HomeMy WebLinkAbout0050 FULLERS MARSH ROAD - Health 50 Fuller Marsh, Cotuit
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arrrr4 Location: 50 FULLERS MARSH ROAD
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'2 Owner: PASS,IONATHAN B&LORI B
00Ba62 - a0t003 _ ..
ReaO r314-
WMI o /' Nap a parcel 006034
r g1p "r•"' — Location 50 FULLERS MARSH ROAD
1y8 A1Tesge 1.07 acres
Naghng Address PASS,IONATHAN B&LORI 6
P O BOX 194
OBt041 COTUIr,MA 02635
jApr3a rueD33
rwopr "s.>{3 Value >Y ztzs7p
6I Features $3,100
s Out Buildings $1,806
Land $251,506
v a
J �� , Buildings $115,100
{ { O 36, 1 /, Thal Appraised $371,500
_ ri l/n G7 i'Bdca Features $3,100
s ^ks 1 l G !^ Out Buildings $1,800 ^
Land $251,500
t� Buildings $115,100
Total Assessed $371,500
r311
'c �C-nstrsaltsan 130ai:
style Ranch
aomo QD ro O rbdd Residential
rrl g,, Z Grad Average
Stories I SOory
Bdedor Wall Wood Shingle
Rod Structure Gable/Hip
Roof Cover Asph/F GIs/Cmp
Interior Wan Drywall
060 Interior Floor carpet
rys Neat Fuel Oil
aa�p►`s Nest Type Hot Air
ao�r1 `R r314 AC Type central
r741. 7 $06 aoe�+�ael
r334 Number of 3 SWrooms
l Bedrooms
Number of 2 Full
set scale 1' :771 1 ' §Aen�Riiitos . "z:;� MAP DISCLAIMER Bathrooms
> Total Rooms 5 Rooms
Copyright 20052010 Town of Barnstable,MA Ail rthts reserved.Send Questions or comments to GIS
earnstabler•'A•+1.2.3667[Production]
http://66.203.95.236/arcims/appgeoapp/map.aspx?propertylD=006034&mapparback= Page 1 of 1
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection ,John G,:tci
• One winter Street,Boston,Ma. 02108 D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
(508)564-6813
WILLIAM F.WELD
Governor
ARGEO PAUL CELLUCCI t �N
Lt..Governor !"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART A
CERTIFICATION '+
> 3LQ
M s
rt � Address of Owner:
Property Address. 50 Fuller Marsh Cotu A f
o c9 ,
Date of Inspection: 2120198 (If different) ^q
Name of Inspector: John Graci Therese Mason/Richard Mason:113� urlong Way L`ot(jot 02
WCp
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number: "N
9 .
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:
x Passes This Inspection Is based on criteria dented inTttle V
code 310 CMR 16.303.My findings are of how the system Is
_ Conditionally Passep performing at the time of the Inspection.My Inspection does
Needs Furth r Ev ation By the Local Approving Authority not Imply any warranty at guarantee of the longevity ofthe
septic system and any of Its components useful Ilfs.
Fails
Inspector's Signature: Date: 2125i98
The System Inspector shall sub it a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of-the replacement or repair,passes inspection.
Indicate 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
Coltipliance(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=97)
One Winter Street • Boston,Massachusetts 021108 • FAX(617)556-1049 is Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 50 Fuller Marsh Cotult
Owner: Therese MasonlRichard Mason:113 Furlong Way Cotult 02635
Date of Inspection:2120198
_ Sewane backup or,breakout or hiah.static water level observed.in.the distri.bution box is due to a broken.
or obstructed pipe(s)or due to 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 leveled 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,] 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 the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH 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 PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a '
surface of water supply or tributary to a surface water supply. .
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has aseptic 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage in 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
cesspool.
SAS is in hydraulic failure.
(revised 04r17197)
I
e I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 50 Fuller Marsh Cotult
Owner: Therese Masonifthard Mason:113 Furlong Way Cotult 02035
Date of Inspection:2120198
D]SYSTEM FAILS(continued)
Yes No
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 112 day flow.
Required pumping more.than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspcol 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 1 of a public well.
An portion of a cesspool or privy is within 50 feet of a private water supply well.
it Y P P . P vY
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] LARGE SYSTEM FAILS:
You must indicate either"Yes".or No as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with s 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.5 nitrogen sensitive area(interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127)87)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 50 Fuller Marsh Cotult
Owner: Therese MasonlRichard Mason:113 Furlong Way Cotuit 02635
Date of Inspection-,2120199
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
,c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_c— — The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System, have been located on the site.
x 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..
x 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 Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
(mleed 04127/97) '
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION "
Property Address: 50 Fuller Marsh Cotult
Owner: Therese MasordPJchard Mason:113 Furlong Way Cotult 02635
Date of Inspection:u20199
I FLOW CONDITIONS
RESIDENTIAL: d/bedroom for S.A.S.
Design flow: = 9 p
Number of bedrooms:
Number of current residents: u "
(Y
Garbage
grinder rinder es or no):
. No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yea last two 2 year usage d "
Water meter readings,if available:( � )y g (gP )• -
nfa
Sump Pump(yes or no): No
Last date of occupancy: nla
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:U gallons/day
Grease trap present: (yes or no) Nc
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nra
Last date of occupancy: nra
OTHER:(Describe) roa
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)Nc
If yes,volume pumped:U gallons
Reason for pumping: nla
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single 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:
APPROXIMATE AGE of all components, date Installed(If known)and source Information:'
1962 w1th new septle In 1991.
Sewage odors detected when arriving at the site:(yes or no) No
(rsvlsed O6r27197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 50 Fuller Marsh Cotuit
Owner:
Therese MasonlRichard Mason:113 Furlong Way Cotuit 02635 j
Date of Inspection:2120198
SEPTIC TANK: x
(locate on site plan)
Depth below grade: 1'
Material of construction:x concreate_metal_FRP_Polyethylene_other(expiain)
If tank is metal, list age rda . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L$16"H67"W410"
Sludge depth:+"
Distance from top of sludge to bottom of outlet tee or baffle:26"
Scum thickness:o
Distance from top of scum to top of outlet tee or baffle:e"
Distance form bottom of scum to bottom o=outlet tee or baffle:0 4
How dimensions were determined: measured
Comments:
fist invert structural integrity,
tees or baffles d e depth of liquid
level in relation to ou
and outlet q
(recommendation for pumping,condition of Inlet P
evidence of leakage,etc.)
Septic tank and all components are structurally sound and Mctloning properly.Recommend pumping evert one to two years.
GREASE TRAP:
(locate on site plan)
Depth below grade: nla
other(explain)Polyethylene_
Material of construction: _concrete_metal_FRP_
Dimensions: rda
Scum thickness:nfa
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: nra
Date of last pumping;va
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.)
rYa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 16^
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction linetovm
Diameter: 4_
Gimments:(conditions of joints,venting,evkience of leakage, etc.)
(revised 04J27187)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 50 Fuller Marsh Cotult
Owner: Therese MasonrRlchard Mason:113 Furlong Way Cotuit 02635
Date of Inspection:2120199
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: n1e -
Capacity: nfa gallons
Design flow: rya allons/day
Alarm level:_Wa Alarm in working order?._Yes_No
Date of previous pumping: »
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: nla
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER: '
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_ve: ;
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
r
(revised OW7r97)
F +
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) ,
Property Address: 50 Fuller Marsh Catult
Owner: Therese MasonfRichard Mason:113 Furlong Way Cotuit 02635 n
Date of Inspection:2120199 -
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavatioln not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
ria
Type:
leaching pits,number: one:1Aoo gallon leach p@
leaching chambers,number:nla
'4 leaching galleries, number: n1a
leaching trenches,number,length: rda
leaching fields,number,dimensions:We
overflow cesspool,number:one:4x-
Alternate system: rda Name of Technology:_nfa
Comments: (note condition of soil, signs o"hydraulic failure,level of ponding,condition of vegetation, etc.)
SAS and as components are structurally sound and functlorfng properly.Leach pit never had more than 4"of water In a.Systems ere both empty.
CESSPOOLS:
(locate on site plan) w
Number and configuration: rda
Depth-top of liquid to inlet invert: rda
Depth of solids layer: rya
Depth of scum layer: nra
Dimensions of cesspool: rda
Materials of construction: n1a
Indication of groundwater: nra
inflow(cesspool must be pumped=as part of inspection)
rya
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
rda
PRIVY:
(locate on site plan)
Materials of construction: n1a Dimensions: rya
Depth of solids: nla
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rds
(revlood 04127)97)
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
50 Fuller Marsh Cotuit
Therese MasonlRichare Mason:113 Furlong Way Cotuit 02635
2120198
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)
S VA
�G '71
x r ,
Pala ! o! 30
pwlud OAR7R7)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
50 Fuller Marsh--otult
Therese Mason/Richard Mason:113 Furlong Way Cotult 02635 w
2120199
Depth of groundwater 12 i
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 conCitions a
Check with local Board of Health
Check FEMA Maps r
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how yrna established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
c
4
(revised0027197) sago 10 of 19
ASSESSOR'S MAP NO. PARCEL S'A .5'o2
Irk CAT10N SEW GE PERMIT WQ. �
V I L L A E
I N S T A LLE 'R'S NAME ADDRESS
To 4
Yf
U1UDEH OR OWN ER
C
PAT ' C0M, P L I A N C E ISSUEQ olIqlffg
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No... 09 Fps..........:................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
� `/: :
( ...... OF........
y
........
AppltrFattuat for DiupuuFal Works Cnonstrurtivat Prrutit
Application is hereby made for a Permit to Construct ( ' ) or Repair (Y) an Individual Sewage Disposal
System at:
teldle.1
------•--.....; ..............................�..�..�...�.....�...�........................ ......................•...._...-•----•---•---•--------.......••--•--------•--•--------------------
. r or Lo"....� .. � .'o.
Own Address
JTO
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms......... ..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building No. of persons............................ Showers
� YP g -------------•------------•- P ( ) — Cafeteria (-----)-
Otherfixtures ................................................•-----.••------•---••----------•-•------------------------...._•--...--
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1----------_.....mir_utes per inch Depth of Test Pit.................... Depth to ground water- _-_-___--______--.
V4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil................. t� ` s�i
---•-----•- ............
•---------------------------•----------------------- - ----- --
V ......... ....... ------------------.......•---------•------•----•-----•------•-•-•---•-------•........................................
W
x •------------------------------------------•-------------•----------- ----••---•-------•--•-----------•----•-•-•..... --------- •---------•-----•----•-•--•----•-••----------••--•----. .._........
U Nature of Repairs or Alterations—Answgr wh/o� applicable__--...41i� J�._..�•S ®_.. _ !_____. .._....____.
Agreement: e e S s/A ol,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'i t LE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Ccmpliance has b iss ed by the board of health.
Signed....... .............. ...
e� Date
Application Approved BY :3� ��s, ` ------....6.. .. �Date
Application Disapproved for the following reasons:------•-••------•-•--•-••--••--•----•-----------------•---••--•--•-------••-•-----•------••------•-------....._
. .....................-..............................................................................................................................................................................
Date
PermitNo......... p --------------- Issued.......................................................
Dax,t
.i
No.... :y.. ? Fxs....7:5..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. .r�..�..-.----
ApplirFation for Binpontai Work, Towitratrtion prrntit
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
�o s
..... __ _ .................................................. -•---------------------------------•--------------------------------.............-------•---••----
g Location-Addre s / _ {` or Lot No. / / �.
��4 SOH C�7u, —S v �c.l�/`,, � !!^ _..-..--"'�-'/ C►r� ' -
..-``..................................... .---- .... ....
aJ04.. OW�4 A, Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___---_-- ...............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............... No. of ersons....._...................... Showers
a YP g ------------- P ( )--- Cafeteria ( )
dOther fixtures ------------------------•------------------------•------------------------------------------------------------.•--- ----------
W Design Flow............................................gallons per person per day. Total daily flow......._....................................gallons.
0� Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter................ Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.--__--____-________--.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------..................
P+ ........•..........- -
O Description of Soil. ~�`$`0 ` •--.....5...� ---------•-••---•---••-------------------------------------•---------------------•---.................
U ............................................................... ---.................................................... .............-................................................................
W
--------------------------------------------------------------------------------------------------------------- ---------•--•---•-••---•---•--•-----•------------••----•-----•--------
U Nature of Repairs or Alterations—Answer whe applicable---------
, a•, O0--_S�_T,..._...Sw�-
Ht c� C---t ....
/D
--•--- ---------------------------------------------•----- --------Q ....... prifL y
Agreement:
The undersigned agrees to install the,aforedescribed Individual Sewage Disposal System in accordance with
/'1T r1'+-
.1..E the provisions of 'i 5 of the State Sanitary Code— The undersigned further agrees riot to place the system in
operation until a Certificate of Compliance has iss ed by the board of Iealth.
_ Signed....... :--•------•... ................
..
Date
Application Approved By--•-------•------�`.:...� '� - ..........6 �•...
----------------•------- Date
Application Disapproved for the following reasons:-------•------------•-•--------•----•------------------•-----------------------•-------------------------•......
----------------------•-----------------•-------------------••-------------....---------....-•----------.-•---------'---------•-------•----••--•-----------------------•-----•-•--••--••--------•-------
G Date
Permit No. o' - D'a Tssued_
Lc_..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL�TyH
�. ...........OF...........`.. s
�rrtif iratr of TompliFanrr
THIS IS stem TO CERTIFY, That the Individual Sewage Disposal S- constructed � or Repaired
�-�� g P �' ) ( )
by - E:- 'r% .....---•-•.....---'--------•------•--------•'----•------------------------------------•-------•-....-----------•------•-------
Instal
at.....................
has been installed in accordance with the provisions of T I T IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------- dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GU RA EE THAT THE,
SYSTEM WILL FUNC S TISF CTORY.
DATE........................ `7i inspector.—= ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL' H
ft�l�r.�..........OF......... .-Gr'_y4:::. �... .............C
........ FEE... ....: ..........
Disposal Worku Ton 'lion rrntit
If
Permission is hereby granted--------•• s J `::t ........s4�. -•--•--------------------•------...--•--•-----.....-•-------................---�..
to Construct ( ) or Repair ( ) an In ividual Sewage Dispo al System
at No. .c.
�' _ .. .
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as shown on the application for Disposal Works Construction Permit No_�Y:__`!-( Dated..........................................
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DATE_ Board of Health
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FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS