The URL can be used to link to this page

Home My WebLink About0022 NOB HILL ROAD - Health 22 Nob Hill Road Hyannis A = 288 192 V ° y ° COMMONWEALTH OF MASSACHUSETTS (� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPA aTMENT OF ENviRoNMENTAL PROTECTIQN ONE WINTER STREET,BOSTON MA 02108 (617)292-5500 fi9,oP tsar ' TRUDY CORE C9 la�—/W Secretary ARGEO PAUL CELLUCCI K DAVID B.STRUHS Governor Commissioner SIMStRIFACE SEWAGE DISPOSAL SYSTM NSPECT1011 FORM PART A CERTNICATiON Prowmv Aadresa:2XI40b141 11 Rcly Aruus ;mg c)Ri q7 N.m.all owner �nuL Glu�Tih Address of Owner: Date of' low-aof :(Please Para R E I Q C. E L L I S 1 am a,DOP system Itt lip sator pursumt i o Section 15340 of Title 5(WO CM 16.0001 ComPWI'ame: ELLIS RROTHERS_QONST CO. MdftAd*"&'23 ENTERPRISE ROAD, N PORT., MA LL CEIMI ICATION STgTB18BItT I certify that 1 have personally inspected the sewage disposal system et,this address and that the information reported below is true,accurate " and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance.of on-s agorae disposal systems. The system: _1//Passes '° _ Conditionally Passes Needs Frt r Evaluation By the Local Approving Authority �. a _ Fails Data. �6 The System Inspector shall submit a copy of tins inspection report to the Approving Authority(Board of Health or DEPlwltMn thirty(301 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.rW.n to the appropriate regional office of the Deparbnent of Environments!Protection. The original should be sent to the system ownerand copies seM to the buyer.if applicable,and the approving authority. NOTES AND COMMENTS RECEIVES AUG J 1 2000 . TOWN OF BARNSTABLE' HEALTH DEPT.' revised 9/2/98 Page'1"of ll Printed on Recycled Piper me. ;r SUBSURFACE SEWAGE DEPOSAL SYSTEM SISPECnON FD= ' PART A CERTIRCATION(contirared) r�property Address:as No 61i!1 Rc 1114111 1spofT)M A Owaer: 'Pp't . RksTi'n Om of brspactiorr: S-1 p_0,0 NISPECfiON SUMMmr: tihedoA_ C. os:D: s A. SYST®il PASSES: AJOf have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 exist. Any failure cditda not evaluated are indicated below. COMOiiS: B. SYSTEM CONDFFK wlALLY PASSES: One or more system components as described in the" Pass"section reed to be replaced or repaired. Ths system.upon completion of the replacement or repair.as approved by the 0 md of Health.will pass. Indicate yes,no.or not determined IT.N.or ND). Describe basis of erminedon In all instances. M-not determined%explain why not. The septic tank is total,unless the owner or ope► has provided the systen Inspector with a copy of a Certificate of Compliance(attached)irdicadnp that the tank was ad within twenty(20)years prior to the date of the Inspection:or the septic tank,whether or not metal.Is cracked, unsound,stews substantial bddtration or exfi7tration,or tank failure is(nmBrrent. The system will pas ins if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static wear observed In the digAturtion box is due to broken or obstructed pipe(s) or due to a broken.settled or uneven distribution tm x. The system win pass inspection if(with approval of the Board of Health). broken pipe(sl are replaced obstruction is removed distribution box is kwaged or reg laced _ The system required puwv ft more than four d*es yeti due to broken or obstructed p1pe(s). The system will pas inspection if(with approval of the Board of Health): broken pdpe(s)are replaced obstruction is removed ArshkL "revised 9/2/98 readti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CEM%VA' TION(continuedt Peopaty Address:aaNab ill Rd,ti'�1,M SPWf �a A O air: lA-L %4T%V) Dceo of bs�eetlon C. FUITFM EVALUATION IS REQUIRED BY THE BOARD OF HEAL : Conditions exist which require further evaluation by the of Health in order to determine if the system Is failing to protect the public health.safety and the environment. 1) SYSTENI WILL PASS UNLESS BOARD OF HE1%LTH DETERNI MES N ACCORDANCE WITH 310CMR 15.303(1)(b)THAT THE SYSTM IS NOT FiNC VNNG N A MANNER WHICH WILL PROM T.THE PUBLIC HEALTH AND SAFETY AND THE EMVqjONR MM- Cesspool or privy is within 50 feet of surface wat w , Cesspool or privy is wWdn 50 feet of a bordering Dgeteted wetland or a salt mash. 2) SYSTEMI WILL FAIL UNLESS THE BOARD OF HEALTH(AM WATER SUPPLER.IF ANY)DETERM=THAT THE SYSTBn IS FUNCTIONING N A MANNER THAT PROTECTS THE PuMtjx AND SAFETY AND THE EMVIRONMi(T: The system has a septic tack and son absorption MS)and the PAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tonic and son absorption and the SAS is within a Zone I of a public water supply well _ The system has a septic tank and soil absorption m and do SAS Is within 50 feet of a private water supply wan. The system has a septic tank and sell absorption s and the SAS is leas than 100 feet but 50 feat or more from a private water supply wen,unless a wan water ansty s for c llform bacteria and volatile organic compounds bmilcates that the wen is free from pollution from that facility and the resence of ammorda nitrogen end rdbete nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valIM. 3) OTHER revised 9/2/98 Pap 3of11 SUBSURFACE$ WAGE DISPOSAL SYSTt3ifl INSPECTION FORM PART A ®l CERTIRCATION tcont;rahsd) y Address: act V 0 11 R�,ay e OW har: PAuL Au►s7n trt oaa of 6�eh:tlolh: �� D. SYSTEM EARS: You must khicade either"Yea"or"No" to each of the following: I have determined that one or more of the following fafinxro exist as described in 310 CMR 16.303. The basis for this determination is idsndfied below. The Hoard of Health should contacted to determine what will be necossary to coned the failure. Yes No _ Backup of sewage into facility or system component i Melo an overloaded or cbggod SAS or cesspool. Discharyp or ponding of effluent to the surface of the pound.. or surface wags due to on overloaded or dogged SAS or cesspool. Static liquid level in the distribution box above oudet von due to an overloaded or clogged SAS or cesspool: Liquid depth in cesspool is buss than 6"below invert avaEabte volume is less than 112 day flow. Requirod pumping moro than 4 tines in the last year duo to clogged or obstructed pipe(s). Number of timas pwnpod�. ._ Any portion of the Soll Absorption System.cosspooi 4 r prlvY,is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet t f a surface water supply or tributary to a surface water supply. . Any portion of a cesspool or privy is within a Zone I a public wed. N, Any portion of a cesspool or privy is within 50 foot of a private water supply areg. Any portion of a cesspool Of privy is loss-than 100 fat t but 9tenter then 50 feet from a private water supply well with no acceptable water qucfity analysis. If the wall has analyzed to be acceptable.attach copy of well water analysis for =coliform bacteria,volatile organic compounds,onhnhonia nitrogen and nitrato nitrogen. E LARGE SYSTEIIA FAMS: You must indicate either"Yes'or"No" to each of the following: The following criteria apply to large systems in addition to critarie above: s The system serves a facility with a deep flow of 10.000 gp I or greater(LagaBystam)and the system is a significant threat to public health and safety and the envba awn because one or moro if the following conditions exist.- Yes No _ the system Is within 400 feet of a surface drh*ft lWater supply _ the system is within 200 feet of a tributary to a an face drinking water supply the system is located in a Ift"M sensitive era► Wellhead Protection Aron-IWPA)or o mapped Zone fi of a public water supply wow The owner or operator of any such system shall upgrade the system In accordpnce with 310 CMR 15.30M). Plea"consult the local regional' office of the Department for further intwmation. revised 9/2/98 POP 4of11 SUBSURFACE SEWAGE DEPOSAL SYSTEM WSPECTION FORM PART B CHECKLIST Pmpsrty Address:as Nab Ni 0 RI,F}i�flv,n s)MA OMM Pact, C4vAsTn z „ - S-i'D-o-b Chack if t7,, owing have been done:You must indicate a"'Yes"or"No"as to each of the following: Yes _ Pumping information was provided by the owner.occupant,or Board of Health. • / Nate of the system comansrrts have been pumped-for-at least two weeks and-the system has beon"receiving•r pop rnei flow , rates during that period. Large volumes of water have not been Introduced into the system recently or as portgat this Inspection. As bulk plans have been obtained and examined. Nato it they are not available with NIA. _ The facNity or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste Now. . The ate was irispected for aligns of breakout. iJ •' _ All system components.c4 the Sal Absorption System,have boon located on the site. The septic tadr manholes were uncovered,opened.and the iatoriouat the septic tank was inspected for condition of baffles or tees.material of construction,dimensions,depth of Nwid,depth of sludge,depth of scum. The she and location of the Sal Absorption System on the site has been determined based on: _ Existing informedw.For example:Plan at B.O.H. n W Detemdned In the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unaccepteMe) (15.302(3)(b)) J The facility owner(and occupants,if different from owner)were.provided.with information on tho proper maintsnapco of subsurface Disposal systems. t. . \s .a revised 9/2/98 PW50rl1 SUBSURFACE SEWAGE DISPOSAL SYSTM d11SPECTIOMI FMA PART C SYSTM!liPORMATM �ropsrtyAddress:�a.�D�D�i(� Q�.�1-��A?�v11Spo�1fY1(a A ` Owner: PAVL AtisTiA one Of kopu torr: FLOW CONDITIM Design Number of bedroo:2125� :, Number of bedrooms(actual)._ Total DESIGN DYE.SIIG�N flowwlN�N�f.�V.w..n�{s�� p Winder Laundry Iseparam system) (yea or nokG�a If yes,separote.(nspocdon required &,Lg-v Laundry system hnpected ( or no) T14 Sonsond use(yes or no): 0 Water meter tesdmgs,if aysilab O(last two year's usage Igpd):= !✓ v �i � � Sump Pump(yes or no):_,G(✓t�_c Lost data of occupancy: '. e Type of establishment Design flow: and I Used on ISM13) r Bests of design flow Grass trap present:(yes or no)- Industrial Waste Holding Tank present:(yes or no) Nonmmdtary waste discharged to the Title 6 system:(yes of no),.. ` Water meter rings,if avWable: Last date of occupancy:�� OTHER.(Describe) Last date of occupancy: ,l t> AL TWril MOVSKI RECORDS and sauce of I t�pv System pumped as part of Wapect(on:(yes or no) If «Volume Reas for — ' SYSTM - Sepik tank/distribution box/soll absorption system * ' Overflow cesspool Pries Shared system(yes or no) Of yes,attach previous inspection records,!Eery) 11A Tochrwlogy etc.Attach copy of up to daft operation and malnteasnse corMVM Tight Tank _ __Copy of DEP Approval, Otlber - At )MIATE AGE of all components,deco Installed(if'larown)and source of informMion: Save odors detected when arming at the site:Iyos o.no) revised 9/2/98 Par 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(condromA Property Address:aXWDIo lit I1 P.cLAP""Spor:1ft owner: �' L i�t4sTm Data of btspeesat: BUILDING SEWER: (locate on site plan) Depth below grads:_, Material of eonataction: cast iron_40 PVC_other(explain) r Distance from private water supply well or suction line Diameter 4.1" Comments:(condition of joints enting,a)n'dence of leakage,ate.) SEPTIC TANK: (locate on site n) /9 Depth below grade: Material of construction: oncrete_metal Fiberglass _,_Polyethylene_other(explain) If tank is metal,list age Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions Sludge depth:_ ., Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: (D _ Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of pullet tee or baffler How dimensions were determined: Q Z O►. Comments: d (recommendation for pumping,c d'ition f Wet and tlet tees ffles,depth of liquid vel' relation to vert,stru r g' r evidence of Isaka e,etc.► ' �/� Qi GREASE TRAP: (locate on site plan) Depth below grade_ Material of construction:concrete_metal_Fiberglass —Polyel tylone Tother(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: (recommendation for pumping,condltion of inlet and outlet teas or b ffies.depth of kind level in relation to outlet invert,structural integrity, evidence of leakage,etc.) revised 9/2/9.8 Page 7ofli . w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM MIFORNIATION(confiraredl �sNoperty Address: Owrbr: PAu.1 AusTn Dace of knapsetian: TIGHT OR HOLDING TANK: (Tank must bs'pumped prior to,or time of,inspection) (locsts on site plan) Depth below grade: _ Material of construction: concrete!metal_Fiberglses Polyeth done. ather(explain) Dimensions: Capacity: gallonszk Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes NO Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches etc.) DISTRIBUTION BOX:,,(locate on site plan) Depth of liquid level above outlet invert: �. ram.^omments: (note if 1 . and di rihnlion is (Clual, vide of s ca yo +' e • e into or t of box,etc.) tAl 00 AVE PUMP CHAMBER (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: 4 Inots condition of pump chamber,condition of pumps and appurten mces,etc.) revised 9/2/98, PW.Itorll SUBSURFACE SEWAGE DISMAL SYSTEM IkSPECTION FORM PART C SYSTBYI NFORMATION(continued) r*\rovcrtY Address:aa.Nob 1 'tI I Rlj I4JAW Sporl MA SOB.ABSORPTION SYSTBN(SAS): trocate on site plan,if possihie;ex on not required,location may be approximated by non intrusive methods) H not located,explain: Type: leaching pits,munber._ leaching chambers,number: leaching galleries,ram*er: d ' , leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:_ Alternative system: ' Name of Technology: yw e, Comments: _ (note of sal,si of hydrauG failure,level of pondin ,damp so : ndrtion o ve e , etf„) `� s d.tJU Yitc43 is ZZ C�SPOOLS: (locate on site plan) P Number and configuration: Depth-top of liquid to(Net invert o fF_�Ospth of solids layer: 2. Japth of scum layer: 1] Dimensions of cesspool: 'h _ Materials of construction: mod, tie 7 ly-44L ` Indication of groundwater: AA7AA4f-- /_ S o ( spool must be s rt in Continents: (mots��soil,si of h�rauli� ,hi of pending,c on of vegetation,etc.) ..Vpa PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of pending,c on of vegetation,etc.) revised 9/2/98 Page 9o[t1 ro SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM UIIFORMATION(continued) sroparty Address: f�2No6 Hd k,Q1r�Avm1S,PofT)"N'A Daft of Insperfdon 3KETCH OF SEWAGE DEPOSAL SYSTM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) i r FO ZJ,3 250 revised, 9/2/98 3 Page foorII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(eontwaked) property Adar n:22 NobHill Rd�lk�l nis�rTj Yn1=} AusTin NRCS Report name Sal Type_ Typical depth to groundwater U30S Date website visited Observation Wells checked Groundwater depth: Shallow y� Moderate Deep_ SITE EXAM Slope wit//IG Surface water Check Cellar Shallow wells Estimated Depth to Groundwate0 Feet Please indicate all the methods used to determine High Groundwater Elevation: , Obtained from Design Plans on record Observed Site(Abutting property,observation hole,basement sump etc.) D termined from local conditions T V Checked with local Board of health- V Checked FEMA Maps Checked pumping records Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Elevation. (Mu be completed) y /7�'� a revised 9/2/98 Page norli . e TOWN OF BARN STABLE L CATION, t1I , 6 SEWAGE # U7-6 7�- VILLAGE A-r4w'b ptt• ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. at.,/5 6z.s ,e-,o T7 771-1,34c; SEPTIC TANK CAPACITY' .1.00o <s o yr' 07"r c- �AP LEACHING FACILITY:(type) (size) r NO. OF BEDROOMS - PRIVATE WELL-OR PUBLIC WATER BUILDER O OWNE � V4�- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 7 VARIANCE GRANTED: Yes No '-� g; J� a� n A No...92:_Ze_7.;t, 2 N�5T3 i l,t„ FicE......9 --:--....^...... THE COMMONWEALTH OF MASSACHUSETTS �._• BOARD OF HEALTH /C7/it/ac/..............OF....... iv�c /✓•�_/ -, .. Appliratiou for Uiip.aial Works Tomitarnrtion Vrrmff Application is hereby made for a Permit to Construct ( ) or Repair ( ).an Individual Sewage Disposal syst a ---------------------------- o wa ocation d dree s ....._ ..__s_._._.............. ....__�....._ �d_�._�__/_.�__J__r_.✓_!_._f___..i.`_._� ------..... --------------------------------------- ----- r .. -__... ...................................... ._..._....._.--------------.-.-.-._•�....1.•.-�.•_j-.. ..a . Adfs Z.�'�O� ______________________ 'Instaler Address Type of Building Size Lot.................... .....Sq. feet. �-, Dwelling—No. of Bedrooms...................:........................Expansion Attic ( ) Garbage Grinder ( ) pa, Other—Type of Building -----------------_---------- No. of persons............................ Showers ( ) - Cafeteria ( ) P' Other fixtures -------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid*capacity............gallons . Length................ Width-__-__--___.-_.. Diameter................ Depth................ Disposal Trench—No. ...................• Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit .No._._-____-_--___--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch . Depth of Test Pit.................... Depth to ground water--.----_-__-_-----_---:- Descriptionof Soil .. . .' +r,----- .........---------------------------------------•------------------------------------------------------- x U ---------------------------------------•-•----------------•---•---...----•-......-----------•------.....-----------------------------------------•-----------------------------------------••-•-----•-- ~= - - U Nature of Repairs or Altera ions—Answer when appli a e----- /_. ... rl __._/____ ��? , '.� 'fi. ..2N, - 1�-d? -----•------------•-------------------•--------•------ Agreement The undersigned agrees to install the aforedescribed Individual.Sewage Disposal System in accordance with the provisions of iiT :aW, y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been is by the board of health. ........................ �^P�� ----------•- ... P V Date Application Approved By--------- ��/ ..........�o--- �� 7 Date Application Disapproved for the following reasons-----------------------•---------------------------------------------------------------------------........------ -•--•--•-••--•-•--••-•----•---••-----••-•---•--•-•--•----•--•••-•------.....-•------------•••••-•......---•••••-•---•-•--•-------•-•--•--••-•-••-•-------•---•-•---•--•----••---•--------•••......----- Date PermitNo......2 k. ----------------- Issued....................................................... Date No.._97:__217 , Fps.. -?.—f THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ✓LvEti'N .....---....OF......13&GL..f/.S�F�.�./C� Appliration for Uhipoua1 Works Tonitxnrtion rami# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at / ...... .------•........- ..---• ..... ocatio Jdress or t N .1 ---------------------------------------- ---- .h`! .... ._..... a ........................................... e!t�l .— = 3�''�G��i"�I/t?q A/ Sol �'i• fllllh 14 ..0,:1 �3 ---•---------- � Installer Address UType of Building Size Lot............................Sq. feet 1—� Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------------•-------•••---•-•-•--------..........----•-------••-•-------•----••-••--•......•-------....----•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons 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........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-..___-_-___.._--_. rZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .. -� --- ----------------------•-----------------------------------------------•--------------•- ODescription of Soil------------. ' a" t✓/� e.1-i....... .d.l.-S.d.l.-I..................................................................................................... x W •---------•---------------------••---------------•-••---••-•---------•--•-•----•---••---••----•-•--•--------•- ----- ------ ---------------- - ------ U Nat re of Repairs or Alterations—Answer when applica le..._ .___f s fz��✓�_:______✓____f / Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T?TL2 j of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i f�d by the board of health. ,Signed,-_ �. '' / ....1'- t t'% -_.s. ----- ---- Date Application Approved By......... 7t ...��:............................ -------- V Date Application Disapproved for the following reasons----------------•----•--•---••--•----•-------•-----------•-----•--------------------------------------.....-•-•-- ..•-•--•-•---••-----•......--•-•----------•••......••-•----------•---•-•-----•-----•--.....-••--•------.._.........••-••---•--••-•-•-••-•-•--•-•----•-•-------•••••-••-•-----•----------•-•------------- e Date PermitNo----- ................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH /f ✓JGl/�ts . .•.-� �✓y/�1 .............................. CTrrtifiratr of TompliFana THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by----------------- -----.'�� ........ f t : �`�?--'---.......-----------------•--------.......--------•-----------....----•--------------- Inst ller has been installed in accordance with the provisions of T 171Z j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No-----K?'._1%22a......... dated________________________________________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE l G' Inspector ------------•..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .� nAl OF................ .......�............................................. No.. j f 7p`Z FEE.. Disposal _Vorku Tonotrurtion Prrufit Permission is hereby granted .....'�--�==�-•--•-...��!z>-5----G?-vie' ............................................... to Construct ( ) or Repair (,1 ) an Individual Sew/age� D,iissposal System at �70. . ��-� �f ��.. YS"� �St "IF==l ��/ � ----••-•--------•--------•-••-•--•------•--------------- Street `rl• as shown on the application for Disposal Works Construction Permit N .�3-?_. •_R. Dated.......................................... -------------------••••-- .._- .. ...................................................... D _...�_a..'.�_7..._._.........._............. Board of Health FORM 1255 HOBBS & WARREN, INC., PUBLISHERS