HomeMy WebLinkAbout0020 EISENHOWER DRIVE - Health (2) 20 Eisenh®wet Drive
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COMMONWEALTH OF MASSACHUSETTS
F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
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DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
01FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 20 Eisenhower Drive DREE
Cotuit Ma.02635
Owner's Name: Charlene Fogarty
Owner's Address: SAME
Date of Inspection: October 15,2003
Name of Inspector: PATRICK M. O'CONNELL MAP '
Compan;i Name: SEPTIC INSPECTION SERVICES CO.
Mailing;Address: 189 CAMMETT ROAD PARCEL, Q
MARSTONS MILLS MA 02648 ® g
Teleph)n a Number: (508)428-1779
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below i 11 rue,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
approvetI system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
__XX Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails Inspwt or's Signature: Date: /o//4
The sys to m inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)wit iin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or groater,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: Tank was pumped for inspection. Liquid level in leaching pit three feet below inlet.
Area%here system is located appears to be an occasional parking area.The system components are not H-20
load rated and should not be driven over.
****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 R;pection Form 6/15/2000 page 1
Page 2 if 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of Inspection:October 15,2003
Inspection Summary: Check A,B,C,D or E/ALWAYS-complete all of Section D
A. Syste m Passes:
_XX I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. Sy!.ti!m 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.
Answe► yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain
'he 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
indicati nj;that the tank is less than 20 years old is available.
ND explain:
0 mervation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruc:e-i pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval ff Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND exflain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass in!poction if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND exf lain:
Page 3 )f I 1
DIFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 20 Eisenhower Drive,Cotuit
P Y
Owner; Charlene Fogarty
Date of Inspection:October 15,2003
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 io protect public health,safety or the environment.
i. 53 stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which 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
*1 This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
thl:presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
fa lure criteria are triggered.A copy of the analysis must be attached to this form.
3. 0.%er:
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Page 4 j`11
GFFICIAL INSPECTION FORM-NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Propert;r Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of l:nspection: October 15,2003
D. System Failure Criteria applicable to all systems:
You miust indicate"yes"or"no"to each of the following for all inspections:....
Yes No
_ X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
_X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
_X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_h:_ 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 DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
_No__ Yes/No)The system fails.I have determined that one oi-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 foll)wing 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
significaiit threat under Section E or failed under Section D_shall upgrade the system in accordance with 310 CMR
15.304.1 be system owner should contact the appropriate regional office of the Department.
A
Page 5 )1'11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of)nspection: October 15,2003
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ _ Pumping information was provided by the owner,occupant,or Board of Health
_ X_ Were any of the system components pumped out in the previous two weeks?
_X_ __ 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 inspection?
_X_ __ Were as built plans of the system obtained and examined?(If they were not available note as NIA)
_X_ _ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
_X _ Were all system components,excluding the.SAS, located on site?
_X 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?
_X_ __ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_X_ _ Existing information. For example,a plan at the.Board of Health.
_X_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CMR 15.302(3)(b)]
Page 6 of 1 I
0 FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propert3 Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of Inspection: October 15,2003 -
FLOW CONDITIONS
RESIDENTIAL
Numbe-of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):330
Numbe-of current residents: 2
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required)
Laundry System inspected(yes or no):
Seasonal use:(yes or no): Yes
Water muter readings,if available(last 2 years usage(gpd)): 2001-94,000 gal. 2002—100,000 gal.= 266 gpd.
Sump f u mp(yes or no): No
Last da v of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of Establishment:
Design flow(based on 310 CMR 15.263): gpd
Basis of,Jesign 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 dare of occupancy/use:
OTHE R(describe): _
GENERAL INFORMATION
Pumping;Records:
Source of information: Homeowner and Real Estate Agent
Was sy;tam pumped as part of the inspection(yes or no): Yes (10/17/03)
If yes, vc lume pumped: 1000 gallons--How was quantity pumped determined? Pumper Truck
Reason f)r pumping: Check integrity of tank and tank-had never been pumped.
TYPE DF SYSTEM
XX Se:xic tank,distribution box,soil absorption system
_Single cesspool
_Ovan flow cesspool
_Pri v
_Shar:d system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtaine i from system owner)
_Ti€,h t tank Attach a copy of the DEP approval
Other(describe):
Approx it age of al components,date installed(if known)and source of information:
19 Years old
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 :)f I 1
13 FFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propert3 Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of Inspection: October 15,2003
BUILDd%SEWER: X (locate on site plan)
Depth below grade: Under slab N/A
Materia l.,-of construction:`cast iron X_40 PVC_other(explain):
Distance from private water supply well or suction line:30
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: X (locate on site plan)
Depth he low grade: 4'
Material of construction:—X—concrete_metal_fiberglass_polyethylene
_oth(:r(explain)
If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1000 Gal.
Sludge depth: 8"
Distance from top of sludge to bottom of outlet tee or baffle:22"
Scum thickness: 8"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: I V
How v cre dimensions determined: STICK WITH HINGE FLAP.
CommE r is(on pumping recommendations, inlet and outlet.tee or baffle condition, structural integrity,liquid levels
as relatixl to outlet invert,evidence of leakage,etc.):
Tank is structurally sound baffles are intact and was pumped as part of inspection.
GREA3 E TRAP: No (locate on site plan)
Depth he low grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimew ions:
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 1 ast pumping:
Comme•rits(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
as relatod to outlet invert,evidence of leakage,etc.):
Page 8 if 11
0 FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued)
Propert3 Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of I nspection: October 15,2003
TIGHT or HOLDING TANK: No (tank must be pumped at time of inspection) (locate on site plan)
Depth be low grade:
Materiel of construction: concrete metal fiberglass polyethylene other(explain):
Dimew ions:
Capacity gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Commtnts(condition of alarm and float switches,etc.):
DISTR IiBUTION BOX: (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
Commt nts(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.): -
PUMP CHAMBER: No (locate on site plan)
Pumps ir,working order(yes or no):
Alarms in working order(yes or no):
Comm(nts(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 A']1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propert3"Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of Inspection: October 15,2003
SOIL MISORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_XX_lc aching pits,number:One 6x6(1000Gal.)pit
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
inn.)vative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): Observed liquid level three feet below inlet Dive with no high stains.
CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan)
Numbe.-and configuration:
Depth- iop of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materia L of construction:
Indicati o.i of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Material., of construction:
Dimens ions:
Depth of solids:
Comme n is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
n
Page W of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Eisenhower Drive,Cotuit.
Owner: Charlene Fogarty
Date of]nspection:October 15,2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchrr arks. Locate all wells within 100 feet. Locate where public water supply enters the building.
�.',�er4,owec mac.
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Page 11 -)f l 1
GFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 20 Eisenhower Drive,Cotuit
Owner: Charlene Fogarty
Date of]nspection: October 15,2003
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 20 feet
Please inlicate(check)all methods used to determine the high ground water elevation:
Obi ained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
C it:cked with local Board of Health-explain:
C it:cked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
'Gown groundwater contour map shows water at el.25 and USGS map shows land elevation above el.
45.Bottom of leaching pit 10 feet below grade leaving more than 10 feet:separation between SAS and
ground H ater.
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LOCATION SEWAGE PEVIT NO.
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VILLAGE
INSTA LLEW'S NAME ADDRESS �r
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DUILDER OR OWNEI;
DATE PERMIT ISSUED t-71t14
DAT E COMPLIANCE ISSUED /5� �
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THE COMMONWEALTH OF MASSACHUSETTS
0\ BOARD OF HEALTH
_ .6cwf�1....................OF......34.................-.................................................
Alipfiration for UhiVasal Works Tons rnrtion ramit
Application is hereby made for a Permit to Construct lG_l or Repair ( ) an Individual Sewage Disposal
System at:
.-----------------------------------
Location- dress or Lot No.
�r W..s,he... 1.._ - ..__.._.... .... ���! ...............................................
.......... ......
ez ddress
a ..__..� 1C. .----•-•-•.........-••...... 8 ...........................••-----•-•••-•••-•--•_...._
Installer Address
Type of Building Size Lot__✓_`—'3,,..__.Sq. feet
Dwelling—No. of Bedrooms___.... _.# _ _ ___________________Expansion Attic (All) Garbage Grinder (l��j
Other—Type T e of Building l�dD_�!I'-_________ No. of persons..... Showers —
p-, yp g --- p (,Z) Cafeteria (,If0)
a' Other fixtures -----•--------- •-----•---
W Design Flow.......... ............................gallons per-person per day. Total daily flow..._._._..13_......................gallons.
WSeptic Tank—Liquid capacity/(?...gallons Length___-)D....... Width---4.......... Diameter---4.......... Depth...2_.........
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 (1,4 Dosing tank ( )
Percolation Test Results Performed by..2IIY,5._..SJ,./1C. ./-A.......................... Date._..
Test Pit No. 1...4__Z__minutes per inch Depth of Test P Depth to ground water....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................
x
` 1? :....• -.._..-•-•-------------------------------- •--------------------.........--------
Description ofQ c ......TI
---------ea----...l1
U
W
VNature 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 iITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee
n issued by the board of health.
Application Approved B _____________________________________________________ y
Date
Application Disapproved for h ollowing reasons_________________________________________________________________________________________________________________
...._..-•-•---•-----•--•-•-••-------------•--•----•----------•---••..._•••---•---••-...•-•---__--_..._........••••-••._......._...••-----•---••--•-•------------_---_._....••-•----------•--•.._....-••--
Date
PermitNo......................................................... Issued_.......................................................
Date
--------------
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0
.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
------*J A- Q............ ....OF......�,...:..+....................---............---------.......---.........-----
Applirtttion for Diipniittl Works Clnn,itrurtinn Prrutit
Application is hereby made for a Permit to Construct (C/) or Repair ( ) an Individual Sewage Disposal
System at:
.........1Z i..e, tl •t-r -�_
Location dress f or Lot No.
...........".?:� �� � l------... ( /-•---._...n.......................... ................................. �=�� ---.......-•----•...............................
Owner d Address..................................................
Installer Address
d Type of Building Size Lot... ......Sq. feet
U Dwelling—No. of Bedrooms......... ................................Expansion Attic (A)L.) Garbage Grinder (/14&)
H
Other—Type of Building .._,/_t�,`���r...._..... No. of persons_..._..5 ................ Showers ( ) — Cafeteria (VU)
0.1 Other fixtures ...-------•--•--•••--------•---- .
d == ---------------------------------------
.........
-••---------------------
W Design Flow...........t�...........................gallons per person per day. Total daily flow__-_.-_--.-?Z 2......................gallons.
Ix Septic Tank—Liquid capacity il.Kt:....gall"ons Length..../6._...... Width...._......... Diameter---z.......... Depth...J•.........
Disposal Trench—No. �! `'_`)Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No... __.. -D amete-`r ...___.__..:,. Depth below inlet.................... Total leaching area..................sq. ft.
Other Distrib}atrnD t Dosing tank ( ) / l
Percolation Test Results Performed b%...�:���! _.._...r !L r 4t A 1!......................... Date...... . .�..l. t�
W ...... .........
Test Pit No. 1__ _._ ....minutes per inch Depth of Test Pir.___.0........ Depth to ground water....A/ .......
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ ----------------------------------------------------------------------.........••............................................................................
O Description of Soil -a t" t .r. .�.. .....-----•-•----------------------------------------------•----------.....................-----
< 4
...----•-•--•-•-"
W
-----------------------------------------------•-------------.....---------......-----•-•--------------------•----------------...---------•---------•-•---•-------••-•-----....-••--•---•-•-----.-----
V 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 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.
--------------- .......----- .
Application Approved BY ; f ace
Date
Application Disapproved for ollowing reasons:..............................................................................................................
---•---------------------------------••--•••-•-•.--•-••---•-....--•-•--••---•----.......-•-------••----•--•----------•-•-•-••-•-....---•••--•---•-----•-----••••-••-------------••-----•---•-••-•-------
Date
PermitNo......................................................... Issued_.......................................................
..Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
r
/..�J<1 OF..................>...........t I
(Inrtif iratr of Toutpliatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......... eL'� ,--1/ ------------------•--------••...............................--•--•••----.....---•------•..............---••---•.....--•-----------•---....--
-..-..--.
_ Installer /
- / /.;L...........L.E....=------- �- _---.----•-•-��, � / --------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s d cribed in the
application for Disposal Works Construction Permit ............... ....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
r� I r
DATE..................................................�• -�-••1=-F=��,------ Inspector..................... .(?..............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.z�o /. '1��'� OF.......��.61. ..r4�.........................................................
No........... FEE.,ifl?..............
Disposal Workii Tunstrnrtion rrutit
Permission is hereby granted.... ...jJ ../�:.� " .�°....._...
��
to Construct ( L)-or Repair ( ) an Individual Sewage Disposal System
atNo....... =,!•` __....................---------------------------•-•--------•---------------------------------------•-----......-•---
Street
as shown on the application for Disposal Works Construction Permit No...... ...... Dated..........................................
( ---- -------
Board of Health
DATE.............................................-/.(----------•------------••-•---• / `" v
FORM 1255 A. M. SULKIN. INC., BOSTON
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