HomeMy WebLinkAbout1119 MAIN STREET (COTUIT) - Health 1119 MAIN STREET; COTUIT
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS ��✓✓ ��,
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DEPARTMENT. OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY:ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name
Owner's Address:
Date of Inspection
Name of Inspector: lease print) �r,/C)/0���
Company Name:.
Diu
Mailing Address: .O y.. G�CO SLd?'
Telephone Number: Oct' cl,;)k- 0
CERTIFICATION STATEMENT
I certify.that I have personally inspected the sewage disposal system at thinspection
nsdect on was pdress and aerformed based on my
rted
below is true,accurate and complete as of the time of the inspection.The p
training and experience in the proper function and maintenance of oft site sewage..disposal systems.I.am a.DEP'
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR'15.000). The system:.
/Passes
Conditionally Passes R
N.es F:rther Evaluation by the Local Approving.Authority
o
F s
Inspector's Signature:/
Date: �/ UI '
oard of Health or
The system inspector shall submit a copy of this inspection report to the Approvingd s stem or hasra deity Bgn flow of 10 000
DEP).within 30 days of completing this inspection.If the system is a shared; y
tem owner.shall submit the report to the appropriate
gpd or greater,the inspector and the sys regional office of the
nd copies sent to the buyer;if applicable,and the approving
DEP..The original should be sent to the"system owner a
authority.
Notes and Comments
***This report only describes conditions at-the time of inspection and under the conditions of use at that
em will perform in the future under the same or different.
time.This inspection does not address how the syst
conditions of use. .
L
Title 5 Inspection Form 6/1-5/20.00 page t
Page 2 of I I
OFFICIAL INSPECTION FORM—*'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _lz� 74pp
14
Owner• .
Date of Inspection:
Inspection Summary: Check k,B,C;D or E 7 ALWAYS complete all of Section D
A. System Passes:
I-have not found any information which indicates that anyofthe 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. 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 of the 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 dete
explain. rmined'.'please
The septic tank is metal:arid 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 Heal.th):
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
Page 3 of 11.
OFFICIAL INSPECTION FORM -NOT FOR,VOLUNTARY ASSESSMENTS
SUB$URFACE.SEWAGE.DISPOSAL SYSTEM INSPECTION FORMPART A
CERTIFI.CATION(continued)
Property Address: / v
Owner:
Date of Inspection: z/I /01
C. Further Evaluation is Required by the Board.of Health:
Conditions exist which require further.evaluation,bythe.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 accor dance with'3 0 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
Z. 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 tht public health,safety.,.and environment:
_ ion system,(SAS)and the.SAS is within 100 feet of a:
The system has a septic tank and soil:absorpt .
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 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.
3. Other.:
3 t
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY`ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: v
Owner 0 Ic
�4p
Date of Inspection: f�
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following`for all inspections:
Yes. No/
jBackup of sewage into facility or.system component due to 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 SAS or cesspool
Static liquid level in the distribution box above outlet invert'due to an overloaded`or clogged SAS or
2cesspool
/.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 100 feet of a surface water supply or tributary to a surface
l water supply.
_ l/ Any portion of a cesspool or privy is within a Zone 1 of.a public`well.
ny portion of a cesspool or privy is within 50 feet of a.private water supply well.
PiA' ny
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 facilityand 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 correctthe failure.
E. Large Systems:
To be considered a large system the aystem mustserve a.facility wiMa design flowof 101,000 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 1I of a public water supply well
If you have answered"yes"to any questibn 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 an operator of large system considered a
P Y g Y
significant threat under Section E or failed under Section 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 11
OFFICIAL.INSPECTION FORM: NOT FOR-VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST .
Property Address:
Owner: -rQ� !'Pl�t� _ } G
Date of Inspection: 1 i -h B `
Check if the following have been done You must indicate.'yes."or."no"as to each of the following:.'_
Yes Slo
_�/_ Pumping.infor'mation.was provided by the owner;occupant;or Board of.Health
V/ Were.any of the.system components pumped out in the previous two weeks?.
— Has the system received normal flows.in the previous two week period
_ t/ 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)
V _ Was the'facility or dwelling inspected for signs of.sewage back up
Was the site inspected.for signs of,break out 2
r .
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 SoilAbsorption 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)[310 CMR 15.302(3)(b)]
,. 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SE WAGE:'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
A
Owner:
Date of Inspection: Z7�-)�/,o
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(desigri):- Number of bedrooms(actual)': . .
DESIGN flow based on 310 CMR 15.203 for example: 11.0 gpd x#of bedrooms): 3-0
Number of current residents:
0
Does residence have a garbage grinder(yes or no):f_ _, ,.:. ;• ;• ._, _,,
Is laundry on a separate sewage system(yes or no) if yes-separate inspection required)
Laundry system inspected yes or no):
Seasonal use: (yes or no):.
Water meter readings, if a ilable(last 2 years usage(gpd)):
Sump pump(yes or no).�
Last date'of occupancy• awd
COMMERCIAL/INDUSTRIAL/-7W
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 inspectio yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason'for pumping:
TYPE OF SYSTEM
jZSeptic tank,distribution box, soil absorption system
rP Y
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):
�p roxVnate age of all components, date installed(if known)and source of information':
Were:sewage odors detected when arriving at the site(yes or no):
lae
6
Page 7 of 11
OFFICIAL INSPECTION FORM—'NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C..
SYSTEM.INFORMATION(continued)
Property Address
.:/.1--
Owner:au 4a
Date of Inspection:
BUILDING.SEWER(locate on site plan)/9�'
Depth below grade:
Materials of construction: cast iron '40 PVC, other(explain):
Distance from private water supply,well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
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) r
Dimensions: k
Sludge depth:
Distance from top of sludge to bottom.of outlet tee.or.baffler
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:
How were dimensions determined:
Comments(on pumping recommen ations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
related to outlet invert,evidence of leakage,etc.):
ODD !D
-$�i
Q"/
GREASE TRAiy2UL-(locate on site.plan)
r
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
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C .
SYSTEM INFORMATION(continued)
Property Address:
Owner.. L(1�Lo
Date of Inspection: ��, J
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 Uolyethylene__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 tpumping-
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:l�M&
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, c.):
l
az zz/ham a3a P� i�tri
PUMP CHAMBER` (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 a ppurtenances,,etc:):
8 i
Page 9 of 11
OFFICIAL INSPECTION FORM:-NOT FORYOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:(.f/Z, eO��
Date of Inspection: ��Ll
SOIL ABSORPTION SYSTEM(SAS):t/ (locate on site plan,excavation not required)
If SAS not located explain why:
.-.. . ....."......
TYPe
eaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches number, lenoth;-
leaching fields,number,dimensions:
overflow cesspool,number: 1
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.),
O. o - /
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• ovate 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 SYSTE JNSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: -4�12
Owner•
Date of Inspection: -a) /p l
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.
3a � ..
3q
�.0
" to
a ,
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: c,
Owner:
Date of.Inspection: b�
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)
Accessed USGS database-explain:
r
You must describe how you established the high ground water elevation �J � ���.
11
• •a
DATE: . 8/.1'0./98 .
PROPERTY ADDRESS: Ill19 -Main Street
Cotuit•,Mass.
02635
On the above date, 1 Inspected the septic system at the above address.
This system consists of the following:
1 . 1 -1000 gallon septic tank.
2 . 1 -Distribution box.
3 . 1 -6 ' x8 ' ' block cesspool.
4 . 1 -1000 gallon precast leaching pit packed in stone.
Based bn my InRc�&ctlon, I certify the following conditions:
5 . This is a title five septic -system.' "(7'8• Code )
6 . The septic system is in proper working order
at -the present time.
81GNATUW7,
Name J P Macomber Jr_
--- -------
Company:*_J. P_Maco0er- & Son-`Inc
Address:--Beac-6�-__---a-- --
__Cent�rvilLeLMass__02.632 '
Phone:__, . I
O .
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
, OSEPH P. MACOMBER & SON, INC.
Tanks-Cesspools-Leachflelds
Pumpad'4 Insttlle-d
Town Sower Connections
P.O. Box 66' Centerville, MA 02632-0066
77.5-3338 775-6412
i rI)
' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON, MA 02108 617-292.5500
WILLIAM F.WELD TRUDY CO
U9
Sccrct
Govcmor
ARGEO PAUL CELLUCCI DAVID B.STRU
Lt.Govcmor i,UBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissio
PART A
CERTIFICATION
Property Address: 1 1 1 9 Main Street Cotuit,Mass. Address of Owner: t ! ?
Date of Inspection: 8/1 0/9 H (If different)
Name of Inspector; ,
P I�P..M3CIImber Jr. ,
sasa_p
I am a DEP approve syst. inspector pursuant to Section 15.340 of Title S (310 CMR 1$.000)
Company Name: J.P.Macomber & Son Inc.
Mailing Address: Box 66 .�P[1terVille,Mass. 02632 "4 AUG
Telephone Number: 5.0-8-77-�3.33R 2 8 1s98
TOWNO v y
CERTIFICATION STATEMEN i,� hfgt y�NpTA81I .
I cenify that I have personally ,spc. : i the sewage disposal system at this address and that the in r;.a ion reported%elow is true accuralr
and complete as of the time insp, Dn. The inspection was performed based on.my training and ex*ience in the propfur�ction and
maintenance of on-site sewa£ ;isp( systems. The system:
�assaGg
_ Conc :;nal :'asses
Neec . un� _valuation By the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall su . :it a :)y of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a are:. ,tem or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate . .:or.. ;ice of the Department of Environmental Protection. The original should be sent to the system own
and copies sent to the buyer, :pp. le, and the approving authority.
INSPECTION SUMMARY: :sec:. ., B, C, or D:
AI SYSTEM PASSES:
-�= SL I have not found an �fcr _on which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.30'
Any failure criteria i eva _d are indicated below.
COMMENTS:
eI SYSTEM CONDITIONALI ,'A'
One or more systen. :rnp ,its as described in the "Conditional Pass" section need to be replaced or repaired. The system, up,
completion of the r( cen or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not deterr :ed A, or ND). Describe basis of determination in all instances. If"not determined', explain why not.
The septic '< i:. :al, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliant u .) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;,
the septic :, A )er or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar
failure is it. ..ner �ice system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approve ;y a �ard.of Health.
V
(revised 04/25/37) Dap• 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.stale.ma.us/dep
Printed on Recyded Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1119 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/9 8
B) SYSTEM CONDITIONALLY PASSES (continued)
1.1r) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a 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 levelled 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 funher 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:
&0 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.
1) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
42� The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
42 The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic 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 presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
�A
(revised 04/25/17) P4y• 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1119 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/9 8
DJ SYSTEM FAILS:
II
You must indicate ei, .er "Yes or
"No" as to each of the following:
g
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The bans
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cornea
the failure.
Yes No
Backup of sewage into 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 SAS or
cesspool.
Static liquid level in the distributioQ box above outlet invert due to an overloaded or clogged SAS or cesspool.
.I[ �
Liquid depth in cesspool is less than'y 6" below invert or available volume is less than 1/2 day flow.
_ —y—/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped Q.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool 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 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. 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 above:
. The system serves a facility with a 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 a nitrogen sensitive area (Interim Wellhead Protection Area • IWPA) or a mapped Zone 11 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 04/25/$7) Day• 3 o1 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:119 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/9 8
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
nd the system has been
None of the system componentsddurithat
ave periode Largevolued for at ines oleast two weeks f water have notabeen introduced into thersystlemrecently normal
flow rates 8 Pe
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
— All system components, e' KIuding the Soil Absorption System, have been located on the site.
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.
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 System.
Existing information. Ex. Plan at B.O.H.
— Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b))
(revised 04/25/97) 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION' FORM
PART C
SYSTEM INFORMATION
Proper,) address: 1 1 1 9 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/98
FLOW CONDITIONS
RESIDENTIAI:
Design flor,. D.O/bedroom for S.A.S.
Number of bedrooms: '
.umber oi currenl residentszalle
Carbagc gander (yes or no)Az
Laundry connected to system (yes or n0)16
Seasonal use (yes Or noVkD !y nn �j
seater meter readings, if available (last two (2) year usage (gpo): e �l ,216 �t '' i/�Fv/�."jA/Svn+p Pump tyes or no):� % / lt7� . ., �� r•r�+e
:ast Cate of occupancy uw�[
COMMERCtAUINDUSTRIAI:
Type of establishment:_ ,fl/SL
Design flow—4w gallons/day
Cacase trap present: (yes or no)ALQ
tndvstrial Waste Molding Tank present: (yes or no),ZL4
1,on•sanitary wasle discharged to the Title 5 system: lye$ or no)A-)*
Wale( meter readings, if available._ A)w
A->1
Last date of occupancy: X-4
OTHER: :Describer _ .12
Last date of occupancy --
GENERAL INFORMATION
PvHPINC RECORDS and Source of information
System pumped as pan of ins ction: (yes or no)"
If yes, volume pumped: gallons
Reason for pumping ,rieY Du
TYPE ' S TEM
Septic unk/distributron box/soil absorption system
_ Single cesspool
_ M Ovcrflow cesspool
Privy
_� Shared system (yes or no) (if yes, anach previous inspection records, if any)
VA Technology etc. Copy of up to date contracil
Other lTIZ''
aP ROXIMATE'ACE of all components/, date installed (it known) and source Jof information:
4 LS 7 s f-e. a,1!/', �Sra✓9
,11144
5—age odors detected when arriving at the site: (yes or no) — t 90/13 .��- ,
tr.rs..0 0�/)s/771 i.9• s of $0
r
r
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:1 1 1 9 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8 1 0/9 8
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron 40 PVC_other (explain)
Distance fro�P�ivate water supply well or suction line A'�"
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
Joints
The system is vPntPH i-h-rniigh the 149use vent.
SEPTIC TANK:'1009'4'udtts
(locate on site plan)
r)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age A2
4L Is age confirmed by Certificate of Compliance V4__(Yes/No)
Dimensions: ��r 1140d
Sludge depth: ��
Distance from top of sludge to bonom of outlet tee or baffle:
Scum thickness:z- �
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bonom of outlet tee or baffle ��
How dimensions were determined: �:
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.) Pump tank every 2.-'1�AarS In1Pt R not At 1 tpQE
are in place.Liquid depth at the r)UH Pt ; nyczrt is fifty
one inches .The tank i G Gtrnr-tnra 1 1 y SQU1 GI &i4d sheifs no Signs
of 1 eakage
GREASE TRAP:-&Ve
(locate-on site plan)
Depth below grade:�I4
Material of construction:4mconcrete'V/metal AFiberglass�PolyethyleneAJ4other(explain)
AM
Dimensions:
Scum thickness: AM
Distance from top of scum to top of outlet tee or baffle:-AA
Distance from bottom of scum to bottom of outlet tee of baffle:,
Date of last pumping: ,
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.)
Grease trap is not present,
(revl&od 04/25/97) ?&go 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PropertyAddress: 1119 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/9 8
TIGHT OR HOLDING TANK:A&LWank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:.Vd
Material of construct ion:-V4concrete.Wmetal,4 Fiberglass4APolyethylene,,other(explain)
R
A1
Dimensions:_41A
Capacity: ALA gallons
Design flow: AIA gallons/day
Alarm level:_ Alarm in working order,VA Yes;&A No
Date of previous pumping: _4VA
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
Tiq t or holding tanks are not present
DISTRIBUTION BOX:—k--",
(locate on site plan)
Depth of liquid level above outlet invert: _
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or,out of box, etc.)
Distribution box has two laterals •No evidence of solids
rarr_v nvar-Nn cyi Aanra of 1 pakaga i ntn nr nuf of the
-Eistr--ib13--A2f3 h ig H
PUMP CHAMBER:AJ21ve
(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.)
ump c am er is no •presen .
Usvls.d 0//�$/17) Y696 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1119 Main Street Cotuit,Mass.
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/9 8
SOIL ABSORPTION SYSTEM (SAS):
-,-/
(locate on site plan, if possible; excavation not required, but may be approximated by non intrusive methods)
If not determined to be present, explain:
Type: ,
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:' e
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Loamy sand to oarse sand;No signs of hydraulic failure
or pondinq;All vegetation is normal_
CESSPOOL!:
(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 (cesspool must be pumped as part of inspection)
Did. not pump cesspool. It is not an in the inflow mode_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Loamy sand to coarse sand:No signs of hydraulic failure
or ponding. All vegetation is normal.
PRIVY: A1041-1
(locate on site plan)
Materials of construction:_ AW Dimensions:
Depth of solids:_
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
Privy -is not present.
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properly Address: 1119 Main Street Cotiut,Mass.
Owner: Bobbie Lizzio
Date of Inspection: 8/10/98
SKETCH OF SEWAGE DISPOSAL SYSTEM: landmarks or benchmarks
include ties to at least two pe
rmanent references
mes into house)
locate all wells within 100' (Locale where public water suppI y co huse
40 t000
CP
U�g
1
lr.v1••d fi�/15/f71 Yoy• .0 of 10
SUBSURFACE SEWAGE DISP(.;S:,l SYSTEM INSPECTION FORM
C
SYSTEM INFOIZ..t JION (continued)
Properly Address.1119 Main Street Cotuit,Mass .
Owner: Bonnie Lizzio
Date of Inspection: 8/1 0/9 8
Depth to Groundwater X Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
bservation of Site (Abutting ro a observation hole, baserner�h sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
_ZCheck pumping records
heck local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groun&ater-Elevation. Must be completed)
Used water contours map.
Gahrety & Miller Model
12/16/94
(revl..d 04/25/97) Y&g. '3.00f 10
WY)
1'OWN OF Barnstable LvjARD OF HEALTH
SUI)SURFACF SEWAGE I)ISPOSAU SYSTFM INSi'FCTION FORM - PART D '- CERTIFICATION
�' ,I...Tn�T•'..::t-T.IIF".T.TT1tn■.111.11.1rI T1'TIRf Af�T r�\7�1T11ti IRsr9'������
-TYPE OR PRINT CLEARLY-
P1?OP ERT Y INSPECTED
STREET ADDRESS
1119 Main Street Cotuit Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Bonnie Liz2io
PARR D - CERTIFICATION
NAME OF INSPECTOR Joseph P.Macomber Jr.
COMPANY NAME J•P•Macomber.& Sorr"fnc.
COMPANY ADDRESS Box 66 Centerville,Mass . 02632 .
street. Town or City state LIP
COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 -1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at
e
this address and that t}ie information reported is true , accurate , and
complete as of the time of �inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
witli my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 , 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form . 1
System FAILED*
The inspection which I have con cted has found that the system fails to
4 Protect the public health and the environment in accordance with Title
5 , 310 CMR 151303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
w ,
Inspector Signature Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF I1EAL1'll,
.Ir 1,.
* If the inspection FAILED, the owner or operator shall upgrade ' the eyetem.
Within o'ne year of the date of the inspection , unless allowed or required
otherwise as providdd in 3,10 CMR 16 . 305 .
partd .doc
r
W
Z7
" SS byV �Dl �
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE S SYSTEM INSPECTOR
as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the
General Laws_ Issued by The Department of Environmental Protection.
_,2 _�� --
hmc X. 1995
nctity. Director of tli1: l) i iutt ul Walec }'ulltiti0n Control
r
TOWN OFBARNSTABLE
LC-1CA.'11ON. ? Al ST- SEWAGE #
VILLAGE ( ' e rLC l ( ASSESSOR'S MAP & LOY�)It n%
PISTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY -;l -t-'U p
LEACHING FACILITY: (type) L. F XC-11 T f T s (size)
NO.OF BEDROOMS
BUILDER OR OWNER /y G L
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
STABLE
TOV�N OF ARN
LOCATION- SEWAGE #
VILLAGE ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I6'� w
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER �L M i
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted:,Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland Tand Leaching Facility(If any etlands exist
within 3fee 00 20chin acility) Feet
Furnished by /!O
Goo t
it
1
L CC AT ION SEWAGE PERMIT NO,
VILLAGE
I N S T A LLER'S NAME fi ADDRESS
ks-S 00- �
B U I L D R OR OWNER
N N e
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED
r ,_ .�:-
-�
� � '
�-
� � �
c--
��� � 5
,�
�. .� ., ,e� , �
\ ! �� �.
��._. � � C
� �
!`\
��
No.. .:.. Fxs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
--•.............. ........................O F..................I_,.......
Appliration for Disposal Works Tonstrnrtinn ramit
Application is hereby made or a Permit to
Construct ( ) or Repair ( ) an Individual Sewage Disposal
SystemQ... ... • ................................ ........------....--•---•-••••......-•-• .....-•--•••••.............••-•••......--A8... catio A dress or Lot No.
...... •• ,t. . ---- _... ---------------------------------------------------
er / Address
W ............
Installer Address
e of Building Size Lot............................Sq. feet
�. Dwelling o. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
A4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ..................................
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................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
- ----------------------------------------------------------------•--------•---------------•-----••-----•-------------------•------
0 Description of Soil........... -------------------------------------------•-----------------------------••--------------------------••••••....._--•-•-----•••-
U .....•-••••••-•----•-•••-•--•-••-•---•-•..................•••••......-••-•••••••-••-•--•------•---••••----•-•------••-•---•••---•---•••-•--•-•••••••-•--•-•--••••-••----•----•--••--••-•----•--•---•----
-----•-------------------------------------------------------------------------------------------------------------------------------•• ------- •.
Nature of Repairs or Alterations—Answer when applicable U P PP ------•-- ••. . -•-•
•----•--•........................••------••.....-•----••••-�=•� '-�-P.....----�-••-••...1- ....................................
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 be n issued by he bard o health.
Signed•. -• ... --• ......... -•-•-•---------.... ------ ------
!� to
Application Approved By....... . • •-•--•--•• • •. -- .• •••. ••----•• _'
' Date
Application Disapproved fort10following reasons:.......................................
-•----•......-•..............•---•--------•-••--.....--------------•---......------------......-----•-•--•-••--•---------•------•----•-•-••--••-•-•------•--•-•--••------•----•-•••-•-••--•••-----------
Date
Permit No...... ...........
:.�...--•--------------------•--. Issued-------••--- . j--.® ..................---
Date
No... ,. - - F�s......fu......:
R
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF......
ApplirFa#inn for Disposal Works Toustrurtinn Prruat
Application is hereby made,for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
f7 . ............................................................................a�•1.
lLocahon Address or Lot No
r
l/' ?- ,,d / ............... _. ......... ....._
! r"ti f p Owner r Address ........--
aL, z �d f ... -.2..........................................- -•--•- --•----•--•-....... ......... ........ ......••---_.....
I Installer Address
U 'Type of Building�.` Size Lot----------------------------Sq. feet
I—. Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
a Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria
Other fixtures .
W Design Flow:;._.::......................................gallons per person per day. Total daily flow................_...........................gallons.
WSeptic Tank—Liquid'capacity.....__.....gallons Length................ Width................ Diameter---------------- Deptli...............
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 ( )
a Percolation Test Results Performed by......................................................................... Date................
...
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------
:--_•-____-I-__--_.
44 Test-Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a =' ..................•-----••••_•••-• •-_.•--_.....
..................................................•---...._...........--•=--_.....
Q Description of Soil-------------.,�«- �; ------...------------------------------------•------------------...---------...-•--•----•-•------ �
U .....................................•••••---------••••---••-•..............•--••...------•-•-------•:..--•-••-•--•--•-----••••...---------••-•--•-----•-------•-•••-
W
U Nature of Repairs or Alterations—Answer when applicable r v.: �-`�)---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage.Disposal System in accordance with'
the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a CertificateAf Compliance has been issued.by the board of health.Zz�,
�{ .. Sigri ; `.rr
`�
p i ..
1 Date^t
Application Approved By-- ----------..-.-=•-----
Date
Application Disapproved for the following:.reasons:....................................------------------------••--•---------•-••......----•- -•--••-•----•--•---
--.......-•-•--•--•-......••-•••-•-••••...e c� ..._ .••----•••-•••••---•...-•---------------•-•-----•••....--••-----• --•............................................................
Date
PermitNo.................................................. -- Issued.-----.
Date
THE COMMONWEALTH OF MASSACHUSETTS
i BOARD OF HEALTH
' F..........................................O .... ..t.�....-.'r.rr........f....F .
Trrtfrtttje of Tnu....:rt......Fl.,.i...a...sn..
r .
TH S ,Ps, T CERTI�. # That the dndividual Sewage Disposal System constructed ( ) or Repaired.(- '
by
•� InsYaller•';.1; r �;1' .
�p
• -----------•--•-----•---------•-•---•---------•---•-------------•-•-----•----------•-•-•_...
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 ,__ •- ....... dated-....................... .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS UED AfA dBTA TE THAT THE
SYSTEM. WILL F NCT ON-SATISFACTORY.
DATE........... --• .:.................•-••......-_----. 'Inspector................ .-- .......--- --•---
J THE COMMONWEALTH OF MASSACHU TS
P
t BOARD OF HEALTH,.,
b J � .:'.......0 F........ %':'. ' �..P
......... ..............................
NO......................... FEE=r '--•..........--•-
t , Tongr inn rmi#
..�
Permission is hereby granted �� + '°.:� r�
ram ..
" to Construct ( ) or ir ( an In v�ua.11Hevtage-I�as�al�Sy em
at No.
Street +—
as shown on the application for Disposal Works Construction Permit N .................. ted_.._ _._......_._.._........
85 --------------------•--•- Board of Health ....----...__...--••-•---...
DATE------. '--------•-----------------•---....._............••--•---•••••---_•-•--
FORM 1255 A. M. SULKIN, INC., BOSTON
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