HomeMy WebLinkAbout0069 LONGWOOD AVENUE - Health 69 LONGWOOD AVENUE, HYANNIS
A= 287 042
COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
3 DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE HINTER STREET. BOSTON. MA 02108 617-292-5500
sy°y
WILLIAM F.WELD TRUDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Steve Lawson
Property Address: '69 Longwood Ave, . Hyanni sport Address of Owner:
Date of Inspection: oz oa ? (If different) 218 Willow St
Name of Inspector: Wm E Robinson Sr W Barnstable MA 02668
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Service
Mailing Address: PO Box 1 089 . Cent ervi 1 1 a., RSA 02632
Telephone Number:;, _5 0 8 7 7 9-R 7 7�
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 train n experience- oper function and
maintenance of on-site sewage disposal systems. The system: O !
p�
Passes l/
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails �-
Inspector's Signature: Gv `1 Date: 0
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 report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check-A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
�ZMENTS:
B SYSTEM 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.
Indilate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:llwww.magnet.state.ma.us/dep
�'j Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: —p.��¢j
B] SYSTEM CONDITIONALLY PASSES (continued)
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). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
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] FU THEIR EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
L
(revised 04/25/97) Page 2 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: :Z. .c}
D] SYSTEM FAILS:
You must indicate ei;!,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy, is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You Ast indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (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:
Yes No
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
Ithe 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 04/25/97) Page 3 of 10
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PAR7i B
CHECKLIST
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: ;_
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and 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. Mote if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
The 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:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 69 Longwood' Ave, Hy.annisport
Owner: Lawson
Date of Inspection: X—A?_ g
FLOW CONDITIONS
RESIDENTIAL: a'" — $50
Design flow: 40400 g.p.d./bedroom for S.A.S.
Number of bedrooms:.3—'1
Number of current residents: 0
Garbage grinder (yes or no):_o
Laundry connected to system (yes or no)�-5
Seasonal use (yes or no):�
Water meter readings, if available (last two (2) year usage (gpd): metered in 1 996
Sump Pump (yes orno):/`O 10/9/96 - 10/10/97 78, 750 gals
10/10/97 - 1 /12/98 0
Last date of occupancy:
COMMERCIAUI N D U STRIAL:
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 available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)ILD
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
(/Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: rt 'S i3 6
e
Sewage odors detected when arriving at the site: (yes or no)A0
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: -7 —Q
B LDING SEWER:
(Loc e on site plan)
Depth below grade:
Mater al of construction: _cast iron _40 PVC_other (explain)
Dist?nce from private water supply well or suction line
Dia eter
Co m ents: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on ,site plan)
�y
Depth below grader
Material of construction: 1/concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
/y
Dimensions: l a ) O T
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:15- _
Scum thickness: `3—41 ' ,.
Distance from top of scum to top of outlet tee or baffle:—
Distance from bottom of scum to bottom of outlet tee or baffle: ]L
How dimensions were determined: 6 Joe - Td X-�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of li id level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) J Ys i
GREA E TRAP:
(locate on site plan)
Depth elow grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimen ions:
Scum ickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date4 f last pumping:
Comm nts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri , evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: '1—9 7
TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(looat on site plan)
Depth low grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensi r
Capacity. gallons
Design low: gallons/day
Alarm e el: Alarm in working order _ Yes; _ No
Date of pr vious pumping:
Comment :
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
f�
PUMI CHAMBER:_
(local on site plan)
Pumn-s in working order: (Yes or No)
Ala r s in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Iv�
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Lawson Ave, Hyannisport
Owner: Lawson
Date of Inspection: -^o�-rl^°' /
SOIL ABSORPTION SYSTEM (SAS): Y
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
�p r
2. d 6 Cr0 a, / �n ' G'&1 ) S 76
J FL, )` aowa is cIZV;YL Can c L%/ �6 •+ a1 /1 T 1 /Vr S � a✓1�_
CES OOLS: _
(locate on site plan)
Number nd configuration:
Depth-to of liquid to inlet invert:
Depth of olids layer:
Depth of s um layer:
Dimension of cesspool:
Materials f construction:
Indication f groundwater:
i f:ow (cesspool must be pumped as part of inspection)
Comm nts:
(note c dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on ite plan)
Materials f construction: Dimensions:
Depth of, lids-
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page a of 10
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: s, -2?-95-
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
� elf
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(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 69 Longwood Ave, Hyannisport
Owner: Lawson
Date of Inspection: 9—(i8
4
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
/
�/ Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
L/Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
6 V IC rlA 177��S
(revised 04/25/97) Page 10 of 10
ll , , i t i E F P E R Ir i T NO. s3
a ►.. A PAP NO:
PARCEL NO.:
't III STA LLER'S rl AIME S A b D R E 5 S
s
s
S
� � � � ii
II
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ASSESSORS MAP NO:
AROE!_ NO
No.-_6�?_�_�.-�. S — - FR$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH ,
..W � .. OF..... i"` - \ Ib� '�........................
Alipfiratiou fo,r`-Uhgp t ial Vorkg Tonstrurtion ramit
`Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System t -
- w oA-a.,�... .fir ---------------- ...._---••----•--••..........------•-••--
'�/� Location-Address or Lot No.
Owner ��77 Address
n_...-:!,7�L � ....�. ......•---••••---------------------•-------•........._....••••••.....-•----...................•••.
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms......... ................................Expansion Attic ( ) Garbage Grinder ( }
`a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' ter fixtures .........
W
Design Flow.. .................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity`�0o.gallons Length................ Width................ Diameter---------------- Depth___-______---__-
x Disposal Trench—'No. .................... Width.................... Total Length........... Total leaching area.......________.....sq. ft.
Seepage Pit NO----I-__..________ Diameter...�d_�.:;_____. Depth below inlet......4............ 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------..................
;%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --------------•--•----------------------------------.......---------................----------.........................................................0 Description of Soil...............................................................................................-..........................-....................------..................
F
x
U Nature of Repair Tr Alterations—A saver w a plicable._..__. t�_t� . ............�__ Q.. ..._ -.�_..____..
----------------------------------------------------------
I `
Agreement: r T
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iTT.-." 5 of the State Sanitary Code—The undersigned 'urther agrees not to place the system in
operation until a Certificate of Compliance has b n i ued by th b r/of alth. _Signed_ V%r ."' _ ............. 5...............
ApplicationApproved By••••••••...... ............ ......... .......................................... --...---- 5
Date
Application Disapproved for the following r asons:----•---------•---••------•-----------•-----•--•-•--•-----••----•--••--...••••-•-------------•-•----------.••.
•----------------------------•---•-------••------------------......--------------........-----------...---••--•••----••--•••••--••-•--•-•••--••-••----------------•------••-••-•----------••------------
Date
Permit No. `.. ........................... Issued..
--------------------------•--•-
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
s ,G
Appliratinn for Uhip sal Works Tunstrurttnn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System t:
sy'UCZ' ------------------ ---- - ---•--------------------...----------- -
Location-Address or Lot No.
W Y' tom! off^..............
............................... -•----••-•---------------------------•---......-----•---------•--•----•-•-•-----•--------•-----•--
COwner Address
Y!114ms... `.h�� r ....................................................
Installer Address
UType of Building Size Lot............................Sq. feet
I—I Dwelling—No. of Bedrooms.......6................................Expansion Attic ( ) Garbage Grinder ( }
a
4 a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
herfixtures ---...........................................---•----------•-•-•-•--...--•---•-----------------•-•-••••-----•-•-----------••-•-••••.............••-
W
Design Flow_. V..............................•__gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid ca acity -0___gallons Length..
-------------- Width................ Diameter---------------- Depth................
Disposal Trench—No..................... Width...._.........._._._ Total Length----------......... Total leaching area....................sq. ft.
See Pit No.. -------------� Seepage p g Diameter__�Q............. 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-----------------_-----
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P+' .....................................•-•-•-••-•...............................•-------•--•--.-•---------•-•---•----•--------•-•-•••••-•....--•--••----...---
0 Description of Soil........................................................................................................................................................................
x
U -----------------------------•-•••••-•••-•••----••-•---•-••-•---•-----------•-•-•••------------•-•-------•-•--••-•-----•----•------••--••--...•----••-•••-•••--•-••--•-••••-......---••-----•----------
w
txj Nature of Repairs rr Alteration —Answer wV
pplicable__....(,1�A �__ .....•...5�/�_ fi Ls�:-t------•----.
J _QLi4 ------------
�
o. A� Q� ��
Agreement.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iTI 5 of the State Sanitary Code—The undersigned -urther agrees not to place the system in
operation until a Certificate of Compliance has b n . sued by th and o^ ealth. _
Signedj ��....... --------------------
Date
Application Approved By .....-----I'sons:
.. - .. -�/--�'------ g�
Date
Application Disapproved for the following ..............................................7------------------------------------------------------------------
•-•••••....-•-•-••--------------•-----••-:-----------•-•--••--------------••-•-•---------......----------•--•-------•---•-•-••-•-......--------•---••-------•-•---•••••---•••--•••--- ---•------------
Date
Permit No...... ....7--- Issued.....................................................-
Date
THE COMMONWEALTH OF MASSACHUSETTS
AA BOARD OF HEALTH
.(4..................OF..g -:e...............C'g --•••..................•••--
Trrfif irab of Toautpliatta
THIS IS'O CE9.T�+IF� That the lIndividual Sewage Disposal S.
aired stem constructed or Re
by............. � --•--•--•-------------•----•---------.................-•--....... ... g P �' ( ) P )
j� Install
at........VA......t,t av(, lJU� .....................
•-• `-4��...I-------------- ---- � � SPd
has been installed in accordance with the provisions of Ti` ' - of The State Sanitary Cod as �escribed in the
application for Disposal Works Construction Permit No.._. �"�`� �-5
---•- ----------. dated---� -----•-----�------•-----------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GU RANTEE THAT YHE
SYSTEM_iff Lij. PUNCTION SATISFACTORY.
DATE............ (4...................................... Inspector---------
)..kn,.------•--••------------•---•••••••---••--......-•----------------
l.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
• (�" �IJ� .............0F......... 5....1.'.�1.. ..��-..... 2 �,
FEE........................
Disposal Workii T.po�nstrwtion autit
Permission is hereby granted..........50.1-;.......=51__ :K- ��.�. � -
to Construct ( ) or Repair f<) an Individual Sewage D' posal System
L -'- -��-D - --•--•--�-�-1'--•-•-•-----....... C�Y1._11_!.S
1 Street i�
as shown on the application for Disposal Works Construction Permit No............... .... Dated..........................................
DATE---� -�•--=-- ..................................
--.......... Board of Health
FORM 125 HOBBS & WARREN. INC.. PUBLISHERS