over such paint and materials remain in.place.
..Sincerely '
;A..elnfnp
Inspector I DPH License No. '
Should you have any question about this letter, call the Department of Public Health's Childhood Lead
Poisoning Prevention Program at (617)522-3700, ext. 188, (after April 14, 1995, (617)983-6900, ext. .6932) or 1-800-532.9571.
Lead 1.nspectioiV Surface Assessment Fonn
.: Z-
`6+ LUAI)l'ATNT Poe / or
i�tlV)e►l,a, •170STINC /
s$ ►t ae$s t M�ye lod Used: 6 Lend polsutllnl; Irluulber CAl'U COD W NiiJS expiladondate,�_ 'f
WHIllun Flynn r= ' ' X-lily Fluorescence
I1.0,ilex 1L0 (�00))390.3G3x Model t Serial N
WoetDOrmla,MA02070 (500I390.3904 < .ti
'Y
Address Apt.# City
(.) Illiti$ehs { BFY) ►sex
c o
Paplit/CilardinnrslSR4•lal9nle llyza1/Ga rAn►Irs ' ajt Name t I
Single Family
Owners Name: u`, Q Multi-Famlly 0
Owner's Address: �
,4' u; Number of Units _
E T, v 4
KEY: CAP capped Romarks/Calibration:
Cov covered �/�C A/
DIP dipped
ENC encapsulated
MI made Intact ,
NA not Occe$oI010
NEe ne alve Scales:($carol of of 1 Paso,acres of 21811j:
Pos posnive
PRE prepared 6udacelftliswtace o.nopalntidpetralntaq 1-<IO%palMnolInted
m 2-at0%pabsnaNted
REM Ieova0 subtirsto 0.Intact 1-e10%noM$r I IWO11paa$dtl REP roptncood KDWTV@Tool 0-wPoWwricyN 1-c1115'PAW MnVM tt-el/te'palra wed
REV toveraod
SCR aropod to bare sulvolar x•Cul Tap@ Tool 0-no ON removed I.Cute'polo IN my M a.swr Psh n"d
v.
fluor it �\ _ floor p
r'-r---r--r—r--r—r-- r
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1 I I r 1 I r t 1 r I P• 1 1 1 1 1 I I I I 1 1 I ( 1 1 1 :x,
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-r-r-r-r-r-r-T-T_R-T r-r-r-r-r-r-r-r-T-T-T-T-T-T• r
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• I 1 I I 1 1 1 1 I 1 1 1 1 1 I 11 I 1 1 / 1 .1 I I I 1 I
-h-h-1._{.-+_+1•+-+-:+-+-{-4 4-4- h-F-h-F_1'_1"'{'-+_+_+-+._+-+--1-
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..1•-h-'{._{._+_+-+_+-+-+_+-{-'1-4- -4_1--{•_I•-1•-+-+-�,-+_�•-4-,1-.,{_•1-L-+-L-L-+-d-.1- -F-L-L-L-4-+-+-+..}-4-4- -J-J-
' 1 1 1 I I I 1 1 1 1 1 1 .1 I I 1 1 .1" 1 I I 1 1 I .) -'•I I
-L-4-L-4_4-L-L-L-L-1-4-4_d-.1- -1--4-4-a.-t.-1.-'L-L-L-+-1�i�,•/-i- .,.
' I 1 1 I 1 1 1 I I 1 1 1 1 I 1 1 I I ( 1 �1 1 I 1 .' 1"',1'i' 1', 1 •. r I'•
A(street side) A(street side)
Pb (lead)more; than Fs2 ing/cnl2 with x-ray flilorescence or positive with Na2S is Daii'erotas.
INSR DATE Load Ilatalds7 REINSP.DATE 1•Incompearlce"
(Y or tf e p / 2.work Inptognu'
lllspocw�r
REINSP.DATE r'� MA,L1CS 11783 nmsp-DATE1177 I.boomp$trlp
T.woAl n reu 2.walk to plegnaat''�
a.rooewp-ncy I .' ..
a.1-11W a./0000a{,erlry ;'iihl,l-:•i...'.
JLj REINSP.DATE I,In cornpllance
s.
2." (kInprogress Full Compliance Date
.. ' a.a.lpbd rooaNaneyp :..... .
/ -
In'SpoClor
old you cumplete'a surface assessment for encapsulation? Yor®
Report
LEA INSPE C TI O 1 I
William Flynn
P.O. Box 123
--_ Vilest; Dennis,, MA. 02670
LL TEIIX STING 508-398-3632 , 508-398-3904
Lead poisoning CAPE COD
�L. 'E'ERA NITIAL LEAD QQ
L�K- E
�.,.N
Manoachueetts Stato CertiGod Inspector # 11783
Member of Massnchusotta Association of Lead Tostors
Date: �,� ^ /Y r�`
Dear S- y 4
This letter is to'cerdfy that I inspected your property located at Dll �' � ,
Vie• �'1 c�5� , and relevant common areas, in the City or Town ofW 0 T 41 ,1
for dangerous levels of lead according to 105 CMR 460.730(A) through (G): Procedures for Initial '
lUEec ' n, Regulations for Lead Poisoning Prevention and Control, and determined that there were no
violations. The inspection was conducted on
Please be advised that Massachusetts law requires that only certain residential surfaces be free of
lead paint. Thus, this letter does not mean that your property contains no lead paint. The premises or
dwelling unit and relevant common areas shall remain in compliance only as long as-there continues to
be no peeling, chipping, or flaking lead paint or other accessible materials and as long as coverings
forming an effective barrier over such paint and materials remain in place.
Sincerely '
slump
Inspector DPH License No. '
Should you have any question about this letter, call the Department of Public Health's Childhood Lead
Poisoning Prevention Program at (617)522-3700, ext. 188, .(after April 14, 1995, (617)983-6900, ext.
6932) or 1-800-532-9571. ,
LEAD INSPECTION/ Page�of
13 '0
LL�AD PAINT TT3STIOl SURFACE ASSESSMENT FORM
.'
CAP13 COD-
Address of Inspection: Apt# City
ROOM /
SIDE LOCATION/ LEAD L OWR DLR SRF SUR/ SUBST INITIAL X•CUT COMMENTS SUIT for DELEAD DELP
SURFACE N EG Y 0 S ABT71 PREP? SUBSUR• COND TAPE TEST ENCAP? DATE METH(
Up walls/Low walls
Baseboards/Chair
Door
Door casing/Jamb o,,'
Door .
Door casing/Jamb
Door \
r casing/Jamb
Door
oor casing/Jamb
Window sill
Win prsirig/Apron
Win header/Slops
Win sash/Mullions /
Exl sill/Pad bead A-`
Exl side sash
Window sill
Win casing/Apron
Win head
/Slops -
Win s ullions f
EA sill�Parl bead
EXI side sash
Window Sill
Win cating/Apron `
Win eader/Slops
sesh/Mulllons
Exl sill/Pad bead
Exl side sash
Window sill _
Win casi g/Apron
Win h der/Slops
Win,fastvMullions
Exl sill/Pad bead
Exl side sash
Closet walls r
CI interior door
CI casing/Jamb (/
Clbaseboards/Floor
CI shelf/Supporla
Ra ' or
44 Floor/Threshold CFT
Ceiling/Closet ceiling
LICENSE# MA.Lic.#11783 -
SIGNATURE DATE--
"� �G
LEAD INSPECTION/ Page of L
LEAD PAINT p TESTING SURFACE ASSESSMENT FORM•�
OF
• carp COD-
Addressof Inspection: Apt# City
ROOM
SIDE LOCATION LEAD L OWR DLR SRF SUR/ SUBST INITIAL X-CUT COMMENTS SUIT for DELEAD DELEA
SURFACE N E G P O S ABT? PREP? SUBSUR COND TAPE TEST ENCAP? DATE METHC
Up walls/Low walls
Baseboards/Chair rail A--
Door
Door casing/Jamb!/
Door
.Door casing/Jamb
Door
D r casingtJamb r '
Door \
casing/Jamb
Window sill
Win pisinn\yApron
/ Win header/Stops
Win-sesh/MlulGons 0/
Exl silVPad bead
Ext side sash
Window sill'
Win casing/Apron V ,
Win header/Stops /
Win sash/Mullions /
EXt.silt/Ped bead /
Exl side sash
Window sill
Win casing/Apron
Win h der/Slops
Win ash/Mullions
xl sill/Parl bead
Exl side sash
Window sill
Win casing/Apron
Win der/Slops
W' sashlMullions
Exl sill/Pad bead +
Ext side sash
Closet walls
CI interior door
J Cl casing/Jambi/
CI baseboards/Floor .f
Cl shell/Supports
Re or
KFloor/Threshold
g/Closet ceiling .
LICENSE MA,LiC.#11783
SIGNATURE DATE '�:
LEAD INSPECTION/ Pago of
LEAD PAINT TESTING SURFACE ASSESSMENT FORM
or
CAPE CODS •
Address of inspection: Apt# City
q
ROOM,J
SIDE LOCATION/ LEAD L OWR DLR SRF SUR/ SUBST INITIAL X-CUT COMMENTS SUIT for DELEAD DELEX
SURFACE N E P 0 S ABT? PREP? SUBSUR COND TAPE TEST ENCAP? DATE METH(
Up walls/Low walls
Baseboards/Chair rail jk_
14 Door •
Door casing/Jamb
D Door
Door casing/Jamb k/
Door
D r cas•ng/Jamb
Door
too(casing/Jamb
Window
Win prsin Pon
Win header/Slops gel'
Win sesh/Mullions ✓
Exl sill/Part bead
Exl side sash
Window sill
i '
Win casing/Apron
Win header/Stops —
Win sash/Mullions
Ext siINP_art bead !/
Ext side sash
Window sill
Win casing/ Pon
Win hea r/Slops
Win sWMullions
t silUPad bead
Ext side sash
Window sill
Win ing/Apron
Win eader/Slops
sash/Mullions
Ex l silUPad bead
Ext side sash '
Closel walls
Cl inlerior door.
DCl casing/Jamb
Cl baseboJrds/Ffoor
CI shelOSuppods
Re or
A74• Floor/Threshold IU
&L Ceiling/Closel ceiling
• LICENSE# MA,Lic.//I 1783 ;�—/ �j/.rug
SIGNATURE \ DATE Y_/vyyi,.
LEAD PAINT LEAD INSPECTION/ Page�of 2,
T13STING SURFACE ASSESSMENT FORM '
Bie.1_. O�
CAPE COD,- •
Address of Inspection: Apt# City
ROOM
SIDE LOCATION LEAD L OWR DLR.SRF SUR/ SUBST INITIAL X•CUT COMMENTS SUIT for DELEAD DELV
SURFACE N E G P 0 S ABT? PREP? SUBSUR COND TAPE TEST ENCAP? DATE METH(
f;Q Up walls/Low walls
Baseboards/Chair rail
Door � .
Door casing/Jamb ✓
Door .�
Door sing/Jamb
Door
De6i casing/Jamb
Door
Door casing/Jamb �.
Window sill
Win prsinpApron
Win header/Slops
C./ Win sesh/Mullions
Exl silVPaa bead
Ext side sash
Window sill
Win casing/Apron
Win hes r/Slops
Win sh/Mullions
xt sill/Parl bead
Ex(side sash
Window sill
Win casing/Apron
Win eader/Slops
n sash/Mullions
Ext sill/Parl bead
Ext side sash
Window sill
Win sing/Apron
Wi eader/Slops
Win sash/Mullions
'Ext sill/Ped bead
Ext side sash
Closel walls
Cl interior door
GCl casing/Jambi/
CI baseboards/Floor
Cl shelf/Supporls
Radiator
1-4, Floor/Threshold atr
Ceiling/Closel ceiling
LICENSE#' MA;Lic.#11783 q/
SIGNATURE DATE y /Y
s:
f
LEAD PAINT LEAD INSPECTION/ Patio•�'• of-f
B 0 1.1 �/ TESTING SURFACE ASSESSMENT FORM
Oil
CAI I3 CQ.D � s
Address of Inspection: Apt 0 �Cily
KITCHEN ....�.... ,,,�.,_,
SIDE LOCATION/ LEAD L OWR DLR SRF SUR/ SUBST INITIAL X-CUT COMMENTS SUIT for OELEAD DELEAD
SURFACE N E G.P 0 S ABT? PREP? S_UBSUR COND TAPE TEST ENCAP? DATE METHOD
t:L Up walls/Low walls
6G Baseboards/Chair rail j
^ Door d _
(J Door casing/Jamb s- _
Door
Doo casing/Jamb
Door
oor casing/Jamb
Door
D6or casing/Jamb
Window sill _
Win casing/Apron
/ Win hooder/Slops v '
l.• Win sash/Mullions ;
Exl silliPad bead
Exl sido sash
Window sill
Win casing/Apron
Win heost1slops
Win sh/Mullions
Exl sNVPad bead
Ext side sash
Window sill y.
Win casing/Apron
Win sder/Slops
W' sashlMullions • ••
Exl sill/Part bead
Ext side sash
Up cab hame/Door
LL Up cabinals walls d
. Up cab shhrs/Supp
Low cab hame/Door •� ,
/BI Low cabinols walls Al"
Low cab shivs/Supp ,.-
Closol walls
Cl lnlerio r
t 01
CI ' g/Jamb
CI shell/Supporis
-18holvqe
_.._Ra alor
Ploor/rhroshold
�.�. ColllnyClosol coiling
EPA I
SIGNATURE LICENSE MA,L10.11 I.1783
DATE
Y y�� LEAD INSPECTION/
LJJ 'PAINT
Suttr'AC •ASSrSSMENT r01'tM
aD r1aS rxrrc
oil
. _ CAP13 COM
Addreae of Inapedon; Apl# City
BATHROOM'S. G Z.
SIDE LOCATION/ LEND L OWR DLR SRF SUR/ SUBST INITIAL X-CU COMMENTS SUIT,for DELfAD DELEA(
SURFACE N E,C P O S ABT? PREP? SUBSUR COND TAPE TEST i
LC- Up walls/Low wells �/ �. GNUAP? DATE METRO(
...--...
LL Baseboards/Cheirfall f
Door' \ y'
Door. -----
D r casing/Jamb _._.._
Window sill
Win'casing/Apron
Win hoader/Slops
Win sesh/Mullions ,�-
ExI ellMarl bead
EXI 81de sash rr
Window slg 1
Win casing/Apron
Win h r/Stops —
W6i eosl✓Mulllone _ .•..,_.,, -,,,,�,+
Exl 911V O bond
[xl aidu snub --
Up cob from r "'--~
U binols walls ��
Up cob shlys/Supp
Low cab frornolum
�LL[—Lowcabinolswalls !/"
Low cab shlvs/supp `• A'
010801 wells
01 Inlerly door ,
CI ca g/Jamb �---•�
Cl baseboards/Floor
CI sholusupporis
3heb ---�---
Dra ers r ----
Radolor
Flm/Threshold `Y
L. Cellfng/CIo8e1 coiling
slc�wiruRl •
LICENSE H MA,Lics 11783 G/
DATE
Ta13AD 1?AiIVT LEAD INSPECTION/ PAge_�•ol.
�r a'•T;;'!'IN T SURFACE ASSESSMENT FORM
GV
OF
CAPE CODS
Address of Inspecllon: r Apt 0 city
HALLWAY `
SIDE LOCATION/ LEAD L OWR DLR SRF SUR/ SUDST INITIAL X•CUT COMMENTS SUIT for DELEA DELEA
SURFACE N E G P O S AST, PREP? SUBSUR COND TAPE TEST ENCAP? DATE METHC
Up wells/Low wells
B G Basebowds/Chnir fall
Door
Door casing/Jamb
Door _
0 r casing/Jamb
Door `
0061,casing/Jamb
Door
oor casing,Iamb
Door
Door casing/Jamb
Door
Door casing/Jamb
Window sill
Win casng/Apron
Will I adodslops
W' 8ash/Mullions
Exl sIIVPod boad
Exl side sash
Window sill
Win c eing/Apron
Win ader/Slops
W' sash/Mullions
Exl silVPad bead
Exl side sash
Window sill
Win casing/Apron
Win eader/Stops
Wi sasldMullions
xl silVParl bond _
Exl side sash j
Closel walls
Cl Inlerior door
41—L Cl casing/Jamb
Cl baseboards/Floor
CI sheJUSupporls,
Closol wady .
CI Inilyfolt door
.CI Ing/Jamb
01 ba rde/Floor -•
01 aholUBupporla
R)delcr
u,IF100riThreshold. _
Cellinp�Closel ceiling• • . —"—'
SIGNATURE LICENSED MA,I.Ic.// 11783 . bATE —/
/3 LEAD PAIN'1'" LEAD INSPECTION/ Page`�of
P TESTING SURFACE ASSESSMENT FORM
Mac
1.1 conD
.. carB .
#
Address of Inspection: t City - ,
EXTERIOR
SIDE LOCATION/ LEAD L OWR DLR SRF COMMENTS DELEAD DELEAD
SURFACE ABT? PREP? DATE METHOD
Siding
)L Comer6oards !�
Lower trim
A L Upper trim I N
Door /
IF Door casing/Jamb .�
'( Threshold
Door
n / Door casing/Jamb
•! Threshold d
Door
D casing/Jamb
Threshold _.
Door -_
Door casing/Jamb
Threshold
Window sill S ✓
Window casing
Winsash/Mullions y'
Window sill 2.
J� Window casing
Y' Win sash/Mullions ✓
Window sill vi
Window casing
Win sashlM ullions�—
Window sill _
Window casing
Win sash/Mullions
Cellar nits
Cellar win units
Cellar Wi sits
Cel win units
4c. Foundation !/ _
G Bulkhead
Fe s
LICENSE p MA,Lic.#11783 - DATE
SIGNATURE .
DATE:_ 9/20/,.95_
PROPERTY ADDRESS:_47 Grouse Lane
_ West Hyanniport
Mass . 02672
x
On the above date, I inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 galon tank.
2 . 1 -61x8l block cesspool.
3 . 1 -1000 gallon leaching pit;packed in stone .
Based on my Ins.nection, I certify the following conditions:
1 . This is a..title five septic System. .j, 78 cede )
2 . Thb.'Septic systeri is in proper working order
at the present time . )
3 . ' The. septic ,tan); must be puipedj. _
4, . Cover on the c•ess pool must Ue raised.
30" below grade .
SIGNATURE:
Name:_J. P.M'acomber Jr..
Company:_J. P_Macomber- & Son-_Inc -t
dd
Address:_-$e -fib-
Centervill,e LMass__02632 � S"
lv c5'
Phone:---548
sz
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
kvW14,
JOSEPN .P. .MA
COMBER & SON,. INC.
Tanks-Cesspools-Leschileld:
Pumped & 'Installed
Town Sewer Connectlons
P.Q. Box 66 ' Centerville, MA 02632-0066
775-3338 775-6412
Commonwealth of Massachusetts
.i, Nil
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
Govemor
Trudy Coxe a
Secretory,EOEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 47 Grouse Lane W. Hyannisport Address of Owner:
Date of InsAction: 9/20/95 (If different)
Name of Inspector: Joseph P. Macomber Jr.
Company Name, Address and Telephone Number:
Box 66 Centerville ,Mass . 02632 508-775-3338
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 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
Inspector's Signature: Date: 9/20/95
The System Inspector shall 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 repon 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:
X=I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15,303.
Any failure criteria not evaluated are indicated below.
6] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
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, 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 8/15/95)
One Winter Street 0 Boston, Massachusetts 02108 0 FAX(617)556-1049 9 Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Grouse Lane W. Hyannisport Mass .
Owner: Mrs . William Ogden
Date of Inspection: 9/2 0/9 5
B] SYSTEM CONDITIONALLY PASSES (continued)
N Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
N The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection 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:
N 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
N The system nas a septic tdnk anu suii absorption systen-, and is within 100 fee, to a surface %rater supply or; bu;ary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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 than 5
ppm.
D] SYSTEM FAILS:
N 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.
N-- Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
j Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
11 Dq'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 47 Grouse Lane W. Hyannisport,Mass . 02672
Owner: Mrs . William Ogden
Date of Inspection 9/20/95
D] SYSTEM FAILS (continued):
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 1/2 day flow.
4z Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped 'jQ�-�
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
4 Any portion of a cesspool or privy is within 100 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.
A� Any portion of a cesspool or privy is within 50 feet of a private water supply well.
f 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.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flov., of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more.of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner 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 8/15/95) 3
60
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 47 Grouse Lane W. Hyanni�sport,Mass . 02672
Owner: Mrs . William Ogden
Date of Inspection: 9/2 0/9 5
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
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.
iThe system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
_/All system components, Wluding the Soil Absorption System, have been located on the site.
ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank 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 existing information or
approximated by non-intrusive methods.
The facility ov.ne; land occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
Recommendations
1 . Septic must be pumped.
2. Cesspool cover must be raised. 3011 below grade .
(revised 8/15/95) 4
�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 47 grouse Lane West Hyanni sport,Ma.ss . 02672
Owner: Mrs . William Ogden,
Dateof Inspection: 9/2 0/9 5
FLOW CONDITIONS
RESIDENTIAL: °
Design flow:,210 allons °
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):
Laundry connected to system (yes or no):F
Seasonal use (yes or no):f
Water eter rea 'ngs if available• .� tJ� j o0 7 '.
Last date of occupancy:9,(417f
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 system: (yes or no)_
Water meter readings if availa le: AA
T w l✓
Last ate of ccupanc :
OTHER: (Describe)
Last date of occupancy: N
GENERAL INFORMATION
PUMPING RECOR S and source f inform tiion: ) / g,
It% J.JvAj% i►h-
System pumped as pan of inspection: (yes or no)
If yes, volume pumped. —gallons ^ ,
Reason for pumping: S VAQ 190M � t'& t o 7r4'Vk.
TYPE O SYSTEM
Septic tank *gt.Filiui:eA box soil absorption_system
Single cesspool
_ Overflow cesspool
Zsadr—
AAL Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
A PROXIMATE AGE of all components, date installed (if known) and source.of'information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) $
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 47 Grouse Lane West Hyannisport,Mass . 02672
Owner: Mrs . William Ogden
Date of Inspection: 9/2 0/9 5
SEPTIC TANK: '/Odd 9,4IkN 74AX. ••
(locate on site plan)
Depth below grade: I/l�
Material of construction: ✓concrete _metal _FRP_other(explain)
Dimensions: ' '3'q `
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: ))f. '(
Scum thickness: f,
_
Distance from top of scum to top of outlet tee or baffle: /
Distance from bottom of scum to bottom of outlet tee or barfie
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liqu' lev I in relation_to outlet invert, structural
in egrit , idenc of I aka�e, eta I 1
GREASE TRAP:
(locate on site p an)
Depth below, grade:
Material of construction:�Aoncrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffler
Distance from bottom n( Slum in bottom or outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integr t , evidence of leakage, etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Grouse Lane West Hyannisport,Mass . 02672
Owner: Mrs . William Ogden
Date of Inspection: 9/2 0/9 5
TIGHT OR HOLDING TANK:k •
(locate on site plan) '
Depth below grade:
Material of construction:Ooncrete_metal _FRP—other(explain)
Dimensions:
Capacity: allons
Design flow: allons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:00
(locate on site plan)
Depth of liquid level above outlet invert: {
Comments:
(note if level and distributiur. i; equal, e\idence of solids carryover, evidence of leakage into or out of box, etc.)
40.__lll`ae/E.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)o
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ropertyAddress: 47 Grouse Lane West Hyanni sport,Mass . 02672
Owner: Mrs . William Ogden
Date of Inspection: 9/20/95
OIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may tFe approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:L
leaching chambers, number:n
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions: {'
overflow cesspool, number:
Comments: (note con ition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)
$ r , IlKie-Zi-,1171
,.
CESSPOOLS:
(locate on site plan)
Number and configuration: "Gb �� r c
Depth-top of liquid to inlet invert:
Depth of solids layer: 0—ri 460
Depth of scum layer:
Dimensions of cesspool:
Materials of construction: ' f
Indication of groundwater: j,/Ad& /1
inflow (cesspool ust be umped s part of inspection) " 009)Q aeul
Cgmmen s: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
l0,V L a AN C- i
PRIVY:
(locate on site plan)
Materials of constru i n: /�i0/ Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 8/15/95) B
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 47 Grouse Lane West Hyannisport,Mass .
Owner: Mrs . William Ogden
Date of Inspection: 9/2 0/9 5
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
i
�"9
0 1
09o7
i
i
i
i
DEPTH TO GROUND TER '
Depth to groundwater: feet
me f determ' ati n or approxpa' n:
(revised 8/is/9s) 9
..*.S.�TM.-r..r__�z__-_;_s-.�r..t-�.r.::•r.-:ter..-rt�-:-r.--- ••
'I.OWN OF Barnstable BOARD OF HEALTH
311II31/RFACE SFWAGE DISPOSAL SYSTEM. INSPECTION FORM - PART D •- CERTIFICATION
F...�....r.•.-::T--::a-.--tr..-:•r.:r.:----rc..•--:••r.T-•t--u--r,-..... -r--.-r.Rr r_x-'rrsrerre-r•r•a•--
••• .—.srrsrs-=TrZT�T:rsr.'*rcr�vrs—rrr�rf•rt-,.�rrr•r.•�.._..�
-TYPE OR PRINT CI.EARL1•-
PROPERTY INSPECTED
STREET ADDRESS /_7 GrnugP TanP WPGt Nvanni 's
ASSESSORS MAP, BLOCK AND PARCEL #
e
OWNER' s NAME Mrs - Wi l 1 i'a m ng-d en .
PART' D - CERTIFICATION -r
NAME OF INSPECTOR Joseph P.Maconber Jr.
COMPANY NAME J.P.Macomber & Son Inc.
COMPANY ADUESS Box 66 :Centerville,Mass . 02632
Street Town or City
COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( stag =!p
508 1 790 157f
CERTIFICATION STATEMENT —4
I certify that I have personally inspected the sewage disposaj system at
this address and that the information reported is true , accurate, and
complete as of the time of :inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
XXXXXSystem PASSED
The inspection which I have conducted has not found any information
which indicates that thetsystem fails to adequately protect public
health or the environment as defined in 310 CMR 15 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection which. I have conducted has found that the system fa
ils
protect the public health and the environment in accordance with Titleto
5 , 3.10 CMR 15 . 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signature Date 9/21 /95
One copy of this certification must be Provided - to the OWNER, the BUYER
( where applicable ) and the BOARD OF H EAL711.
* If the inspection FAILED, the owner or•" 'P' erator shall u
within one year of the date of the inspection, unless allowedd or t required
otherwise as provided in 310 ctIR 15 . 305 .
partd.doe
Cr..m n� inn nr --z C7, se
:����� Ci �NeG � .,� i�a Cam, .., c;iS
EXecLgrve Office cr -nvl(Cr',mentC: A"*' .:,5
Demartment of
Environmental Protection
WarTer Pollution Ccnrrol Tecnnccl Psswcnce ana Training SecTnons
Wlulam F.Wed
Go�
Trudy Coz•
Soov—l.ECEA
Thomas & Powws s
Nary Conv.r.norrr
i
06/12/95
ATTN: Joseph P. Macomber, Jr.
Joseph Macomber and Soli
PO Box 66
Centerville, MA 0263'-
Dear Joseph P. Macomber, Jr . ,
I am pleased to inform .you that you have attended training, met
the experience qualifications, and have passed the Title 5 System
Inspector exam, pursuant to 310 ,6MR. 15. 340 . The passing grade for
the. exam was 39/52 or 75% .
This is an official notification that you are a Certified Department .
of Environmental Protection System Inspector pursuant to 310 CMR 15 . 340 .
You will receive a System Inspector certificate at a later date.
If you have any futher questions, please write to me at the following
address :
Kimball Simpson
D.E. P. Training Center
. Route 20
14illbury, MA 01527
Thank you very much: -IFo: time and consideration in this matter.
rr
Sincerely,
Kimball T. Smpson,
DEP Training er Director
(2905)
Roues "0 • Millbury, MA • FAX ;Ca-755.9257 • ,n• 50&756-7:01
i
Water - ---.,�
conservation
SAVE Tips . . .
ME!
CHECK FOR LEAKS
Water Loss in Gallons Due to Leaks
Leak
this Loss Per Day . Loss Per Month
Size
120 3,600
360 10,800
° 693 20,790
• 1,200 36,000
11',920 57,600
0 3,096 92,880
® 4,296 128,980
® 6640 199,200.
6,984 200,520
8,424
252,720
9,888
29Alk 6,640
11,324 339,720
12,720 381,600
14,952 448,560
I
TOWN OF ARNSTABLE
LOCATION SEWAGE #
VILLAGE w ` ASSESSOR'S MAP OT
,INSTALLER'S NAME & PHONE NO. a ,
SEPTIC TANK CAPACITY /..
LEACHING FACILITY:(type) (size)
NO."OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
�-r
VARIANCE GRANTED: Yes No
v
h
_ `�
r
�i
__ ��
�� �
� ,
�/ - �,�
��
- �
d
a� ',
.. � - �
� �
� .
., .�-
I
.t
- -
No._� . ��,-
..--•---....... '
THE COMMONWEALTH OF MASSACHUSETTS
_ EOAR®AF HEA T
Du/�1 0F.....--:.
App irFatilan for Disposal Works Tonstrurtiun jkrmit
Application is hereby made for a Permit to Construct ( ) or Repair (4''an Individual Sewage Disposal
System at
..J,g
....Locat: Addr s or Lot No.
Ad-.dress.
---
Installer Address
Type of Building- Size Lot----------------------------Sq. feet
Dwelling- o. of Bedrooms_________________'___________-_.____----_.__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ..........................................
14
W Design Flow............................................ per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity------------gallons Length................ Width--_----------- Diameter---------------- Depth................
Disposal Trench—No_ ____________________ Width......._............ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area---_..............sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by...........................
---------------------------------------
------• Date........................................
aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water---------------_----
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...........................................•....... -
O Description of Soil......... -•---•---------------------------
V ---------------
•-------------------------•--•--------------
--•----------------------------------------------------------------
----------- -------
w •-•-••-•------------ ........................................................................................•---- ------- ••... - •-
UNature of Repairs or Alterations—Answer when applicable----- .-. ----.�l�. ' ► !!
---------------------------•-----------------------------------------.._._....-------------------------------•---------------------------.........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i T lE ;of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued blye,,the, Vrof health
py
Signed _.. . - !' � ��
e Application Approved B
Date
Application Disapproved for the following a sons:--•------------•-----------••--•------------•----------•-------•----------------•-------------------------------
..•--••---•••-••---•-•....--•-••----------••-•-•----••-•-----------•••-•--•--••--•-----•----•--••-----...---•-•---•--••--•-•-----•--------•-••-•-•••••-•••••••••-•••----•••----•----•••......•----------
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEA.LT
............ f' .......... .. J:.'1, .................
Appliration for Disposal Works Tonstrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) -or Repair (/,) an Individual Sewage Disposal
System at
.........:.... ........ ... , 's `�°r -----•---•---•-•----•--------...•..............•......---•---•-------•-----------•
f Locatjon'-Address or Lot No.
�w�ier Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling-A no. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
G I Other fixtures ---------------------------••••. -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) ` Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
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 Pit.................... Depth to ground water........................
..y.
Description of Soil--------? o r ....---•---•-------------?..
......... -•-- ---------
U -------------------•-•---...--......................................
-•------•-•-----------------•--•----------..._......._.........---- ------ f ----------•-------------------------
U Nature of Repairs or Alterations—Answer when applicable..... - ,max
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of 1_' t.. '
p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
Signed
Application Approved By-•----- : ............... ----------•----
b
Date
Application Disapproved for the following a sons------------------•--------------•----------------•-----------------------------------------------------•-•••..
-----------------•••......•••--•----•---------.........----------..........------•-•-•-•••-•---•-----•-•-•----•---------------------••-----•---------------•••--••--•••----•••-------••••••••----•---••-
Date
PermitNo.........................-............................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH �, r
! '� .....g f . 'f t
........ . .........O F.. ..................... .............................................
�rr�ifirtt#�e ,af f�unt�rli�nre
TH,!S_IS TO CERTIFY, That the In4i-vidual Sewage Disposal System constructed ( ) or Repaired
by . .� r .a� a 'y '` f -••---...... --- ••--- -•---•--------------•--.....:...----•-•----------...--------_..._
r Installer f ' 1
at - --'---------- --•• ------------------------•--------------------•----------•----•------•-------------
has been installed in accordance with the provisions of fi1,fl
'i of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.. ----..,65.__....._.. dated-------I_7_.--4. --- "--�)(�.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------..).. .��� ...................................... Inspector-•----. ----•-•--......._.....------------------------•-------...-----.............
,A THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF..... ?', ' '.!.' 1 .. . `��....................
........... . .:..
BilIV11,94-t r s on*urtion troth
,Permission is hereby granted........:f=-._ !...... .�t.�:z e 61 r:..................
to Construct/�*- ) or pair ( � n Individual Sewage Diss s Syy t to ,',
at No..... •- ?s -----. lrfi .�� ..... .. - :r', <i� f
Street
as shown on the application for Disposal Works Construction Aermit NS6_=r.? I?ated..L'L_.q_:7:::&..............
l� " r j Board of Health
` �.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS