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HomeMy WebLinkAbout0043 EASTWOOD LANE - Health 4AA3 Eastwood Lane (Cotuit) i ;... � H. CERTIFICATE OF ANALYSIS Page. 1 Barnstable County Health Laboratory Report Dated: 06/28/2001 Report Prepared For: RECEIVE® Order Number: G0110235 Linda Chessman , 226 Grove Street J U L 0 5 2001 Chestnut Hill, MA 02467 TOWN OF BARNSTABLE Laboratory 111)#: 0110235-01 Description: Sample#: 10235 Sampling Location 43 Eastwood Lane,Cotpit MA Collected: 06/15/2001 Collected by: L Chessman �� Received: 06/15/2001 Routine ITEM RESULT UNITS MCL Ytethod.# Tested LAB: IC Lab Nitrates <0.1 mg/L 10 EPA 300.0 06/15/2001 LAB:Metals Copper .. 0.2 mg/I 1.3 SM 3111B 06/19/2001 Iron 6.9 mg/L 0.3 SM 3111B 06/19/2001 Sodium 8 mg/L 20 SM 3111B 06/19/2001 LAB: Microbiology Total Coliform Absent P/A - Absent P/A 06/15/2001 LAB: Physical Chendstry Conductance 81 umohs/cm EPA 120.1 06/15/2001 pH 6.0 pH-units EPA 150.1 06/15/2001 Note: Based on the results of the parameters tested,the water is suitable for drinking but may present aesthetic problems(taste, odor,staining)due to iron. Approved By: , (Lab Director) t - i i t a t 'V I . Superior Court House, PO.Boa 427, Barnstable, MA 02630 Ph: 508-375-6605 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF.ENVIRONMENTAL PROTECTION / r TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: d ���Y RECEIVED M Owner's Name: Owner's Address: �= JUL UL 0 s 200, _104 Date of Inspection: (4 1—)4 &.1 TOWN OF BARNST HEALTH DEPT. Name of Inspect vr , leas pr t) 1(�Company Nameyv Mailing Address: •0- 17 y OP&W Telephone Number:222&- 27/• 9439V 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 ection 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes aN ds rther Evaluation by the Local Approving'Authority -ails Inspector's Signature: Date: — �1_14 �t7f 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 ****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. Title 5 Inspection Form 6/15/2000 page I 0 r Page 2 of 11 OFFICIAL INSPECTION`FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: �Z A Owner: Date of Inspection:. Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A.)ystem Passes; I have not found any information which indicates that any of the failure criteria described in310 CMR. 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B: System Conditionally Passes:. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion ofthe replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND).in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old*.or the septic tank(whether metal or not)is.structurally unsound;exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the, existing tank is replaced with.a-complying septic tank.as approved by the Board of Health. *A metal'septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the.distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution.box is,.leveled or replaced ND explain: The system.required.pumping more.than-4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain: 2 r Page 3 of Il OFFICIAL INSPECTION-FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 7 �i 'la'(1� Owner• - Da to of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety" or the environment. 1. System will pass unless Board of.Health determines in accordance with 310 CMR 15.303(1)(b)that the, system is not functioning in a mannerwhich.will protect public health,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 any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has.a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank.and SAS and the SAS is.within 50 feet of a private water supply well. _ The system has a septic tank and SAS.and the SAS is less than 100"feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed:at a DEP certified laboratory, for coliform bacteria and volatile:organic`compounds indicates-that the we11 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: 3 Page 4 of I l OFFICIAL.INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: A Owner: 1� Date of Inspection: wl.L//ol 0 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections:. Yes No/ VBackup of sewage into facility or system component due to overloaded or clogged SAS or.cesspool Discharge or pond.ing of effluent to the surface of the`ground or`surfi6 wafer'"§due to an'overloaded"or / clogged SAS or cesspool [/I Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or _ V cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is.less than ''/Z 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 SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within I00.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. [This.system passes if the well water analysis, performed at a D.EP 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.] (Yes/No)The system fails: I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: - -� To be considered a large system:the system must serve a facility with a'design flow of 10.,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II.of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or 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 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SE WAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: D &O& Owner: o Date of Inspection: Ca,4V,1/'L' Check if the following have been done.You must indicate"yes"or."no"as to each of the following; _ Yes No _- Pu!npina:information.was provided by the owner.occupant;or Board of Health !/Were.any of the system components pumped out in the previous two weeks? vHas 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 inspection? Were as built plans of the system obtained and examined?(If they 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 breakout? Were all system components,excluding the SAS, located on site _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? 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 _ Existing information.For example,a plan.at the Board of Health. _✓/— Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[31,0 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL-INSPECTION•FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION.I4'ORM PART C SYSTEM INFORMATION Property Address: A Owner Date of Inspection:_(Q� -0z FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):- . Number of bedrooms(actual): DESIGN flow based on 310..CMR 15.203 (fo example: l 1.0'gpd x#of bedrooms): Number of current residents. Does residence'have.a garbage grinder(yes or no): /10­ Is laundry on a separate sewage System(yes or no) if yes separate inspection required] Laundry system inspected. yes or no):,,�Qp— Seasonal use:(yes or no): Water meter readings, if a ailable(last 2 years usage('- d)): Sump pump(yes or no);,� ' - ` Last date of occupancy:OS 9c 64aew ZCO COMMERCIAL/INDUSTRIAL— 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: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no : If yes,volume pumped: gallons--How was Juan D�'�ity pumped determined? Reason'for pumping: TYP F SYSTEM eptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy Shared system.(yes or no)(if yes,attach previous inspection records, if any) Immvative/Al tern ative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)- -Tight tank _Attach a copy'of the DEP,approval —Other(describe): A proximate age of all components,date installed.(if known)and source of information: Were sewage odors:detected when arriving.at the site(yes or no)L i 6 1 Page 7 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: A Owner: Date of Inspection: BUILDING SEWER(locate on site plan) v/ Depth below grade: Materials of construction:_cast iron _40 PVC_other(explain):- Distance from private water supply well or suction line: Comments(on condition ofis;"venting,evidence o oint f leakage,etc.): SEPTIC TANK: !O(locate-on site plan) it Depth below grade: Material of construction: 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: .,j,k(gip' x 5 Sludge depth /- (y x� Distance from-top of sludge to bottom of outlet tee or baffle: Scum thickness:s!/ 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 were dimensions determined:,XZ/7.l�CZI Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): GREASE TRAEoffi:(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.): 7 r Page 8 of I 1 OFFICIAL INSPECTION FORM-.NOT-FOR VOLUNTARY,ASSESSMENTS SUBSURFACE SEWAGE mSPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORIVMATION(continued) Property Address: C 3(21ahm�� Owner:. Date of Inspection: TIGHT or HOLDING.TANK (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(ezplain):. Dimensions' Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:. V (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distributions equal,any evidence of solids carryover, any evidence of akage into or out of box etc.): PUMP CHAMBER ocate 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.): 8 1 • ' Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART. C / SYSTEM INFORMATION(continued) oe Property Address: 11 Owner: Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type Ieaching.pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil;condition of vegetation, CESSPOOL/ (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil;signs of hydraulic failure;level of ponding,condition of vegetation,etc.): PRIcate 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.): 9 Page 10 of 11 OFFICIAL-INSPECTION FORM=NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION(continued) Property Address:. 7' Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Lvv %t �i 693 o 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: (ACC .> 4"a Ad A Owner: Date of I spection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet, Please indicate(check)all methods used to determine the high ground water elevation: Obtained from.system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: {Checked with local excavators, installers-(attach documentation) y Accessed USGS database:-explain: You must describe how you established the high ground water elevation �1 �' L G . r 11 LOCATION SEWAG -M T NO. VILLAGE li R I ST LLER'S NAME DDRESS X/_ys -B WI L D E R � OR OWN E DATE PERMIT ISSUED 1-76 DAT E COMPLIANCE ISSUED r _Noo.zv.... / a THE F TS BOARD OF HEALTH _1 e9lu-t ...........OF...... Appliratzon -for Uitipoottl Workii Tonitrurtion Vquift s , Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal Syst 76at: Location-Add r s or Lot No./ / - •. --- Owner Address / a -•...............a c,N use T � _ ----•--- .................. --`-•-----------------------------•-------- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms------------------___•-------------- _Expansion Attic (yt,� Garbage Grinder (7 o) Other—Type a of Building _ _r�_..C�t�-t.1/.��i�____ No. of persons..______. __ ___._______ Showers ( ) — Cafeteria ( ) d Other fixtures --------------------------- -•--------•---- Design Flow-----------------------s��.)-----------gallons per person per day. Total daily flow--------------JcO..................gallons. USeptic Tank—Liquid capacitv�.06 gallons Lenorth---------------- Width................ Diameter-----.---------- Depth......... -. xDisposal Trench—No--------------------- Widtl}-.-_.-_-----.-_---- Total Length_................... Total leaching area.-..-.--__--..:.----sq. ff. ` Seepage Pit No._-_-.-_-_-e�-__.___ Diameter-__-_* ----- Depth below inle -----_____ Total leaching area----------________sq. it. z Other Distribution box (� Dosing tank ( ) C '�! -' �lo "�7 ~' Percolation Test Res is Performed by......_.� t_.__ ___ _Q_�'_ __________________________ Date....%--------.--.---.-.-:._._--._-_... a Test Pit No. _ ________-.minutes per inch Depth of Test Pit-------------------- Depth to ground water_--------------------- ` f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit.------------------- Depth to ground tx water r_.....__.___.___--.--__. ---------td ----- �------------------------------------------------ il -/ Description of So ------ -- - --------------------------- x ,-----------c � ... ------- w 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 \I 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 health. Signe _5,. K-.� -- ---P ---- Application Approved B 1?/IsL ------------------------ O- ----77... PP Y 4� Date Application Disapproved for the following reasons---------------••---•---.-.-•----••-------------•------------------------•----•--•----- .......................... I �� Date _Permit No........................................................ Issued.---1- 71--------------------------------------- Date �- -_ --- --- ------- -- - -- .... .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...... -------OF........ Application is hereby'made for a Permit to Construct or Repair an Individual Sewage Disposal System at: A) .......yr .... ...... ­19 ..,-1� ..W........ ......................... .................................................................. Location-Addres — -------- .............. .....T)l C.....11_jt:�Jr No --------------- Owner...... Address t...... .... ..................... ................................ ............................................ Installer Address U Type of Building Size Lot.... -----------------------Sq. feet Dwelling—No. of Bedrooms---__--_.-_----- 3-----------------­--Expansion Attic ( 14)a Garbage Grinder (*...Ak; —1 PL, Other—Type of Building ----- No. of persons... ............0---------- Showers Cafeteria PL4Other fixtures '1�--------------------------------------------------------------------------------------------------------------- ----------------------------------- w Design Flow........................ 4t_.........gallons per per-son per day. Total daily flow---------------- __._.....--__._.gallons. P4 Septic T,,.iik—Liquid capac�ty_..IP ftallons Length................ Width._.._.._........ Diameter__...___----:-._ Depth---------------- Disposal Trench—No_ -------------------- Widtli_�---------------- Total Length..-.------.-______-. Total leaching area--------------------sq. ft. Seepage Pit No.............I--_-- Diameter----D o s 1 t-- tan- .. Depth below inlet area Total leaching area._...--_-:-.-__-_sq. ft. '%". k 7 Other Distribution box A Percolation Test Resu ` Performed ---------- -------------------- Date._.....-:-------------.----...._- ------- , Test Pit No.11jr..........minutes per.inch Depth of Test Pit____________________ Depth to -round water___._.____.._._____..... Test Pit No. 2------..........minutes per 1,ikh_Depth,,of Test Pit____________________ Depth to ground water_..-..__--_--___._.. --------------- . ................ #-------- __­*--- ----- -- - -------------------------------------------- -- 0 eY Description Soil_ ... ----- . ... . .......... ..1. r a -------------- ------------- ----- ------ •...... ­----------- .... ......... --- ------------------------ U ------------­--- --------------------------------------------------------------------------------- ------------------------- ------ -------------------------------------------I------- U Nature of Repairs or Alterations—Answer when applicable...-,.................... -------------------------------------------------------- ----------------------------------------------- ---------------------------------------------------------------------------------- ------- --------------- -------------------------- Agreement The undersigned agrees. to.,_install the aforede'scribed Individtia"I Sewage Disposal System in accordance with 1010-f the provisions of Article XI 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.health. 7 igned ---------- ----- ........ L a e '0 7 7 Application Approved BY----------- ... .... ; _W�/4 �a ---- - ------- :-------- ----------­-- ....... ----------------- Date Application Disapproved for the following reasons:------- ---------------------------------------------------------------------------------------------- ........................................................................................................................................................................................................ Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......... ......:n."41........OF........ .................................. %Uertifirativ of 1,11=0anve THIS IS TO,OERTIFY, at the yidual Sewage Disposal System constructed or Repaired by.... .45" _. Z 0� t",.... .. ............... -----------------------*------------- - ------------------------------------------------------------------ ----------- Installef at................................ .......:4� 40 --------------------------------------- ..................................... has been installed in accordance with the provisions.of A I of the jp,State Sanitary Code as described the application for Disposal Works Construction Permit No.-OX.7--9,1----------- dated------ .............. ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------- ............................................. 'lnspector.......14.....C-.�_ _ ........................................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Te -7 ........................0.f 0F......No...................... FEE------{ ........ CIT'VokstraV 1, M il 40 < Permission is hereby granted---------------A-C it ........................--------------------------------------------------------------------------------------------------- to Construct ( "),Or Repair`. . ndivi -1Sewage D�posal System at No.......................... . ...........i........ �6W X'-1- ! *, . j— Street as shown on the application for Disposal Works Construction Permit No----------------------- Dated._-.__._.._.._-_____..____......__........ ------------------------------------------------------------ .......................................... Board of Health DATE................................ ................................................ FORm 1255 HOBBS & WARREN. INC.. 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