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HomeMy WebLinkAbout0037 ABBEY GATE - Health 37 Abbey Gate: r Cotult A=022- 111 TOWN OF BARNSTABLE 1 P& � C� z LOCATION SEWAGE# VILLAGE CptU i ASSESSOR'S MAP&PARCEL i A orNAME&PHONE NO. \'p � SEPTIC TANK CAPACITY LEACHING FACILITY: (type)���rc K= i (size) G;K NO.OF BEDROOMS OWNER l� l DATE: p�, COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY q2_ c � ZZ ' Y TOWN OF BARNSTABLE : 3� e �) LOCATION .. SEWAGE # a` O VILLAGE C ASSESSOR'S MAP LOT 6 Q, , INSTALLER'S NAME 6T PHONE NO. i SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) w NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER - '"� e DATE PERMIT ISSUED: 9la- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No » �,� u - ��_� �, � �s �°�, y. � � �� � EUCLTTIVE FFICEr'AWSACHUSETrS v ' , OF ENWRONMENT DEPARTMENT OF ENVIRO AL AFFAIRS NMENTAL PROTECTION OFFICIAL IWSPECTION FORM TITLE S NOT FORV SUBSURFACE SEWAGE D SpOS LUIYT AL SY TE FORM�IE PART A NTS CERTIFICATION ProPerty Address: a �� Owner's Name: Owner's Address: t - Date otInspec don s S�E oro 3r�s Noun of Inspector(please nt) Mailing Company t Address: , Telephone Number: J CERTIFICATION STATEM NT I certify that I have p�on�Y inspected the sewage below is true,accurate and complete as of disposal system at this address and that training and experience in the the time of the inspection.The - information approved system inspector pryctlon and maintenance of on site aeon was Performed based on reported pursuant to 3ectloa 1S.3g0 of Title S(310 C'MR l sw s.� Q systedam a DEp Passes Conditionally Passes = F Needs Further Evaluation by the « Fails Local Approving Authority, - - Inspector's Signature- The system inspector s Date: P hall submit a co DEP)within 30 days'of co le ' copy°f this inspection report to the Approving or greater, the ' completing this inspection.If the system is a shared Authority inspector and the system owner shall submit the r hared system or ty(Board°f Health or Dom'The°regal should be sent to report to the a has a design flow of 10,000 authority. system owner�d copies sent to the buyer, reg;onai°�be of the Yer, Notes and Comments if applicable,and the approving �`� ,� � i btu r�. This report only describes conditions at the time Of Inspection and under time- This Inspection does not address how the system will perform conditions of use, der the conditions otuse at that p form 10 the future under the same or different Title 5 Inspection Form 6115120o0 page 1 I� L . OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSpE PART A CTION FORM CERTIFICATION(continued) Property Address: C.�'� Owner: ,ems Date of Inspection: a b Inspection Summary: Chock . AJkC.D or E/ WAY complete an of Section D A. System Passes: I have not found any information which 15.303 or in 310 ur nducat"that any of the failure CMR 15.304 exist,Any failure.criteria not evaluated are irudica criteria��in 310 Comments: Cb� F ,44 B. System Conditionally Passes: Or more system components repaired. system,upon comletion of the embed is the"Conditional Pas'section need to be replacement or repair,as approved by the Board of Heal laced�. i Answer yes,no or not rtmined explain. (Y.N.ND)in the_for the followin If"not d » g statements. etermined please The septic tank is metal and ov , unsound,exhibits substantial infiltration or years old or the septic tank(whether metal o existing tank is replaced with a co 1 tration or tank failure is ' structurally •A metal septic tank will ass r is seP as approved by the rvi11 Pass inspection if the indicatingthat P inspection if it is struc so of Health. tank is less than 20 years old is available. �no • g and if a Certificate of Compliance ND explain: Observation of sewage backup o eak out or hi obstructed pipe(s)or due to a brok settled or uneven distribution box.gh static water gel in distribution box ' approval of Boatd of Health): y9Lem due to broken or inspection if(with broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain:' The system required pumping more titan 4 times a year due to broken Pass inspection if(with approval of the Board of Health): or obstructed i e s . • pip O The system will broken pipe(s)are replaced obstruction is removed N'D explain: i . ' `i"irin � lnanu. inn C.'nrry ����,7nnn 2 J OFFICIAL INSPECTION FORM.NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION T ON FORM PART A FORM CERTIFICATION(Continued) Property Address: Owner: ` —Y"" �c Date of Inspection: C. Further Evaluation b Required by the Board of Health: is failin onditions exist which require further evaluation by the Board of Health in ord 8 sect public health,safety or the environment er to determine if the system 1. System w PASS unless Board of Health determine in accordance with 310 C111$1530 i system Is tlonin8 la a manner which wiD protect pubile health,Saf )that the ety and the onment: — Cesspool m is within 50 fed of -------- -----___ - ._.-- Cesspool or - -•--aifhia SO fed of a bordering vegetated wetland or a salt h 2. System wW fail unless the Board of He system Is functioning in a manner that protee (and ublicC W er Supplier,if any)determines that the P th,safety and environment: _ The system has a septic tank and soil absorpti surface water supply or tributary to a surface s (SAS)and the SAS is within 100 feet of a — The system has aseptic tank ands . ��°S'�is wi a Zone 1 of a — The system has a septic public water supply. tank SAS and the SAS is wit hin SO et of a private water supply we1L —_ The system has a sePti and SAS and the SAS is less private water supply we .Method used to determinethan 100 fee 50 feet or more from a distance **This system p if the well water analysis, bacteria and vo a organicey a,performed at a DEP certified laborato the Presence compoundsindicates that the well is free from .for coliform P ammonia nitrogen and nitrate nitrogen is a Pollution from that facility and failure cri are triggered A copy of the anal �1 to or less than 5 pprm provided that no other Ysis must be attached to this form. 3. Other: 3 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INS ASSESSM[ENTS PART A INSPECTION FORM CERTIFICATION(continued) Property Address �7 Owner: .� Date of Inspection: D. System FaUurs Criteria applicable to aU systems: You aM indicate cs"no"to each of the following for alLimpections: Yes N Backup of sewage into facility or system con:ponent dute to overloaded Dischuge or ponding of eMwnt to the surface of the ground or clogged SAS or cesspool clogged SAS or cesspool waters due to an overloaded or _ Static liquid level m the distribution-box above-outlet inverfdu to as overlo - - - - - - - cesspool-- — - a --- ailed o thar clogg%dayed SAS or- --Liquid depth in cesspool is less than 6"below invert or Requited in available vo of times pumped g°tee than 4 times is t>us last year due to clogged orl orb Pamnow ()Number ...5Z Any Portion of the.S��AS,c Any Peron of ces esepool or privy is below high ground wad elevation. WON fly spool os privy is within 100 feet of a mr6ce water supply or tributary to a surface -� Any porbtoa of a cesspool or ✓� Privy is within a Zone 1 of a public well. ny p J — — ardon ofs cesspool or Privy is within 50 feet of portion of a cesspool or privy is less than 100 feet but vats water supply well supply well with no acceptable water quality analysis. �i'h greater than 50 feet from a private water P�ormed at a DEP certified laboratory,for co in- b ern passes if the well water analysis, Indicates that the well is tree from pollution tram that tacUf�and volatile organic nitrogen and nitrate nitrogen is equal to or less than t h'and the presen o mmonla compounds are triggered.A co PPm,provided that no other fail a criteria copy of the analysis must be attached to this form.j (Ye&Wo)The system f I have de - described in 310 � erefor ed that one or more of the above failure criteria exist as Health to d CI1�IR 15.303, therefore the system fails.The system owner should contact the Board of etermine what will be necessary to correct the faihu+e. E. Large Systems: To be onsidered a large system the gPd- system must serve a facility with a design flow of 10,000 You must in a either"yes"or"no"to each of the following; 00 gpd to 15,000 (The following crit ply to large systems in addition to the criteria above) 7 Yes no _ the system is within 400 feet o ace drinking water supply _ the system is within 200 feet of a tributary to ace water supply the system is located in a nitrogen Sens' ' ea(Interim Zone II of a public water su a ad Protection Area— IWPA)or a mapped If you have answered " " to any question in Section E the s ste yes"in Section ove the large system has failed. The owner or m Is eyed a signific significant threa under Section E or failed under Section D shall uof eat' °r answered 15.304.The system owner should contact the appropriate regional office of any large system.c ' eyed a upgrade the system in accordance with 10 C.�1R the Department 4 f OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FOR S PART B CHECKLIST Property Address: 37 . Owner, r'tl�ty� Date of Inspection: no Check if the following have been done.You must indicate es"or"no"as to each of the fo llowm , Y No _. Pumping information was provided by the owner,oc cupattt,or Board of Health . - -` -4Z Were any of the system components - - - / ---_-- Pumped out in the previous two-weeb-?— �L _ Has the system received normal flows in the Previous two week period? Have large volumes of water been introduced to the system recently or as part of this `� -- Were as built pleas of the system obtained and exami�? inspection? ��y were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? '� �✓ _ Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncover o of the baffles Were tees,material k construction,o e4 mod,and the interior of the tank inspe�d for the condition / n,dimensions,depth of liquid,depth of sludge J 8 and depth of scups? _ Was the facility owner(and occupants if different(roan 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 de Y no ternuned based on. 7- _ Existing information For example,a plan at the Board of Health, Determined in the field(if an of ? is unacceptable)[310 CMR 15.302 3 Y the failure criteria related to Part C is at issue approximation of distance T;N ►ncn>rfinn Gn^„All ar-)nnn 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 177`Z Owner. I\e'ti Date of Inspection: RESIDENTIAL FLOW CONDITIONS ° Number of bedrooms(design): -S Number of bedrooms(actual): DESIGN sow based on 310 CMR 15.203(for example: 110 gpd x#of bedroonn). Number of current residents:1— Don residence have a garbage grinder(yes or no):�0 Is laundry on a separate sewage system(yes or no):�,0 [if Yes separate inspection re Laundry item inspected(yes or no)*�V 9�d] Seasonal use•. (yes at no): r^-� Water axtes_r+eadingti if available 3 —_ -- - Sump Pump(yes or no): w e Last date of occupancy; COMWERCLUANDUSTRIAL Type of estsblisbment: Des flow(based on 310 C1bIIL 15.203): Basin o w seaW]Persondsgfketc.): Grease ftV present(yea ar no Industrial waste holding tank present — Non-sanitary,waste discharged ilia S Water meter readings,if -a le: system(yes or no): Last date of occu �; OTBT (describe): Pumping Records GENERAL INFORMATION Source of information: S Was system Pumped as Part of the inspection( es or no):1LS� hrm �O If yes,voe Pumped: t t,� allons—How was Reason for pumping: C�5 quaatitYumped determined? E OF SYSTEM Sepdc tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool 7 —privy Shared system(yes or no)(if yes, attach previous inspection records,if any) _Innovative/Altemative technology. Attach a copy of the cun'ent obtained from system owner) operation and maintenance contract(to be --Tight tank —Attach a copy of the•DEP approval _Other(describe): Approximate age of all components,date installed(if kno and source o ormation: f � b• -1. Were sewage odors detected when arriving at the site(yes or no): vt Q T:IIn C �ncna�linn r:�....F,l c,�nnn h OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR S PART C SYSTEM INFORMATION(continued) Property Address: �} �c L Owner: Date of Inspection:his t BUILDING SEWER(locate on site plan) Depth below grade: 6 Materials of construction:_cast iron � other 40 PVC_ > tance frrom private water supply well or suction line: (explain): Comments(on condition of joints,venting,evidence of 1 aka ge,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade; z 4 1 uc Material of constrtion:1oncrete—metal m._other(explaia) _maw--polyethylene . If tank is metal list age:_ Is age Confirmed by a Certificate'of (yes or no): Dimensions: _(attach a copy of . 1 V ` [ p p Sludge depth: c Distance from top of sludge to bottom of outlet tee or baffle:- Scum thiclmeas: Distance from top of scum to top of outlet tee or bale: tf Distance from bottom of scum to bottom of outle tee or bale: l " - �czr�^--� S How were dimensions determined; �^o #? bcr Comments(on pumping recomma'anons,inlet and outlet tee os baffle condition,strut as rely too invert,evidence of leaks e,etc.): rural integrity,liquid levels vM� GREASE Tom:_(locate on site plan) Depth be w grade:_ Material o coon:_concrete_metal—fiberglass_po y y(explain): g 1 eth lane_other Dissensions: Scum thiclmess: Distance from top of scum to top of outlet tee or battle: Distance from bottom of scum to bottom of outlet tee or baffle:Date of last pumping; Comments(Ono commendations,inlet and outlet tee or baffle conditio �stru -as related to ou et invert,evidence of leakage, etc.): n , liquid levels Tirin � ►ncnaMinn �nr.n!./��/�nnn 7 ro OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:--`—r-- IICN C �. Owner: ��.n Date of Inspecdou: TIGHT or HOLDING TANK: (tank must be Pumped at time of inspcctionxlocate on site plan) Depth be INatarial of cons eracti on. metal __fiberglass polyethylene other(explain): Dimensions: Capacity: nllons Design Flow: ¢e11onns/dg �---- - - - - - ---Aler-m Prraent(Yea or no).- Alarm level: arm in working order(yes or no): Date of loaf pumping: Comments(condition of alarm and float switches,etc.): ------------- DISTRIBUTION BOX: (if present must be o � Pemd)(loeate on site plan) Depth of liquid level above outlet invert: Cs " Comments(note if box is level and distribution to outlets e leakageto of of box,etc.):` q�1.any evidence of solids carryover,any evidence of e S �r ur p r UMP CHAMBER: (locate on site plan) 1'umpa in wor ' der(yes or no): Alarms in working order Comments(note condition of pumppb-�-c endition of Pumps and appurteaan� } Title i fncnortinn Rnan All 9/1)lVVI 3 L v• OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE CTIIOON FORM PART C FORM SYSTEM INFORMATION(continued) Property Address: 31 /)Ma Owner: AN l Ve Date of Inspection: Nn SOIL ABSORPTION SYSTEM(SpS); (locate on site plea,Mavatlon not required) If SAS not located explain why: Type - -- -- -- lcaching_P ts,number-la— — - Inching chambers,number:_O�.�T.- �t Inching galleries,number leaching t muhes,giber leaching fields,number,dimensions: overflow cesspool,number. immmdveJalternative ayste� Comments(note condition of so' signs of hydraulic of technology; etc.): 1 soil, gns of hydraulic failure,level of P° &damP sci1, condition of vegetation, CESSPOOLS: Ce II ( sspool must be Pumped as part of inspecdon)(locate on site plan) N configuration: Depth-top o .d 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,leve g,condition of vegetation,etc.): PRIVY: (locate on site .Materials of co ction: Dimensio_ . Depth o solids: Comments(note condition of soil, signs of hydraulic failure, lever of ponding,condition of vegetation,f neq etc.): 9 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address. Owner: Date of Inspection: SMCS OF SEWAGE DLSPOSAL SYSTEM provide a sketch of the sewage disposal system inclndmt ties to at least two permanent reference landmarks or benchmarks,locate all wells within 100 feet 1-ocate where public water supply chters the building Or- rc�er 2-z Pc _ 'n OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM ASSESSMENTS PART C SYSTEM INFORMATION(continued) Property Address: Z Owner. � Da te b of Inaptc tion: O to $ STI'>i EXAM Slope Surface water Check cellar Shallow well Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained$om system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hold.within 150 feet of SAS) Checked with local Board of Health-explain- Checked with local excavators,installers-(attpch documentation) Accessed USG$database-explain: S b 2 S I ZLvv - 1 Ae-)J — -� Yo must describe how You established hi ground water elevation: 1 SA G 6 D b Tula Gn- A'I G1')IlOn 11 fx� .......... THE COMMONWEALTH OF MASSACHUSETTS P �� _ BOARD OF HEALTH ..............OF........ 3.tt............................ 1AVVIlration for Ehapoiial Works Tomitrurtion Frrutit Application is hereby made for a Permit to Construct (,K) or Repair an Individual Sewage Disposal System at: ............ .......................!T............. ........................... .................................................................... or L Lot No. . ................................................................................ -------- ..... Address .... ........ ............................................................... Installer Address U Type of Building Size ......Sq. feet , Dwelling—No. of Bedrooms............................................Expansion Attic 4) Garbage Grinder PL4 Other—Type of Building ............................ No. of persons......................_..... Showers Cafeteria Otherfixtures ...................................................................................................................................................... Design Flow..._......J5_7........................gallons per person per dal. Total daily flow-----:�?_,)o...........................gallons. 1:4 Septic Tank—Liquid capacity-t(M---gallons Length.!K.'-Z!. Width._,5_-'d". Diameter__._......._. Depth.C!:.P..... Disposal Trench.—No. .................... Width.........._.._._._.. Total Length___.........._...... Total leaching area....................sq. f t. Seepage Pit No.-...__--I------------ Diameter-___ ....... Depth below inlet................A.1........... Total leaching area.:Q)......sq. f t. z Other Distribution box (YO Dosing tank �C)_ ., Percolation Test Results Performed by--- - 5..k....I.t A.. !.!. Date.AADI­85............... Test Pit No. I---�g------minutes per inch Depth of Test Pit----kZ25....... Depth to ground water----N nT_------ rX4 Test Pit No. 2...4Z......minutes per inch Depth of Test Pit__-__410...... Depth to ground water...a [Pu 51&ezx"> 9 ..................................................................................C�...............S. ................. 0 Description of Soil...77.1'....0,i 0ekbAJU LOAM ? - ----------- ........ S-....0_5=AJ;tt........ ................................................ I..... .........D__ 66 -E-.c .....TR_ j U - -----------W, tL .5v ------4-5.-A -15----- ..................... 6vt(_:_Aj4,L0&Wt 6,S'-Z Loh,&,y 14-.Wt 5u650te_L,Q-4,Q -Pt D A(Se- --- .-. _--- - ------------------------------------------------ ­7--- --- --------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable. �_ _7 k4AD-----Yq.&Q5A3;QD--- ....................................................................................................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Enviro, a Co The undersigned further agrees not to place the system in operation until a Certificate of Corn i e issued by t_ e board of health. 67-l-, Sie ..--------- --- -------------------- ----- ---- -------- -------------------­---- ........................................ Date ApplicationApproved By ------------------- -------- --------------------------------------------------------------- -..,g.......��.1,- Date Application Disapproved for the following reasons: -----------------------------------__................................................................................................. ...............................................................................................................................................................................................­­------------ ................Dace..............--.. PermitNo. .......... ........IV.01..................... Issued .................................................................... Date •o.. R rr"t 1 No...:..:. .. ....` Fss.......;.................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................... .��..............OF..... "�.,� ,v .... .s L............-••..................-- ApplirFa#inn for 11ispos al Worko Tnnstrnr#inn "anti# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System t: 1 •-------•-------••-------------J...... .- --•---- •----------......._......---•------ ...................-r..............------. ..- ................................... Location-Address or Lot No. ......................_..........................-............................................... -•-••--•-•-----------•--•._....._....•-•--.....•••--.......••----••--••..........••-••............ Owner Address W Installer Address _ QType of Building Size Lot._ I_'}_.___..Sq. feet Dwelling—No. of Bedrooms........._�...................._........Expansion Attic ( ��) Garbage Grinder ( t) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures ............................ d ,-.. -----------•---••---------------------- W Design Flow........... ....._........__.._____..gallons per person per d4,y. Total dai i�flow........ .... .......................gallons. WSeptic "Wank—Liquid capacity!.'--gallons Length....`��__ Width--�- Diameter."".` ....... Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......I---.--.-----. Diameter.......... .......... Depth below inlet.... ............. Total leaching area. ......sq. ft. z Other Distribution box (I Dosing.tank Percolation Test Results� Performed by....�:-`"�...............�:` ....'''�.•........................ Date___..../_�.`:�!`.� Test Pit No. I................minutes per inch Depth of Test Pit-----�.;. _...,-- Depth to ground water------�"�---..-.--. (i Test Pit No. 2..4.Z.......minutes per inch Depth of Test Pit.................... Depth to ground water........................ ----------•----•-- O Description of Soil. ...t �_' fJ U _t +.,v ls�A,a�1 {j.5 - C ,rt rti� .:._..... •-----------------•----------••--------------------------------------- A.1 `/' ... L4 \`� 1�'{ (_,,,I.f �7!`lt U� r�V�}.• �,,. 1 l r..... t {.._ «s[ (_� ly e'er �,,'_r `,� t_ - 1\1 t.t� `�P'�.11.1 \ ...................................................•.._____._..........._........ W �:..`?, �rltl..� U ) - c.< f-4r1•��y .tut� `. l�;rj .�t�3;- C............ =:,j��j---,.�1�.�..�-•�--�%\1�}� ..-•-•----------------------------------------"•-•-------------------------•------------•-•-----------...... ... _..... x 4 [ rift "° v�i:c t_j Ufa tV J 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 Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the-h off Signed ............................................:.......... ........ .: ........................................ Application Approved B % ' ....... " - ---/- 7 PP PP y ------------------�-------------. e - Application Disapproved for the following reasons- -------------------------------------------------------------------------------------------------.................................... -------------------------------------------------------------------------- ------------- -- --- ----------------------------------------------------------------------------- -------------- -- -- ...........................------------ - ` r r, D Permit No. ---...---- -� -- -..........................................� a[e Issued ............................................................... .. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ .............................................. OF ....... -- --..--.........-- ----------------------------------------------- TWrtifirax#e of C�omplia n e THIS.IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) v by ------------------------------------------------ ----------------`A.....----`------......-- ---------....---- --.--.. ---............---------....----------------- -------------------------------------...---...-- ------- Installer +� _ at ......�......-.......I.�p�, ......_..,......v ...` t i .... i } has been installed in accordance with the provisions of TITLE 5 of-The Starp"vironmental Code as described in the application for Disposal Works Construction Permit No. -------�. `.:'..--../.....X..-- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...........................�.. . " .-.--- -- --.............................. Inspector .................. ------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS �... BOARD OF HEALTH ..........................................O F...... .......................................................................... . No......:................. FEE...:.................... Disposal,Worko Tannstr inn amit Permission is hereby granted...................... ........................, ..............•..........--••-----•-•--......... ---------•............-------- to Construct (' -) or Repair ( �-) an. Individual Sewage Disposal .,.__,System at No -------------------•--••-.=... --- ........................................................... Street 1/ =r as shown on the application for Disposal Works Construction Permit N :.:._ .�. _._�_. Dated........................................ .. J _ -----------------------••-- DATE. � Board of Health FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS sH EEc %ec Z �>✓51 Cz� ��.. 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