HomeMy WebLinkAbout0283 MARINER CIRCLE - Health [222 EISENHOWER'D fZ 1 VE ..__ ,z - ---- - --- -- - -- ---
A- d -9 C9 1
'c .. COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
MAY 2 9 2001
TOWN OF BARNSTABLE
TITLES HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:222- Eisenhower Dr.
Cotuit, MA
Owner's Name: James Carens
Owner's Address:GamP
Date of Inspection:
Name of Inspector: (please print) wi 1 1 jam E_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 81 7 7 5-8 7 7.6
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sect'oia 15.340 of Title 5(310 CMR 15.000� The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
1001
Inspector's Signature: i y Dater —6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaKh)or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
k
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 1
c
Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:222 Eisenhower Dr.
Cotuit
Owner• Carens
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys em Passes:
1 have not found an information which indicates that an of the failure criteria described in 310 CMR
y y
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
IN
B. Sy em Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. a 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 determined".please
explain.
Th�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 is replaced with a complying septic tank as approved by the Board of Health.
*A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indic ' g that the tank is less than 20 years old is available.
ND a lain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
ob cted pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
appr val of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND plain:
7
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:
Page 3 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 222 Eisenhower Dr.
o ui
Owner: Carens
Date of Inspection: "Cl t
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 fa'ling to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
sy tem is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is.within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front 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
Page 4 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 222 Eisenhower Dr.
Co uit
Owner: Carens
Date of Inspection: IZ
D. System Failure Criteria applicable to all systems:.
Yo must indicate"yes'.'or"no"to each of the following for all inspections:
Yes No
Backup 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
cesspool
Liquid 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 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
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a 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 failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gp
Y must indicate either"yes"or"no"to each of the following:
( e following criteria apply to large systems in addition to the criteria above)
y no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well.
If ou have answered"yes"to any question in Section E the system is considered a significant threat,or answered
s"in Section D above the lace stem has famed.The owner or or of tare system considered a
S o g system operas any g
si nificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
1 .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 DI
SPOSAL SYSTE
M
INSP
ECTION FORM
PART B
CHECKLIST
Property Address: 2 9.9 Ti;
Cot-I]i ;-
Owner:
Date of Inspection: 6 !
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes No
✓_ Pumping information was provided by the owner,occupant,or Board of Health
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?
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.?
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 3
mai tenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
_ Existing information.For example,a plan at the Board of Health.
_1/ 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)J
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 222 Fi -;Pnhnwar Dr.
cotuit
Owner:
Date of Inspection: 3-G- 0
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual):_
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):,i, a
Is laundry on a separate sewage system(yes or no):/-6 [if yes separate inspection required]
Laundry system inspected(yes or no):/-o
Seasonal use:(yes or no): /1. v
Water meter readings,if available(last 2 years usage(gpd)): 2 0 0 0 3 Z, 0 0 0 'ga 1.
Sump pump(yes or no):iv o 1999 55,000 gal.
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type o establishment:
Design ow(based on 310 CMR 15.203): gpd.
Basis of esign flow(seats/persons/sgft,etc.):
Grease ap present(yes or no):
Industri 1 waste holding tank present(yes or no):_
Non-s itary waste discharged to the Title 5 system(yes or no):_
Water eter readings,if available:
Last d to of occupancy/use:
OT R(describe):
GENERAL INFORMATION
Pumping Records
Source of information: J�
Was system pumped as part 6f the inspection(yes or no): 4
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYP F SYSTEM
IF
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 own)and source of info tion.
J f3 Gu
Were sewage odors detected when arriving at the site(yes or no):mac)
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: 222 Eisenhower Dr.
Cotuit
Owner: Carens
Date of Inspection: J--6 - o f
BU DING SEWER(locate on site plan)
Depth elow grade:
Materi is of construction:_cast iron _40 PVC_other(explain):
Distan a from private water supply well or suction line:
Co nts(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
: 1
Depth below grade: 3
Material of construction:concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate) ► '
Dimensions: �, �" Ce
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: L
Scum thickness: L ,
Distance from top of scum to top of outlet tee or baffle: '
Distance from bottom of scum to bottom of outlet tee or baffle: / j )
How were dimensions determined: 6 Joe—
Comments(on pumping recommendations, inlet and outlet tee or baffle,condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,�etf�.):
60
GR E TRAP:_(locate on site plan)
Depth b low grade:_
Materia of construction:_concrete_metal_fiberglass_polyethylene_other
(expla•
Dimens ons:
Scum t ickness:
Distan a from top of scum to top of outlet tee or baffle:
Dista a from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as r ated to outlet invert,evidence of leakage,etc.):
7
Page 8 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 222 Eisenhower Dr. .
Cotuit
Owner: Carens
Date of Inspection: 3 d 2 1
TIG T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Materi 1 of construction: concrete metal fiberglass_�,olyethylene other(explain):
Dimen 'ons:
Capaci gallons
Design low: gallons/day
Alarm resent(yes or no):
Alarm evel: Alarm in working order(yes or no):
Date last pumping:
Co ents(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:
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 HAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms i orking order(yes or no):
Comme s(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 999 ' i conhowQr- Dr.
_1-(z ti.1 i t
Owner:
146
Date of Inspection: :S 4 45
SOIL ABSORPTION SYSTEM(SAS): Z (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): i ? y
1�4-
CE POOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Numbe and configuration: -
Depth top of liquid to inlet invert:
Depth o solids layer:
Depth o scum layer:
Dimens- ns of cesspool:
Materia of construction:
Indicati n of groundwater inflow(yes or no):
Comm nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
P (locate on site plan)
Ma rials of construction:
Di ensions:
De h of solids:
C ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 222 Eisenhower Dr.
Cotuit
Owner: Carens
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
------------
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10
-Page 1 l of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 222 F.i -,anhnx.iar nr.
CC)t-n i t-
Owner.
Date of Inspection: •—L —c;. y
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
x
Estimated depth to ground water 9-0 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:
�bserved site(abutting property/observation hole within 150 feet of SAS)
hecked with local Board of Health-explain: / w& ' b v j -
Checked with local excavators,installers-(attach documentation) J
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
J A4 W& 5
1
11
i
y r at•
3 Fmc..............................
No....---••- --•.. �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........A /^s... OF /S? N.ST.- -T..t.G.r.............................
, ppUration for Uhgpnaal 10orks Tnntrnrtinn ramit
Application is hereby made for a Permit to Construct (,() or Repair ( ) an Individual Sewage Disp sal
System at:
S,EA1 h101',/,E2.....T --c
....................... ....................Z.&7.........../.0................... .........
.......... ............ ......
._.
Loc Address o E For
---------------------
......... . , ...�Y� N --SN .----_........Lot N!o'....:.....................................
Owner --------------------------------Address
Installer Address
d Type of Building Size Lot.J�.!qa5;�......Sq. feet
U Dwelling—No. of Bedrooms........... ................... _Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures ................................
;awi5�WAs;k -----------------------•-------•----•----•------•••....._._.. -•--------- '
W Design Flow.........JI-P--------------------------gallons per person per day. Total daily flow.............,?_3.0_................gallons.
WSeptic Tank—Liquid capacity./DOO-gallons Length_50"____ Width.__-O.'/VP Diameter________________ Depth............
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-----1------------- Diameter_/4.eFT.... Depth below inlet.._.Oe!".... Total leaching area....9 .7..sq. ft.
Z Other Distribution box (X) Dosing tank (
'-' Percolation Test Results Performed by-_��acY___. _�FFO2 D,____ _S_______.____ _...._....
1.4a Test Pit No. 1_.L.z.....minutes per inch Depth of Test Pit..... Depth to ground water........_____......
Test Pit No. 2.. .Z_....minutes per inch Depth of Test Pit---4Z.:FT Depth to, ground water________________________
R+' .--•-•----•------••------------------•---••-------•-----•-•-•--•--.-•-..............•----•......---------•-•---
0 Description of ........ .....
x /
vraa_�.�> -•y------.- _..Z.'...... -----•-••------- •---------------------------------------
W ................-.............................................................................................-•••-------------------•-------•------•---••.............................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
..---•--•-----------••-•--•----------------•--•---•------------•----•------------------•---------•----...----------------------------------------------------•-......----•----•--•--............._.-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI'i IE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sign0 . . . .................••-•--------•..........................-•------•-•.•---• ............D........--.._
D
Application Approved By------- 0"41"(,�//l4. ----•- -4p--•"a O' *...--
Date
Application Disapproved for the f oHowing reasons----------------------------••--•--------------•-----------------------------_.......... ............_
Y
45 r
_________________________________________________________________________________________________________._._........................____._..............................................................
Date
PermitNo......................................................... Issued. - ` 7_�......................
Date
77-
No.. •-• f---- Fss..............................
THE COMMONWEALTWTOF M)ASSACHUSETTS
BOARD OF HEALTH
T ww..............OF..........�,.�f�lz ............
App irtttion for Bispn,itt1 Marko Tnnitrurtiun ramit
Application is hereby made for a Permit to Construct (j e) or Repair ( ) an Individual Sewage.-%Dis osal
System at:
4_7t t .........----------LGr......-��9------.......... �:. .-.
••Location-Address, or Lot No
............. ^' Q: / ..N.1..S.,, i9........................--•---.
Owner Address
(� ...
Installer Address O
,rr d Type of Building Size Lot.-?0- --------O�
-----------Sq. feet
0-4 Dwelling—No. of Bedrooms...--._. ................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a'' Other fixtures-- -------------------- -------
W Design Flow........11p............................gallons per+@Ffen per day. Total daily flow.................33.0...............gallons.
WSeptic Tank—Liquid I capacity/09�9gallons Length.8.� .... Width.#'�'.- Diameter................ Depth..S....'....
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......1............. Diameter......140-F T'. Depth below inlet... en.. Total leaching area....Z.6.-7.sq. ft.
Z Other Distribution box (X) Dosing tank ( ) _
'4 Percolation Test Results Performed by__.......eo?_.._�� F O�D� S Date_�/ ��
aj Test Pit No. l.:_ .Z_..minutes per inch Depth of Test Pit..../.Z-_....... Depth to ground water........................
r Gi, Test Pit No. 2... ..Z...minutes per inch Depth of Test Pit...41.......... Depth to ground water..................
a ----------------------------------••----•-------. r.....
D Description of Soil...Q----Z........49e9�......./--r.. �i�1So/� 3_'_../ EI>_.,S!9^i ....P-__21 41"
U 6 li t.?Y45.�._ '-1 z' .c tz....F �v Q_.__._... f3 r�r Hoc. .i- --------------------------------- --
---------------------------------------------------------•-------------------------------------------------...------------------------••----------------------------................------•----••.......
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provis ns of TITI-E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
oteration to til a Certificate of Compliance has been issued by the board of health.
Sign ---- --- --•---•----•--------•� ........... ...................
Da
Application Approved BY / � � %... '`
i Date
Applieatf'on'Disapproved for the following reasons----------------------------------------•----------------------------------------------------------........---•--
....----••---------------------------•...............----....--•-•--••---•••-----•-••----....-----------•-----•......--------------------...-------------------•--------••---------------------------••-
Date
r
PermitNo. ......•--••-•--------------------------------•--. Issued......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF' HEALTH. `
..................... !f.......:OF. ...............................
.r . �rr#i�irtt�r oaf ��ant�rlittnrr .�
AS LIX
TERT Y, That the Individual Sewage Disposal System coi}strutted ( or Repaired
by , -•-- "' �.. ........................................................ •-• L.............................................. ...--------•--
Installer
' .................... ................................................
has been installed in accordance with the provisions of of The State Sanitary' Code as described in the
P >
application for Disposal Works Construction Permit .............. dated ." .__ ----------
THE .ISSUANCE OF TI IS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUTARANTEE TH T THE
SYSTEM. WILL FUNCTION SATISFACTORY.
7
DATE................
.............? .............., .............. .............. Inspector...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 O F...........t{ � 'Z....... ............................... FEE........................
N /// .................. � �
Disposal, nrkv �.ttns �irjtilan rrmi# ,,, y
Permission ' hereb`y granted....:: ---------------------•-....--•-•-.-----------------------------••-•------•---•-------.--... ......._.
to Constru or R/erair ( ) an ivi ual Sewage 'sposal S stem ►ys
/
Str eet to- ....................
as shown on the application for Disposal Works Construction Permit No _____________ _ Dated f2,�: 7.
._.___._._....
�, .[ ! 'Board-ozetlf
t ��i
DATE........ = = /--------------------------------------•.-----
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS -
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