HomeMy WebLinkAbout0334 STRAIGHTWAY - Health 334 Straightway, Hyannis
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL GIs�A-1. S 12
DEPARTMENT OF ENVIRONMENTAL PQREOTECThON
ONE WINTER STREET. BOSTON. MA 02108 617-_-292� 50V
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WILLIAM F.WELD `. � � W
t3 ��,qp� �� w TRLDY COaE
Governor y0°1T96 � Secretary
ARGEO PAUL CELLUCCI 4qDAV1D B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
334 Straightway, Hyannis V Braithwaite
Property Address: q g Y r Y Address of Owner:C/o J. Henry
Date of Inspection: /0—1 9 -7 (If different) . 12 Hillside Ave
Name of Inspector: Wm E Robinson Sr Randolph, MA 02368
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: him E Robinson Septic Service
Mailing Address: PO Box 1 089 , Cent'_Prvi 1 1 e- pqA 02632
Telephone Number:; 5 0 8 7 7 5-R 7 7r
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_j,/Kasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: e LlV�;- Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 31.0 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
1
STEM 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.
Indic e yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: httpJ/www.magnet.state.ma.us/dep
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SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 334 Straightway, Hyannis
Owner: Braithwaite
Date of Inspection: /j:5—/I-1 -7
B] SYS M CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
p blic health, safety and the environment.
1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
HICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
NVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OT ER
(revised 04/25/97) Page 2 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 334 Straightway, Hyannis
Owner: Braithwaite
Date of Inspection: /0-1 1—31I
D] SY FAILS:
You must in Jcatie ei;+,er "Yes" or "No" as to each of the following:
I ha a determined that the-system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for i iis determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the ailure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LA GE SYSTEM FAILS:
You ust indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
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)
The wrier or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requi ements of 314 CMR 5.00 and 6,00. Please consult the local regional office of the Department for further information.
(revised 04/25/97)' Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 334 Staightway, Hyannis
Owner: Braithwaite
Date of Inspection: /G—
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by:he owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 334 Straightwaite, Hyannis
Owner: Braithwaite
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 13 y P.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents:
Garbage grinder (yes or no):,&,O
Laundry connected to system (yes or no)>L1:::5
Seasonal use (yes or no): ti"
Water meter readings, if available (last two (2) year usage (gpd): NO usage/over two years
Sump Pump (yes or no):L- O
Last date of occupancy:,
COM RCIAL/INDUSTRIAL•
Type of ablishment:
Design flo gallons/day
Grease trap resent: (yes or no)_
Industrial W ste Holding Tank present: (yes or no)_
Non-sanita waste discharged to the Title 5 system: (yes or no)_
Water met r readings, if available:
Last date f occupancy:
OTHER: ( esc 'be)
Last date f occupancy:
GENERAL INFORMATION
PUMPING RECORD and source of information:
System pumped as part of inspection: (yes or no) L:'.S
If yes, volume pumped: gallons
Reason for pumping: a, e
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
gle cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
® r
APPROXIMATE AGE of all components, date installed (if known) and source of information: o-2-sci it-3
Sewage odors detected when arriving at the site: (yes or no) 6
(revised 04/25/97) Pago 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 334 Straightway, Hyannis
Owner: Briathwaite
Date of Inspection: /p—,( 7—� /
8 UlkEING SEWER:
(Locate n site plan)
Depth be ow grade:
Material f construction: _cast iron _40 PVC _other (explain)
Distance from private water supply well or suction line
Diamet
Commen s: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on ,site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificai:e of Compliance _(Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE T P:
(locate on si a plan)
Depth belo grade:
Material of onstruction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensio s:
Scum thickness:
Distance top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last p mping:
Comments:
(recommenda on for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, ev' ence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 334 Staightway, Hyannis
Owner: Braithwaite
Date of Inspection: /b•—I 7 -1)**7
TIC" OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate n site plan)
Depth ow grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimens ns:
Capacity gallons
Design fl w: gallons/day
Alarm I el: Alarm in working order_Yes; _ No
Date of previous pumping:
Com nts:
(con tion of inlet tee, condition of alarm and float switches, etc.)
/91
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover,,91dence of leakage into or out of box, etc.)
[ a 8L
PUMP HAMBER:_
(locate n site plan)
Pumps in working order: (Yes or No)
Alarm in working order (Yes or No)
Comme ts:
(note co dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 334 Straightway
Owner: Braithwaite
Date of Inspection: /6 r/'!— 07 '7 SOIL ABSORPTION SYSTEM (SAS): t//
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, ;number,length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note ondition of soil, signs of h drauli�,fallure, level of ponding, condition j9f vegetation, etc.) /
�b� �4:-AC.1 =ouarR I— a w G p l� b4 ie.z ��
tlp COndf r %1 t
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer: A--L) "
Depth of scum layer: — '
Dimensions of cesspool:
Materials of construction: J ;l o e 6 $
Indication of groundwater: CJ
inflow (cesspool must be pumped as part of inspection) $lL` S
Comore
(note cond ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on s e plan)
Materials o onstruction: Dimensions:
Depth of soli s'
Comments:
(note conditi n of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 09/25/97) Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 334 Straightway, Hyannis
Owner: Braithwaite
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks �}
locate all wells within 100' (Locate where public water supply comes into house) I
J
1
i
i
J
r
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 334 Stra-ightway, Hyannis
Owner: Braithwaite
Date of Inspection: /O
k
Depth to Groundwater /ID Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
!/ Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data �.
L .
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
(revised 04/25/97) Page 10 of 10
LOCATION SEWAGE PERMIT NO.
1-3v
VILLAGE
INSTAL-L R'S NAME i ADDRESS
IIU1LDE' . OR PWNER
�►�I�u9rao
DATE PERMIT ISSUE D
D A T E COMPLIANCE ISSUED`
1p
V
No.......... Fim$......... ... .:04...
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...................--T�n_.......O F.....Barnstabl e
..................................................................
ApplirFatiou for Dispaii al Works Tumitrurnart "Pun fit
Application is hereby made for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at:
...334 Strai�htwa�,__Hyannis , MA _02601
.. ......... ........... -------------------------------
.---------•---•---------".......
...._.
c `Locatiop-gdress , or Lot N4
BraithwaY 1 h!4' ...................................... r1 O 1 �a
,qw
W ess
A" & B Cess�sol Sera ce 128 BisYDDs Terrace,arHyannis,_ MA_ 02601
a ---.. .....--- -•..................... ------------------......-• -- ....................... --
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms..............3.._..........._ .Expansion Attic ( ) Garbage Grinder ( )
.............. No. of ersons........_............._...._ Showers — Cafeteria
pa, Other—Type of Building ............. p 4 ( ) ( )
Q' Other fixtures ..................................
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........................................
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 water-___.__-___--__----_____
ODescription of Soil--------•------------•-••------------------------------------------•---•---•-----.....----------------------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable----.ins_-ta.11abin._of__a..l,.OD_Q..gallflb,:..pra-cast,
pit...(.nverf LOX).....................................--................................. ..............................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITi LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boa d o ealth.
t. I
Signed. .......................`C-•- C ` .... 4-2,82---.........
Date
Application Approved By.................. ' =---� -----..........•-•...........• -••---.....9`..2/82...•--------
D ate
Application Disapproved for the following reasons-.........................................................:.......................................................
--•---•----•---------------------------•----•------•-----.....-----------...----•------•....-----------......-----------------•---------...............................................................
Date
Permit No....... 2....---------------------------------------- Issued_.----g42-82---------...---.......---•---•---
Date
I �
No..........�:?- �%�?_lf'B F�s...........r_. .: .. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
I 'CJFTni.
- .....OF......Barnsta le....
Appli.ration, for Di-spu,ia1 Workii C ontitrurtion amit
Application is hereby made'for a Permit to Construct ( ) or Repair (X ) an Individual Sewage Disposal
System at
...334 Straightwa Iianr7s, IAA 02601 ......
4 ---_ - ....................... ..•------•--
i Irpeahon,, A dress or Lot N
Braitl wa ' 1 �q------------------------------------- P. . . '..j C .._ _._.L,:?l�! ?.CJ ,`�.'��... - �
d� -
•-
W A & B Cesspool ex�tace 128 Bishops Terrace,Teliyannis, .A 026.61'
,-1 ... ---•......................•-------- -•--•• .-- ..... ..... .. ...... ....
--•---.
ys Installer Address a
Type of Building Size Lot............................Sq. feet ~_
Dwelling—No of Bedrooms...............3..........................Expansion Attic Garbage Grinder
aOther—Type of;Building ..._..... No. of persons............................ ShowersCafeteria ( )
dOther fixtures ---,•-----'--------------------------•---••----•...... -------•---••-•-...•---------......---•---••-•-..............--•••••••••.......-•••--•-•------
Desi n Flow...... `'
W g :. ................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.
3 Seepage Pit No.............:........Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box,.(-'-,)..,: Dosing tank ( )
aPercolation Test Results Performed%y................................................................-......... Date........................................
Test Pit No 1 _minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
44 Test Pit No 2 ..:_. _.._.minutes periinch Depth of Test Pit.................... Depth to ground water.........................
O Description of Soil ..............................................darn
xs-•..............••----••----•-•----•-•-•-••--•----------••-••-•.
U ••-•••••••-••---•••---••--••-•-••••••--------=--.......................................................................................................................................................
W .............................................I
Nature of Repairs or Alterations—Answer when applicable.____.l?.s.�aiatimt..of_.a__l,000. ?lon,_..pre-Cast,
stone packed. leach fit' (overflow)
----------------------------------------------------------------------------------------•...
Agreement:
The undersigned',agrees; to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T ITIE. 5 of.the State Sanitary Code— The`'undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by,the board of�healtli.
Signed-- --•----------- --------! �.---• •- ----�s-� G:.----= ----•- � ----91--2l`�2_ _-
9a F,
Application Approved°By----••. __....,- ......-•-----� ...---------------- ------------9...... `'2-----------
Date
Application Disapproved for.theJollowing reasons-...............-................................................................................................
.. ........• -------------•--------•--.....--------------•--------•-•--._._...._.........----------------------------------------------•------------------•--•••----
Date
Permit No.......82.-............................................
Issued......g/ 2/82
•r � Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
T own Barnstable `
..........................................O F.....................................................................................
(Irrfifiratr of Toutphatta
T I, S TO CERTIFY, That th I ual Se ,a e Disposal System construe ed ( ) or Repaired (X )
A Cesspoo erv�cE f.... s: ®ps :e ce, Ityannis, I;A I
by •---------------- ----------------•------.......---.....-----------•----.......---...-----............._....----
334 Straightway, Hyannisr M 02601 _Inst Aithway
at ----------------------------•--•-•-•-•---•••-•--•--•-••-•-------•-----•--•-•-••••••-•••......•--•-•--------•-
has been installed in accordance'witli the provisions of TIT LE- off he,State Sanitary Code as gdts�•i in the
application for Disposal.Works Construction Permit No........... .........� ®___..... dated__-.._____..._.__........__......._...............
THE ISSUANCE::;OF. THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATIS ACTORY.
DATE ----- ...:. ---�} � '----- Inspector.... ............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
62- y8� ,•.,, Town........OF._......l+arnstable �,
No FEE.. 0......... ......
1 t
Dip1 �r� ���truan rani
y granted •-- A & D C esspol Service
Permission is hereb ....... .. .
to Constru ( or Repair ( .) an Individual Se ra e Disposal System ;
S raihtway, :+yannis, TEA 01 - Bra3fnyway \,
at No... -........--. --•----••--�•-----....--•-•••-••-------------•----------•-----•...•---......
----•---•--------------------•------•------•-----..._......--•-•-. sT - ----
Street
as shown on the application for Disposal Works Construction Permit No ....... Dated.......9�-2182..................
•- d-- ... .......
rBoar of Health
DATE ... --- "----------•------
FORM 1255 HOSES & WARREN. INC.. PUBLISHERS
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