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HomeMy WebLinkAbout0050 MAINSAIL LANE - Health (2) 1-9 Mains'le Lane Hyannis P A = 288 064 i I CONTRACT Customer Name Customer Slgnature_,_�,.,!s a, SKETCH Contract Date "1��C� Sales Representative ATTACHMENT Customer Phone 5"S'_�7�- - . � k�3 r t�t 1 i 7 r � �,` _ Contract Price_ I 2 3 4 5 6 ) G 9 10 11 12 13 16 1i 18 to 20 21 23 2J 26 i:G i:t 26 29 31 3. 31 34 35 30 d:l JI J:.' a3 •16 IG .0 Sd 58 59 01 6 IA�IPt"l�C .:, . 6 I 14 - n II I 16 41r �s�nt.l. Alec_ 1B '�'_ '�•g .,.a.s"....'.,�f '.,.p/ �G. � :...� �... •' ' 1:.4�,t t �:� } --i;.;;.�.4��' � , O'S Dit)p 23 Ph 22 jo 31 n NO7ES'—._._..___._��_...._—...."_..,._.�....,__._...,.,, E.,�l box 1qu.tl.,one t,ut unb?..>otitenwisf,flot("V lhu:,ketch is a good la1111 -......� ............_,.__.._......_.�....�....._._..�,.—_...__—.-. .._...__ rCpnsonL'diim oI thu work to`Ie d!'n W, it in undi.n;tood that all dimension rl8ilvcal f1nn1 tlnc 1�koWh r.ue If l)... n;;de,;Irld thnl till l(woliotis of outlets, light fixha0e 111w1 l i AI m,l'c11 switch �;art:subjr-t to it,ngo it necessary TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A RECEIVED CERTIFICATION AI NS1 L-E LAND JUL 2 2 2002 Property Address:59 Mainsail Lane Hyannisport,MA 02647 TOWN OF BARNSTABIE Owner's Name:Nick and Athena Bardanis HEALTH DEPT. Owner's Address:22 Bogastow Circle_ Millis,MA 02054 Date of Inspection:-7/11/02 Name of Inspector:(please print)Janet E.DuPont Company Name:Wind River Environmental Mailing Address: 120 Great Western Road MAP South Dennis,MA 02660 Telephone Number:508432-7790 PARCEL A.(0 4- CERTIFICATION STATEMENT L.OT 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/16/02 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 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 DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: I have found no conditions that indicate failure of this system however,it should be noted that the house has only had minimal use over the winter season. ""This report only describes conditions at the time of inspection and under the conditions of use at , that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I L f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A " CERTIFICATION(continued) Property Address:59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection:7/11/02 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: 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 the for the following statements.If"not determined" please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic 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: 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: i OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:59 Mainsail La. Owner:Nick and Athena Bardanis DAte of Inspection: 7/11/02 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 30-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:59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection: 7/11/02 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.i _No (Yes/No)The system fa' s.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 necessaryto correctthe 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 11 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 answereda"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 VOLUNTA RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 59 Mainsail Ln. Owner:Nick and Athena Bardanis� DAte of Inspection: 7/11/02 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_ Has large volume 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-not available note as N/A) _ X_ Was the facility or dwelling inspected for signs of sewage back up?Agent not on site.No indications in tank or d-box to indicate backup. X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X_ _ 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 ? _X_ _ 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. X_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection:7/11/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_3_ Number of bedrooms(actual):_3____ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA No plans on file Number of current residents:_2 occasional residents Does residence have a garbage grinder(yes or no):No(per conversation with RE Agent) 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):Mainly Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):no Last date of occupancy:House has had only occasional use for-past 11 years. COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203)s gpd Basis of design flow(seats/persons/sgft,etc.): 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: GENERAL INFORMATION Pumping Records September 9,1990 Source of information:Barnstable Water Pollution Control 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 _Privy _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: House Built 1982 per owners 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: 59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection:7/11/02 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _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:_(locate on site plan) Depth below grade:_14"_ 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):T(attach a copy of certificate) Dimensions: 1000 gallons_ Sludge depth_2" Distance from top of sludge to bottom of outlet tee or baffle:2+-feet Scum thickness:Minimal Distance from top of scum to top of outlet tee or baffle: 10" Distance from bottom of scum to bottom of outlet tee or baffle:-12" How were dimensions determined:probe 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 appears to be sound with no signs of leaking,baffles are in place,liquid levels are normal 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:59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection: 7/11/02 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: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Liquid at outlet invert 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 appears to be quiet with no signs of backup or significant carryover,sound condition 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.): I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection: 7/11/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _X_leaching pits,number: 1_8 X 6 leaching chambers,num_ber-: leaching galleries,number: leaching trenches,number,length: leaching Melds,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.): I-found-the leach pit to be dry 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.): OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection: 7/11/02 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference 1"arks or benchmarks.Locate.all wells within 100 feet.Locate where public water supply enters the building. 4 J ' Fo- r3 s El A" F 3la ' ��C Z Z y O B-n .2-3' y �� OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 59 Mainsail Ln. Owner:Nick and Athena Bardanis DAte of Inspection: 7/11/02 SIT EXAM Slope Level Surface water None Check cellar Shallow wells Estimated depth to ground water 10.4 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained-from system design plans on record-If checked,date of design plan reviewed Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Accessed groundwater information on file Barnstable BOH Checked with local excavators,installers-(attach documentation) _X_Accessed USGS database-explain: On line groundwater information for USGS monitoring wells You must describe how you established the high ground water elevation: Site is monitored by Well MIW 29 Zone B Adjustment for Maximum potential rise is 2.7' Groundwater is at 7.5'. Site elevation per maps in file Barnstable BOH=30.6' Bottom of SAS is 10 Ft. below grade 30.6—( 10+2.7+7.5 )= 10.4' separation between maximun groundwater and bottom of SAS r THE COMMONWEALTH OF MASSACHUSETTS BOAR® E HEALTH A#p iratiun for Disposal arks Tonstrurtiun 1hrutit Application is hereby made for a Permit to Construct or Repair ( ' ) an Individual Sewage Disposal System at • a lion Address - or Lot owner Address W a ...................................... .......---•••-.......••---...•-----.....-•--•-.................---.................•-•--•------•-• Installer Address Type of Building Size Lot..//,,. Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder•��j Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) 04 d Other fxures ....................................• --•---•-----........_......_.........-••- _-•••- WW ... Per day. Total dail fl o,W------------------------------- Septic Tank—Liquid ca acity Ions Len th.? ._.. Width__ ?... gal Diameter................ Depth_______......... x Disposal Trench—No..................... Width .................. Total Length.................� Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter... Depth below inlet... Total leaching area.A�7..sq. ft. Z Other Distribution box ()Q Dosing y�®' , a Percolation Test Results � Performed by........................................................��� �......__...____. Date..?�� Z�__.. 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........................ a O Description of Soil.�_=0 '. 4 �� z—l�f`------��ls ... .. W -••••-••-•••..........-••-•---•......._••-•••...--------••••...--------•-•--••-------•----••-------•-••---•-----••••--•••••••••--•-••-•--••--•-•-••-••-•-. x ------------•---•----------•-••------=--•-----------------•---....•-------•---....----•.....------••••-----------•••-•--------------•.......------••-------...........••----------•--.......--•----_... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... j ••••----------------•---•-••----................._............-----.............•----_..._ ----..........-•--••--------------...-----.....--•-----...........-----------•-•••-•...._•---_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of MIL LE 5 of the State Sanitary Code—The undersigned further agrees not to place the s stem in operation until a Certificate of Compliance has been i ed by the board of health. .. . Signed••• • -•--- •�-•---------------••. -••- � ate Application Approved B / P PP Y f'� ._...._.. - � -'��'----•------•---- Date Application Disapproved for the following reasons:---•---•---------•--•---••-•--•---•------•-------•------------•----•-----------------------••--•--•-••--.._ ------••-•--•----------------------------------•-------... .._...--•-- Date PermitNo......................................................... Issued.................................................... Date V No......R.1=11S Fzz.. . ............... THE COMMONWEALTH OF MASSACHUSETTS BOAR® F HEALTH ......................OF. .... ....... Appliration for Disposal Works Tonstrurtion Frrutit Application is hereby made for a Permit to Construct (/,;'<) or Repair an Individual Sewage Disposal System at ............................ ,n�Address 4.L ot'No owner.......................................... .....................;A---------------------Xzres.a.......... ................................................................................................... .................................................................................................. Installer Address Type of Building SiZe Lot, .......Z.......Sq. feet ............. Dwelling.—No. of Bedrooms...................... .........Expansion Attic ,( Garbage Grinder aOther—Type of Building ............................ No. of persons...._..._................... Showers Cafeteria 04 Other fixtures ........................................ Design Flow............. ............................gallons per ay. Total daily j9w.............................. ...9-994S. Septic Tank—Liquid capacityi/ gallons Length.0�4..... Width..�(!/ ... Diameter..................Depth-__.....:_...._."""'' Disposal Trench—No..................... Width.._................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter../P./� .5.k.('Depth below ...... Total leaching areL-!�' 7..sq. f t. z Other Distribution box Dosing" nk' - ' w 11 1-4 * Percolation Test Results - Performed by.-A< �-j ......*......... ................. Date.g/ Test Pit No. 1.��..?'.minutes per inch Depth of Test Pit....e'�'... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.._................. Depth to ground water...................._... ----------- ....................... ............................................................. O Description of .. ... <,/- ,....................................z.................................................................................... ............................................................................................................................................................................. *--------.,.-.-.,.,-,---,-.-.--*.*.......................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ....................................................................................................................................................................................................... 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/thhes stem, in operation until a Certificate of Compliance.has been i jpmed by the board of health. .................... ... .................. t;e Application Approved By........... .1-4�- ----------------------------------- .... . .. . .... .................. Date Application Disapproved for the following reasons:............................................................................................................. Date PermitNo.................................................... Issued....................................................... Daft THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....................................OF...................................................................................... Tatifiratr of Tomphanu THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by-------............................................................................................................................................................................................. k...'-,- 11 . 10-'.......... I tau at pZjer.... K, '11; --oi, has been installed in Zcord; ate Coed as &K--�re�-d of The WeSanWitaey" Code Er' ed in the an itlh the pr'ovisi TITLE 5 application for Disposal Works Construction Permit No----- ............ dated._...__.,:_.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS rA GUARANTEE THAT-THE SYSTEM. WILLe'FV?;dTION SATISFACTORY. DATE.... Inspector........ .... .....................................................................---------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF....................... . .... ........................ 3X FEE........................ Disposal Varks Tonstrurtion "Prrmit Permissionis hereby granted.............................................................................................................................................. to Construct or Repair an Individual Sewage Disposal System at No. ...... V............. as shown on the applicat* n for Disposal Works Construction Permit ................. Dated.7................................ et t at .. ................................................... 0 ard of Health DATE. .. .......... .. . . ................................................. ,FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS r . , ,« l# t ! 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