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HomeMy WebLinkAbout0052 GUIMQUISSETT ROAD - Health 52 Guimquisett Road \� cotuit - A = 019 - ill �� - -- - - - - - -- �I I r , ` COMMONWEALTH OF MASSACHUSETTS 191,11 r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: J�Z 4!�-14 i ✓MOLA ti © Owner's Name: o Owner's Address: D Date of Inspection. /� Name of Inspector:(please print) , g✓!� /fo w/� " Company Name: !�i O — ~- Tc c�} . Mailing Address: C-' Telephone Number: ,�o CERTIFICATION STATEMENT :Z I certify that I have personally inspected the sewage L�g disposal system at this address and that the information reported below is true,accurate and complete as c the time of the inspection.The inspection was performed based on:my training and experience in the proper function and maintenance of on site sewageM approved system inspector pursua:�,s on 15340 of Title 5(310 CMR 15.0 0. The systems. $m a DEP se asses ' Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 4ZL � The system inspector shall submi a copy of this inspection report to the Approving Authority DEP)within 30 days of completing this inspection,If the system is a shared system or has a design flow of 0,000 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 Page 2 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (�i��o l�c r J e�jL- kc) Owner: 6 3� Date of Inspection: p Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D F A. Syste sses: c 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. i Comments: B. System Conditionally Passes: V One or more system components as described in the"Conditional Pass" E repaired The system,upon completion of the replacement or repair,as approved by the Boadrd of replaced will pass Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Ile 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: T41a i�onartinn r?nrm!./1 GMAnn 7 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A /CERTIFICATION(continued) Property Address: S� (r—U,'Mo 6%4 � ( / 63� Owner: Date of Inspection: o�' C.f' Further Evaluation is Required by the Board of Health: y Conditions exist which require further evaluation by the Board of Health in order to determine if is failing to protect public health,safety or the environment. the system 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 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 an determines system is functioning in a manner that protects the public health,safety and environment: that the _ 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 colifo bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and rm 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: Title� Tnonvrfinn Rnr.r.!./1 G/1AAA Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �� Gti i,,,,p i(41 �- i d Owner: d Date of Inspection: �� D. System Failure Criteria applicable to all systems: You=indicate`fires"or"no"to each of the following for all inspections: Yes No kup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ Discharge or s g of effluent to the surface of the ground or surface waters due to an overloaded or cesspool S or ce ogged SAS or cestatic liquid level in the distribution box above Aaspool outlet invert due to an overloaded or clogged SAS or quid depth in cesspool is less than 6"below invert or available volume is less than%day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed i s pumped S8 p pe(s).Number day portion of the SAS,cesspool or privy is below hi an water — c—/ cesspool or privy ��° d �elevation. Any portion of p vy is within 100 feet of a surface water supply or tributary to a surface der supply. v y portion of a cesspool or sP° privy is within a Zone 1 of a public well. _ n;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 0feet 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.] (Yes/No)The system fails.I have determined that one or more of the above fail described in 310 CMR 15.303,therefore the system fails.The system owner sshoculld riteria tact the Bond 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) es no — system is within 400 feet of a surface ddnldng water supply the system is within 200 feet of a tributary to a surface drinking wad supply — th system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zon of a public water supply well If you have answere "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 15.304.The system owner should contact the appropriate regional office of the Dapartment Cm. Tiffin�Z Ino..e..4--10-- a i,s n....... Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: ` U 1✓�`O NLlI Jr* 12c Owner: Date of Inspectio . Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes _ Pumping information was provided by the owner,occupant,or Board of Health I,- Were any of the system components pumped out in the previous two weeks? 41 Has the system received normal flows in the previous two week period? /e 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 break out? / 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 ng,_� Ming 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)[310 CMR 15.302(3)(b)) T41a 4 Tnonartinn T7nrm 4/1 vMnnn 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ,[ l SYSTEM INFORMATION Property Address: 5� 1 v"O 62 /Z- o Owner• A-/,. ---T Date of Inspection: FLOW CDITIONSON RESIDENTIAL Number of bedrooms(design): oZ-Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): -Z);)U Number of current residents: /_ Does residence have a garbage grinder(yes or no): /vO Is laundry on a separate sewage system(yes or no):/GAD [ 'yam separate inspection required] Laundry system inspected(yes or no): /f�0 Seasonal use:(yes or no): ti0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): 1119 Last date of occupancy: i/et)74- COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and 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 ys (yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 19,Q 6 Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYYZp F SYSTEM ✓Septic tank distribution box,soil absorption system _Single cesspool Overflow cesspool —.Privy _Shared 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 obtained from system owner) —Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate age of all components,date installed if]mown and source of information: Were sewage odors detected when arriving at the site(yes or no):/'0 Title 4 rno-+:_in-- ell-.- L Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• G k 1 rid� Owner: A--IV-h Date of Inspectio : $AS BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction_ iron �_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:—(1" ocate on site plan) Depth below grade: a/ 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) 11 Dimensions: j X-(!r Sludge depth: Distance from top of sludpe to bottom of outlet tee or baffle: Scum thickness: a Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 6 How were dimensions determined: A/e Q Gv Comments(on pumping recommendations,inlet and ou et tee or baffle condition,structural integrity,liquid levels ass elated to outlet rove evidence of le�akage,etc.): / / GREASE TRAP:�ocate 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 battle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition'structural integrity, as related to outlet invert,evidence of leakage,etc.): liquid levels Page g 8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Sam r 7 CZ Owner: iv r Date of Inspection: TIGHT or HOLDING TANK:iV (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION B V , OX: (if present must be opene/d)(locate on site plan) Depth of liquid level above outlet invert: f140r "�GL✓` Comments(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: P(locate 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.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Sj fyp a%415,O Co Owner: ✓ Date of Inspection: j SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Typel�g pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: ��S ,3 /oc/✓ sP� innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, 30 etc.): i CESSPOOLS: 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.): PRIVY: (locate 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.): T41a c i..e..e..+:__a .c/t a innnn 0 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �U ✓"►O �,r ifs {� �� o N Owner: Date of Inspection Q�0 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 b ' g. 171 Ci S ,._4, C/f/nclrJ T41a i inenaetinn Rnrm 411lgt)AA 1 10 " . Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) r Property Address: 5) i ryo 6-0--rle# ,Q� I o �6._" Owner: /j V- Date of Inspection: r SITE EXAM Slope Surface water Check cellar 7 Shallow wells �- r a Estimated depth to ground water L `feet 040 Please indicate(check)all methods used to determine th e hi o gh ground water elevation: Obtained from system design plans on record-If checked, Observed site(abutting �fe of design plan reviewed: ( g property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers_(attach documentation) Accessed USGS database-explain: You myst descripe ho you establislh7d the hl ground w ter elevation: n r CY�OHnC firma ✓ c fGtrl Occ�ro 0 ✓� w� �o \ 000 O 1r C O O m 0 B 0 d n < LOCATION EWA E PERMIT NO. rd , VIL;IAGE I N S T A L L E R'S NAME i ADDRESS a/�-� �- /n BUILDER OR OWNER DA T E PERMIT ISSUED 7- 7� - DAT E COMPLIANCE ISSUED��_2� _ 71- 46 Is) ' r., TC)Wfq OIL bA.RINs`rABLE ,.00":.'I'::C3N 52 G uimquessette Rd. SE W AC E #._..�. VILLAGE� Cotuit _ ASSESSORS MAP INSTALLER'S NAME & PHONE NO. Robert B. Our - 432-0530 SEPTIC TANK CAPACIT-Y 1000 gal. (solids) - 1000 gal. (liquid) Y EACI-IING FACILITY:;tppe-) — NO. OF BEDROOMS Z PRIVATE WELL OR PUBLIC WATER Pqsblic � BUILDER OR OWNER Owner DATE PERMIT ISSUED:___aom jjme__abQut DATE COMPLIANCE ISSUED: V R!ANCE GRANTED: Yes Nu �, ,/.=ivy✓'' fire v.S L C cS7��_ No..........7?1 ........... FmAl..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA L OF....... ..... . ............... ........... ............ . Appliration for Dipposal Works Tontitrurtion Vamit Application is hereby made for a Permit to Construct or Repair ( an Individual Sewage Disposal System at: el R/........ ..................................................................................................uo ddress or Lot No.. .................................. ...... F...................................................... Own et......CC Address ......................................................... ................................... ....... Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons............................ Showers Cafeteria PL4 Other fixtures ------------------------------------------------- el **---------------------- --------------*------­ :L ----------------------------------------------- W Design Flow...................::.......................gallons per person per day. Total daily flow............................................gallons. 9 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 0-4 Percolation Test Results Performed by.................................... ............................. Date........................................ 4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.__..__................. ................................ ---------------*"**----------------------------------*------*----------------*­-----------*---------- 0 Description of Soil....................................................................................................................................................................... W ............................................................................. '­--------------------------------------------------------------------------------*-------*-------**---------------------- ...................... ................................................................................... ----- ...... .............. Nature of Repairs or Alte t' —Answer when applicable-----------------/-------- Al&�V 5 ------ . ................................. ............ -D ..............4..'.�.................w............................................ ... ........ ...... ....Y9.. ...... 6 Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TLITIE 5 of the State Sanitary Code,—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has heen issue y the board of health. Signe ... ........... .................................... ...... Date Application Approved By.._.....-. ­'a"j ........... ... .......... 7 I- - ........................ ------- ------ Application Disapproved for the following reasons:....... D'a'te ------------------------*----------------------- ................I—-------------------------------- .......................................................................................................... ........................................................................................ 7 C­— PermitNo......................................................... Issued...........................................Date............ .` Lt No..............c ` ... FE ..................... r' THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD F F-IEAL f� --............OF........ rfiutt#ivit for BhoposFal Workg Tonstrurtion Famit # 3 Application is hereby made for a Permit to Construct ( )_ or Repair *O' an Individual Sewage Disposal System at: . ,4 i ..... .. ... ad _ .: .a.?. ter•........ ........•- -............................----...._.......--•-----....._.._...._....._ .. do ddress or Lot No. .. IV q r......_ �:�1.. ..- ....._._._.. -•. tJ.�l��..�":..............................................................7n Address �e t ..... ...<---------------------•..... .......1_g 1Zr r:.C, H..... ........---..........._----........ Installer Address Type of Building Size Lot............................Sq. feet �. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—T e of Building No. of ersons____________________________ Showers Wf�l YP g •--------------•---•--._.... p ( ) — Cafeteria Otherfixtures ................................---................... ----•----------•-•-•••-•-•••-------•-•-••-••--•....... WDesign Flow...................:........................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-------_:=::ga]lons Length:...:.......:..: Width................ Diameter................ Depth................ x Disposal Trench—No_....................AWidth.................... 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 ( ) Percolation Test Results Performed by__::,_-____"_____________________ -------------- ______________________ Date........................................ a Test Pit No. 1________________minutes per inch Depth of Test Pit_.__..._...________. Depth to ground Water........................ fi, Test Pit No. 2................minutes per inch. Depth of Test Pit.................... Depth to ground water........................ .,:_.... -- ..:.:::.......................:.................................... ODescription of Soil -•--------•-----•----------------------•-•----"=----=•=----"---._...-------•--...----------••••-••---_----- x . U UNature of Repairs or, lter tions Answer when applicable_ !— �!� �° _.. I ...._' ;'' _____________ � ---•-- -"- --- `g;: .-... .... . � - -- -, ................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?.E 5 of the State Sanitary Code—The undersigned further agrees not to place the-system in operation until a Certificate of Compliance has een issue y the board of health Si .0000, gn ... - ._ ", -�tiC ... ! w. .. ,.; Date l Application Approved By......-Ir'... •-- • -------------------- ....... r - "-'-7_49- Date Application Disapproved for the following reasons__________________•_____..__..._____________________•________________.__...__._________.___.______________-_-___ ---•-----------------•----•---•---•--•---.........-••---------•--•••--•-••--•-•----•._.........••-------- Date PermitNo...................................................•••-. Issued_........................................................ Date •, ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ........f,00_1 ..........OF.... ..... .................. .. F Tn#ifirFatr of Tuntpltttnrr THISIS CERTIi'hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) byt.• ..._ -............................................................•........................................................................... Installer s I. at................................................................................................................................................------"-----------•---==-•--•=-----------•----------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated.............................. __.p__..________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......��— 2 `7� ..... Inspector P ------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD O H EAj=T f Q"'r . .OF....... �:•' '.................... � . �'` No.......... FEE....�!:............... �i tit rko uni#r m- ,: Trani# Permission is hereby ranted---- ••-...... : .... .. ...... .. Y g . to Construct or a it ( a In ividual Sewage posal S j�stem r f Street .',f. as shown on the application for Dispos Works Construction Per o......._.-- ed...( ;�:7"'M.............. "'L{ .++ oard ofeeah - } DATE-1 l -•-• ......----....................................... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS \