HomeMy WebLinkAbout0100 LONGWOOD AVENUE - Health 100 Longwood'AVeuue
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:_I00 Longwood Ave.
_Hyannisport
Owner's Name: Paul&Carter Catalano
Owner's Address: 100 Longwood Ave.
Date of Inspection:_12/13/08 �7 5ZIA
Name of Inspector:(please print)-,Eric D.Stevens
Company Name:_E.Stevens Construction,Inc.
Mailing Address:_P.O.Boz 71 Marstons Mills,Ma.02648
Telephone Number:_(508)776-9054 .
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection.The inspection was
performed based on my training and experience in the proper function and maintenance of on site sewage
disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 12. I S-d a
The system' spector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DE )within 30 days of completing this inspection.If the system is a shared system or has a
des�igp flow o 10,000 gpd or greater,the inspector and the system owner shall submit the report to the
app gpriate re ional office of the DEP.The original should be sent to the system owner and copies sent to
the buyer,if a pI' able,and the approving authority.
Notes and Comments System is in good working order and passes title V inspection.
C'n i °
***T6is report only describes conditions at the time of inspection and under the conditions of use at
4 that time.This inspection does not address how the system will perform in the future under the same
or different conditions of use.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
)2)100
Property Address:_100 Longwood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X_ I have not found any information which indicates that any of the failure criteria described in 310
CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: System is sound and in good working oreder.Tank was very full at time of
inspection,recommend pumping now and every 2 yrs.there after.
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.
Answer yes,no or not determined(Y,N,ND)in them for the following statements.If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:ain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_100 Longw000d Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
C. Further 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 public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)
that the system is not functioning in a manner which will protect public health,safety and the
environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet
of a surface water supply or tributary to a surface water supply.
— The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more
from a private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to
this form.
3. Other:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_100 Longwood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_x Backup of sewage into facility,or system component due to overloaded or clogged SAS or
cesspool
_x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
_x_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
x Liquid depth in cesspool is less than 6"below invert or available volume is less than''/2 day
flow
_x_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe
(s).Number of times pumped
_x Any portion of the SAS,cesspool or privy is below high ground water elevation.
x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_x_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. [This system passes if the well
water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd..
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
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
If you have answered"yes"to any question in Section E the system is considered a significant
threat,or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the system in
accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the
Department.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT_ S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_100 Longwood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x _ Pumping information was provided by the owner,occupant,or Board of Health
_x_ Were any of the system components pumped out in the previous two weeks?
x _ Has the system received normal"flows in the previous two week period?
_x_ Have large volumes of water been introduced to the system recently or as part of this inspection
_ x— Were as built plans of the system obtained and examined?(If they were not available note as
N/A)—
x _ Was the facility or dwelling inspected for signs of sewage back up?
x _ Was the site inspected for signs of break out?
x — Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and
depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on
the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined
based on:
Yes no
x Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation
of distance is unacceptable)[310 CNM 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_100 Longwood Ave.
Owner:_Paul&carter Catalano
Date of Inspection:_12/13/08
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_ Number of bedrooms(actual):_4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):_440
Number of current residents:_4
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no):_no [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):_no
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): no_
Last date of occupancy:_present
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): and
Basis of design flow(seats/persons/sgketc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Homeowner
Was system pumped as part of the inspection(yes or no): no_
If yes,volume pumped:_,gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
—ivy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to
be obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:_System was
installed in 1978.
Were sewage odors detected when arriving at the site(yes or no):_no_
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_100 Long wood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
BUILDING SEWER(locate on site plan)
Depth below grade: 30"
Materials of construct_ion:_cast iron _X_40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: X (locate on site plan)
Depth below grade:_12"
Material of construction: x concrete metal - fiberglass_polyethylene—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Dimensions:_1500 gal.
Sludge depth 24"
Distance from top of sludge to bottom of outlet tee or baffle: 20"
Scum thickness:_2"
Distance from top of scum to top of outlet tee or baffle:_5"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.): Tank is very full.recommend pump
now and every 2 yrs.there after.
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass polyethylene_other(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_100 Longwood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:-off.
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.): D-box is sound and working
correctly
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_100 Longwood Ave.
4
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:"
Type
x leaching pits,number:_2_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.): Pits were in good shape at time of inspection. Staining to 5"in one pit,staining
non-exsistant in second pit.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
e
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_100 Longwood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks °
or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_100 Longwood Ave.
Owner:_Paul&Carter Catalano
Date of Inspection:_12/13/08
SITE EXAM
Slope x
Surface water x
Check cellar x
Shallow wells x
Estimated depth to ground water_>15 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X Obtained from system design plans on record-If checked,date of design plan reviewed:_1978
Observed site(abutting property/observation,hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
X Accessed USGS database-explain:_Internet
You must describe how you established the high ground water elevation: Soil log on_Install
plans dated 1978.USGS web-site.
1.
I.
TOWN OF BARNSTABLE
f LOCATION 100 L"jjcjj oX I�ae_. SEWAGE# y
VILLAGE ('I�n�; C ASSESSOR'S MAP&PARCEL o(/
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY.(type) !Pi (size) IOMgAl, (6)&(
NO.OF BEDROOMS
OWNER {PAuLT1A@Tgl_ C.ATPILA&30
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF F LEE TH
OF_;��................................
Appliratiou for UiinnsFal Works Tomitrurtinn Frrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System?at:
..... .`,� �2-• .....
..-•---•. ``". a .............................................................
•-
} � a................
on-Address or Lot No.
S
.... ..................................................................................................
e Address
Wda� .. ........ .. ....... .................. ......•---------------}-
y s
.1 AI aller Address
Type of Building ize. Lot______.....................Sq. feet
Dwelling No. of Bedrooms.______ �Ex ans>on Attic Garba e Grinder
Other—Type of Building No. of ersons__________________________ Showe s:, —
a YP g -----•---------------------- P . ( ) Cafeteria
Other tur ,_. )
d ------------ ---------------
W Design Flow -------
allon�per person per day.,,,Total daily flow_____ �� -gallons.
WSeptic Tank—Liquid capacity S gallons Length W>dth _____________ Diameter._____-- llepth
x Disposal Trench No ............ � `Width x� Total Length Total leaching area....................'sq ft.
Seepage Pit No .. ':_____. Dlameter ._._._.. x`q� Depth liel'ow inlet___t. . Total.leaching area_____ ________ sq ft;
z Other Distribution'box'
Dosing f' nk
Percolation Test Results Performed byi __ ......... Date*______________________________________
Test Pit No 1 minutes pei me Depth, of;_1`Test`Pit Dep to ground water________________________
44 Test Pit No 2_______________minute per in Depth of W§t Pit ____...____._____ Depth to gro�ind.water........................
� 4P
----- -------•-•-••--•---------------------
Description of SoiL_______ __________ ______'�l ___ .'• ` .:
x �• ---------------• -------- ---------------------•-----------------------
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W ________________ ________ .________________ ._ __.._.._..._.__._.__.______.___. __
UN tur epa teratioAn . r w a ica e _
rd
. . .. . ---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with ..
the provisions of TITI,, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in ;r+'
operation until a Certificate of Compliance has e'e issue . y the bo d th.
>g ------
1, ., Da
Application Approved By •. _ _:_ ��� w:_. f...
D
t • ate
Application Disapproved for the following reasons ;x___:
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.............................................................:: _.... ................... .............................................--.. ------ '' � .' ..
t �'s Date
' Permit No.... ._ i n aE .,1$$11CC1... .....__.. ` ° r. ..........
THE COMMONWEALTH OF MASSACHUSETTS
3 a µ
BOA OF HEALTH
1 ........................ ..............OF...... ......... ................_. ............. -_..... ........
Tritifiratr of ToutpH attre � j,,�.,�.
.w..,;
TIFY hat t individual Sewage Disposal System constructed ( ) Rep red ( )
xrby _:._._ •---•------•--------•---------------------•---••------- ua ...._
,,, tauer a
f !'
{ has been installed in accordance with the pra tsions of Tr „� o he State Sanitary C�.de a de��bed in the
application for DisposalQVVorks Construction Permit N __ ._______ .' __...__ dated- sJ._�. "°_. '_______________
THE ISSUANCE F TIflS""CERTIFICATE SHALL NOT BE CONST ¢!E® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. r � �''
j�ATE.-••••-•� -.. :. `° Inspector-------
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k THE COMMONWEALTH OF MASSACHUSETTS
"K;BOAR ®'F LTH
No........................_ FE
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Perm>Mission is hereby gran d_ :.
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to Constr ct ( ) or Re air Indivldu. e , e Die seal y
at No. - •---- i , .......
"a Q
as shown on the application for Disposal tit�orks Construction Pitt : __ __ __ Dated_._��.+�_"..7k' .
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7PBoard of Heal
DATE__ r . ,,. �-••----------- �!
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
No.-- •--- •-- -- A Flc .. ...............
-a D THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�C?�"�- �? .. OF..../ .. '.� -------------------_-•---
ApplirFation for 11ispos ai Works Tomitrurtion ramit
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Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System�t -
........ .: . ..---..... M. _ ........_ ..-----••................................
Location-Address or Lot No.
.... ..... ...................... .................................................................................................
Ow er Address
>.a 9 ........... •-•..........- ---------------------•---------
In 11er Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixture_______________
W Design Flow...............6..y...................:gallons per person per day. Total daily flow........ . ....................gallons.
Ix W Septic Tank Liquid capacity./.�_... a. 11ons 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........................
n+' ------......•. --- -----•---
0 Description of Soil Lge., --••-------------------------------------------------------------------------------------------
x
V ------•------------ ---------•---------.........._..-.------.•-.....---------------------•- -
-•----------- ---------------•----------•-----------------------=
W -----•-•-----------•----•-----------------------•--------------•----•-•--•--••--•------•-----------------•-•.
UNature Repai Aeration —Answer when ap cabe_ �!! / ---!__ - - . --------------
. .. ......... -- . � .....................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b6en 'ssued y the boaxd f h h.
Sign �----- ---• ���1''-`- --���-•--- ......................�
_ Date
Application Approved By........ �•........--------- --- -- -- •.--��� . .......�.......-- - `-? -
Date
Application Disapproved for the following reasons:.............................. .................................................... •-...............
•-•-------------------------------•-------------------------••---•---------------._....----•-------------------.........-----------------••----•---•----••-••-----•-•---••-----•------•--•--------
Date•-'`'
Permit No.......................................................... Issued........°� ......................7�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f........................ ...........OF... ......................................
%lorrtifiratr of ToutpliFanrr
Tn M
C TIFY, hat th ndividual Sewage Disposal System constructed ( ) or Repaired ( )
by ... - - -" - ----- -/`
at. .. ................
has been tilled in accordance with the pro of T e State Sanitary Code as described in the
application for Disposal Works Construr-tion Permit,No:j ..._.._ _f. /
dated V.. r 7
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTI®N SATISFACTORY.,
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DATE........? ................... Inspector. e% -t
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