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HomeMy WebLinkAbout0041 MARK LANE - Health R . 41 Mark Lane Hyannis A=289 148 , 0 i ��I Commonwealth Of Massachusetts Executive Office Of Environmental Affairs Department Of Environmental Protection TITLE 5 Official Inspection Form -Not For Voluntary Assessments Subsurface Sewage Disposal System Form Part A Certification Property Address: 41 Mark Lane Hyannis Ma.02601 Owners Name:Ralph Barolet Owners Address:41 Mark Lane Hyannis Ma.02601 Date of Inspection:6/27/2006 Name of Inspector(please print)Sean M.Jones Company Name:S.M.Jones Title V Septic Inspection Mailing Address:74 Beldan Ln. Centerville Ma.02632 Telephone Number:508-7784597 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 Inspectors Signature Date: 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:Although this septic system was installed in 1977 it has seen very little use and is in excellent condition. ****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. Page 1 7 OFFICIAL INSPECTION FORM w NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION wowmm Property Address: 41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection:6/27/2006 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:NIA 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 the 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 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: OFFICIAL INSPECTION FORM•NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(corr mim) Property Address:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection:6/27/2006 C.Further Evaluation is required by the Board of Health:N/A Conditions exist which require further evaluation by the Board of Health in order to determine if thei system Is failing to protect public health,safety or the environment. 1.System will pass unless Board of health determines in accordance with 310CMR 1$.303(1)(b)that the System functioning in a manner that protects the public health,safety and the environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a Surface water supplyor 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 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(CONTWUED) Property Address:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection: 6/27/2006 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 '/a 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 cesspool or privy is within Zone 1 of a public well. X Any portion of cesspool or privy is within 50 feet of a private water supply well. X Any portion of 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 pp,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form.] X (Yes/No).The system fails.I have determined that one or more of the above 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:N/A 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: 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 waterr supply well If you 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 CM15.304.The system owner should contact the appropriate regional office of the Department. r OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection: 6/27/2006 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 system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? N/AWere as built plans of the system obtained and examined?(If they were not available note as NIA) _X ^ Was the facility or dwelling inspected for signs of sewage backup? X_ _ Was the site inspected for signs of break out? X_ _ Were all system components,excluding SAS,located on site? _X Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the battles or tee,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 C is at issue approximation of distance Is unacceptable)[310 CMR 15.302(3)(b)J OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection:6/27/2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-3— Number of bedrooms(actual):—2_ DESIGN flow based on 310 CMR 15.203(for example): i 10 gpd x#of bedrooms): 330 GPD Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no)_No [if yes separate report required] Laundrysystem inspected(yes or no): n/a Seasonal use:(yes or no) YES Water meter readings,if available(last 2 years usage(gpd): 2005=9000 gallons--2005=1.1250 gallons-=30 GPD Sump pump(yes or no): No Last date of occupancy/use: Curren COMMERCIAL/INDUSTRIAL:N/A Type of establishment: Design flow(based on 310 CMR 15.203): 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: i OTHER(describe): GENERAL INFORMATION Pumping records Source of information: Was system pumped as part of the inspection(yes or no): No_ If yes,volume pumped: gallons—How was this quantity,pumped determined? Reason for pumping: TYPE OF SYSTEM 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 the 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:,1977 Original system Were sewerage 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:41 Mark Lane Hyannis Ma.02601 Owner.Ralph Barolet Date of Inspection:6/27/2006 BUILDING SEWER(locate on site plan) Depth below grade: 18" Materials of construction: 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.): Joints were in good condition,no sign of leakage. _ SEPTIC TANK: X_(locate on site plan) Depth below grade:_6"_ 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: 8`6"X5`6"X4`10 1000 Gallons Sludge depth: 12" Distance from top of sludge to bottom of outlet tee or baffle: 3` Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle:_6" Distance from bottom of scum to bottom of outlet tee or baffle: 064 How were dimensions determined: opened covers and took measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels As related to outlet invert,evidence of leakage,etc.): Inlet and outlet baffles were intact and in good condition.Tank was not leaking,water level was at bottom of outlet pipe. GREASE TRAP: N/A (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:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection:6/27/2006 TIGHT or HOLDING TANK:_A/A (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: - 0" 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.): Distribution box was level and in good condition No evidence of solids carryover Box was not legkin PUMP CHAMBER: N/A (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:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection: 6/27/2006 SOIL ABSORPTION SYSTEM(SAS)_X_(locate on site plan,excavation not required) If SAS not located explain why: Type _X_Leaching pits.Number:_1` Leaching chambers,number: Leaching galleries,number: Leaching trenches,number,length: leaching fields,number,dimensions: . overflow cesspool,number: innovative/alternitave system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,.condition of vegetation,etc.): Soil was dry,vegetation was normal.At time of inspection the leach pit had 6"of sEanding water with a stain line approx. 3"higher. CESSPOOLS: N/A (cesspools 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: N/A (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:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection:6/27/2006 SITE EXAM Slope X Surface water Check cellar X ' Shallow wells Estimated depth to ground water 10+_feet Please indicate(check)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) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) ^X_Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was determined by accessing the Town of Barnstable Groundwater Contour Map.Also by noting that the property is elevated high in relation to Mark Lane. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:41 Mark Lane Hyannis Ma.02601 Owner:Ralph Barolet Date of Inspection:6/27/2006 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or Benchmarks.Locate all wells within 100 feet.Locate where water supply enters the building TANK REAR OF HOUSE_ A-1=21' A-2=25'6" A ; B B-2=21'6" D-BOX A-3=28' B-3=24' 1 LEACH PIT A-4=23' B-4=34' 2 3 4 TOWN OF BARNSTABLE J LOCATION lMarw La-4t SEWAGE # / VILLAGE t:j:�A^^IS ASSESSOR'S MAP & LO-r_ L✓IW&9s rS �,M, 201V65 Ti>c!e i/ StP>tic �nSPCc/io� 'S NAME&PHONE NO. SEPTIC TANK CAPACITY /OVD C-;16A1 1 /Corer LEACHING FACII.ITY: (type) 24 c4 P;) (size) 666 6a I NO. OF BEDROOMS '2 BUILDER OR Oe�) Jcaro I e f — PERMTTDATE: COMPLIANCE DATE: _ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility fy 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 z� b >4 r - O No................ l FHx............:...."� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .....-.....OF............�.a✓.�J�!--�_.............. ... ............ Apphratiun -for 11-4piaiittg Works Cnonstrurtion Prrutit Applicatio h. eby"made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at n. /� r ...1�1.._ filar =1----------------•-------•-- •+C� --------------•-----••---•-------- hon tLddress v \ or Lot No., / Owner // � Address Installer Address d Type of Building Size Lot_.I.4 0_ 0._-..__-Sq. feet U Dwelling—No. of Bedrooms----2 _______________________-.___..--Expansion Attic ( ) Garbage Grinder 04 a' Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) P4 Other fixtures ------------------------- ------ - - ------------------------------------•----------------------------------....------------------------------•----•--- W Design Flow._6 ---------------------------------gallons per person per day. Total daily flow---Z_04-------------------------------gallons. WSeptic "funk—Liquid capacitvJV.0_0gallons Length................ Width-----__....---- Diameter---------------- Depth.----.--_-.----- x Disposal Trench—No. ........... Width-------------------- Total Length-_-.-___-_._.___---. Total leaching area-.-_...._----------_sq. ft. Seepage Pit No.166- __ Di. eter.................... Depth below nlet........._......_... Total leaching area.--_---_-.-.----.sq. it. Z Other Distribution box ( ) Dosing tank ( ) O�o aPercolation Test Results Performed by-----------------_ -------------------------------------•---------------- Date---------------------------------------- ,� Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...---.-----..-----.---. (i Test Pit No. 2................minutes per inch Depth of Test Pit---_"-.--_..___----- Depth to ground R+ water--.--.---__------__- ----------- - ---- ---------- - ----------- .--. ------........•.••I V .--- ---•---- x escriptonooil------ --•------------- ------ ---------- T_,4 .. "--"------"----- --------------------"-------------- e------------------- ------- - S�... d W Nature of Repairs or Alterations—Answer when.a...licable.-.-_------------- -----------------------------------------_-.__--..-.-.. --.-._.--- ' U- P" � PP --- ---------------------------------------------------------------------------------------------------------------------------------------------------------------=------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article LI of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of:Compliance has b n is ued by the bo rd f health. ig / '7 L riefry'_-"- -" ----•--"--"---•-•------------- e.,� Application Approved By------------ ... ----- ---- % ' S -7 Date Application Disapproved for the following reasons----------=-------------"-.....................................................--•--.--•-•--------••----------- --------------------------------------- ----------------------------------------------------------------- ------•---•---- r. Date PermitNo.---------•--•----------------------------------•-----• Issued........... ---------- ................................. Date No............... F.Ex............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, HEALTH ... ... . .........0F...... ..... y .404-.4-0.40_1 .1.1..................................... .ApVfiratitin -for Uhipviial Works Tomitrurtion Vrruift Application is heieby'made for a Permit to Construct or Repair an Individual Sewage Disposal ;S, stem al q1 rt Pe 0JA1tJ _Z.6w 00V ................. ---- on Address Lot N# r j 1-7 eMA;le r,_4 or . . .. ......... .... . ...................... .........................C: .. ........... ......... Owner 'dress.......... .... ......... .. ................7........ .... Installer---------------------------------------- ------- ............................Address........................................... Type of Building Size Lot_MF,.000."07--Sq. feet U Dwelling—No. of Bedrooms---_ ----Ex ansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons..-____-__--________-__-_-__ Showers Cafeteria aOther'fixtures --------------------- < ----------------------------------------------------------------------*------------------------------------------------------- W Design Flow_.0 ---------------------------------gallons per person per day. Total daily flow...Z-00-------------------------------gallons. V4 Septic Tank—Liquid capacity104-0gallons Length................ Width.----..-...----- Diameter__-.-.---...__-_ Depth---------------- Disposal Trench—No Width ----------------- Total Length_-_-___-_-__----_--. Total leaching area--------------------sq. f t. (----------- --- ... 1.. ----- Seepage Pit NoJ6_6_4,.j_Q_� D�d Reer---------------------- b'epth beloynlet-----------_------ Total lea ling a a------- ----------sq. ft. Other Distribution box 9 Dosin tank . Percolation Test Results Performed by.-:------------------------------------------------------------------------ Date----------------------------------------- Test Pit No. I.................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-_--_------------------ . . --- ------------------------------------------------------ 0 0 -i--._�--7- �e_V!Pd�_ ---:M. � ---- -------A Description of Soil----- ------------------- ..... ­---------------------__----­--------------- jv �+ -1w,.4.otl ------------------------------------ -------­-----------?-------- ------- '44 U 'I ------ --------------­­----------_--_--_---------------------------------------------I------------------------------------------------ ....... ---------­-­­1---------------------------------- 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 Article XI of the State Sanitary.Code— The und6rs,* ned further agrees not to place the system in I ' ' 'ur"'operation until a Certificate of Compliance has b n is ue �he o f health. igne .....; 4-T-ze---------- .... ..... ........................... Application Approved By--------- p ... . ... .. .. ....... .......... ................. . ........................................ Date Application Disapproved for the following reasons_______________________ __________________-- --------------------------------------------------------------------- .............................................................................................................................. Date PermitN Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OFY HEALTH p ................. 0 F... ............................................. ............ (9rdifiratr of Tomphaurr' TI�JI TO r$Tl� , That.the Individual Sewage Disposal System constructed or Repaired j el; by---- - -- ........ ... ........ .............. ............... ........... ... ----------------I—----------------------------------7---------- n at r at.. ....... .. ...... ....... . ... . -- ----- ----------------------------------------------------------------------------------- Ap has been installed in accordance with the provisions of .2P I of The State Sanitary C in the -- -------- c .......application for Disposal al Works Construction Permit No. elated__________ _________ __t.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Inspector------------- DATE------ ..........�_/... ................ ..................................... ---------- THE COMMONWEALTH OF MASSACeTTS BOARD OFIHEALTH .......... e�..�jij� ..... ..... OF....... ........... .............................. N ......... FEE------- ............. tritrur ion ramit P e i on hereby anted: ------ _- - -------- --------- ----- - ---------------------------------------------------I - -----------------toC ons �- or R n & ivi I Sews Disp a e atNO. y -------- -if.... .......... ................... - ------ -- --------------- ------------------------------------ -71 St t- A/%_ 1',- ­7 as shown on the application for Disposal Works Construction Permit Njon. Dated.._ .................................. ------------------------ ---- ------------------------ Board of Health DATE..... ------I -------------------- FORM 1255 HOBBS & WARRE.N. INC.. PUBLISHERS c �p k�:.as�d" i CZf ''fi ,�y y er« 4.j+Jy Yf tts,:°% x4 YYv ktY q KS St 1OSC3`F . +4r3S+ct e x •4• ``.r , �.411,1 r$r',�. `'!S,rit y: ,�, ." 1�� " �.r t AI`,` �-cs1� f+ ur". -... "x I �I i do Mat a t Y b �� 5 a. 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