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HomeMy WebLinkAbout0142 OCEAN VIEW AVENUE - Health 142 OCEAN VIEW AVENUE, COTUIT A= 033 028 i i i 033 DATE: 315/97 PROPERTY ADDRESS: ..142 -Dc-ean1vi•ew Ave Cotui•t,Mass . 02635 , On the above date, I Inspected the septic system at the above address. This system consists of the following: 1_. 1 -1000 gallon septic tank. 2. 1 -6lx8l block cesspool. Packed in stone . Also has a precast top. Based on my Insoactlon, I certify the following conditions: 1 . This is. a title five septic system. ( 78 Code ) 2 . The cesspool 'is dry. Has root intrusion. 3 . The house is vacant. 4. The septic system is in working order at the present. SIGNATURr-: G`�( Name:-J. P.M'acomber Jr•. Company; J. P_Macomber- & Son-_Inc . g Address:__B.q_x_b�------- ------ ti Q s RECEIVED __Centerville , Mass__02632 MAR 11 1997 Phone:-_ ------- - MVH�L _50.8�J 7-5�.3338 1 r, � r Ol � THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY 6 • JOSEPH P. MACOMBER & SON,. INC. Tanks-Ceupools-Leachfields . Pump#d 4 Installed Town Sewer Connections P.O. Box 56' Centerville, MA 02632-0066 775.3338 77"412 ti • Y Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection F.WeWGavernor Trudy core Ar"o Paul Celluocl &`"-" David e.Struhs LL Go►ema CanMrwslorw e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PropertyAddresa: 142 Oceanview Ave Cotuit,Mass . William Burgess Addre"ofOwner.. 26 skating Pond Road Date of Inspeotlon: 3/5/9 7 (If different) Name otInspector Joseph P.MaCOmber Jr. Weston Mass . 02193 Comp Name,Address and Telephone Number J. M Macomber & Son Inc. Box 66 Centerville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I artily that I have parsonal),y.inspected the sawage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maiatens.nce of on-sit* wage disposal systems. The system: 7Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails f --7 Inspector's Signature:d /. Date: i—I The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inapectioa 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 otdoe of the Department of Environmental Protection. The original should be seat to the system owner.and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B, C, or D: A);_MT,EH PASSES: have not found any information which indicates that the system violates any of th* faihue criteria as defined in 310 CMR 15.303. Aqy failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: Al2 Ons or more system componsatl need to be replaced or repaired. The system,upon completion of the replacement or repair, panes inspection. Indicat*yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank ls metal, cracked, structurally unsound, shows substantial inilltration or=111tratio a,-or teak failure is imminent. The system will pan inspection If the existing septic tank is replaced with a ponforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 On*winter Street * Boston,Massachusetts 02108 a FAX(617)SWI049 a Telephone(617)292•Sb00 �� Pmld on Recycled Pape f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(oontinued) PropwtyAddr*" 142 Oceanview Ave Cotuit ,Mass . owes. William Burgess Date of lnsprootioa: 3/5/97 B)SYSTEM CONDITIONALLY PASSES (oontinued) .U&k- Sewage backup or breakout or ho static water level observed in th ,distrbtttioa boa is due to broksa or obstructed pip*(,) or due to a broken,settled or uneven distribution ban. Thesystem w jZi in if(with approval of the Board of Health): broken pipe(s)are replace obstruction is removed distribution boa Is levelled or replaced The system require pumping more than four times a year due to broken or obstructed pipe(s). The system will peas 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; V Conditions exist which require further evaluation by the Board of Health in order to determine if the system is tailing to protect the public bashh4 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. A O Cesepool or privy is within 60 feet of a surface water .&/Q Cesspool or privy is within 60 feet of a bordering vegetated wetland or a salt marsh 3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERUMM THAT THE SYSTEM 1S FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to e surface water supply. �[Q The system has a septic tank sad soil absorption system and is within a Zone I of a public water supply wel The system has i septic tank and soil ab oorption system and is within 60 feet of a private water supply wall. 10 The system has a septic tank and soil absorption system and is leas than 100 feet but 60 fest or more from a private water supply w4 unless a well water analysis for ooliform bacteria and volatila organic compounds iadicatw that the wall i, tree from pollution from that facility and the presence of ammonia nitrogen and nitrate titrOPa is equal to or lean than 6 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) PropertyAddre... 142 Oceanview Ave C'otuit,Mass Owner. William Burgess Date of Inspection: 3/5/9 7 D) SYSTEM FAIL& e I have determined that the eystem violatw one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Q6 Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. Qm Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. &WP_ Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. *D Liquid depth in cesspool is leas than 6"below invert or available volume is lew than 1/2 day flow. �10 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped d f Q Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. �d 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. &_0 Any portion of a cesspool or privy is within 60 feet of a private water supply well. Azy portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analysed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. Ej LARGE SYSTEM FAILS: 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: 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) 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 Auther information.. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address 142 O c e a n v i e w Ave C o t u i t Owner. William Burgess Data of Inspection: 3/5/9 7 • Check it t=fonnghave been dons:g information was requested of the owner,occupant,and Board of Health. 21NOns of the system components have been pumped for at least two weeks and the system has been receiving normal now rates that lei Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. �Ths facility or dwelling was inspected for signs of sewage back-up. ZTh,system does not receive non-sanitary or industrial waste flow , The sits was inspected for signs of breakout. ZAII system components,jseiuding 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 baffies or Z, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. Tba size and location of the Soil Absor ption System on the site has been determined based oa existing information or •P fed by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub. Surface Disposal Syctam. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner. Data of Inspection: FLOW CONDITIONS RESIDENTIAL Design flow: D aallona 0"A'y s Number of bedrooms: a Number of nrrrent residents: Garbage grinder(yes or no):_d& Laundry connected to system(yes or no): Seasonal use(yes or no):-°j Water meter readings, if available: 1 �rrsl �' jS�aNi Last date of occupancy: COMMERCIAL/INDUSTRIAL:- Type of establishment: 42V— Design flow:_,&� gaIIons/day Grease trap present: (yes or no),J Industrial Waste Holding Tank present: (yes or no).&,�' Non-sanitary waste discharged to the Title 5 system: (yea or no)&IO Water meter readings, if available: Last data of occupancy: OTHER (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING ORDS a�zor of informatio ystem af inspecti (yes or no)_ If yes,volume pumped: gallons Reason for pumping: TYPEJ�F SYSTEM t/ &P��diatrs�atlIIII'bos/soil absorption system �5 Singis spool Ovvrflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date in,#AUsd(if known)and source of information: Sewage odors detected when arriving at the site: (yea or no)_f/6 (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION (continued) Property Address: William Burgess Owner: 142 Oceanview Ave Cotuit,Mass . Date of Inspection: 3/5/97 SEPTIC TANK:�J'eeAAU (locate on site plan) �r Depth below grade: � � Material of construction: Yconcrete _metal _FRP —other(explain) Dimensions: r r AV Q Sludge depth: * 411 1 �r Distance from top_jof:slud a to bottom of outlet tee or baffle:_.._ Scum thickness:_/y'/� Distance from top of scum to top of outlet tee or baffle:- Distance from bottom of scum to bottom of outlet tee or baffle,, '<' • Comments: (recommendation for pumping, condition of inlet and outlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural riry, evidence of leakage, etc.) Pum se tic tank ever — ears : inlet & out t tees are .in lace : _ nn . GREASE TRAP. IV04,V-- (locate on site plan) Depth below grade:;4 material of constnw­ti6n;,6*ncrete _metal _FRP —other(explain) '.. ' A719 Dimensions Scum thickness. Distance from top vr scum to top of outlet tee or baffle:-,,(/-1 Distance from bonorn ni srurn In honnm of outlet tee or D'ahte•_41 Comments. (recommendation for pumping, cond,r,^n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, et Grease tray is not present rw3 saC 1/15/951 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddrese: 142 Oceanview Ave Cotuit,Mass . Owner. William Burgess Date of Inspection: 3/5/9 7 TIGHT OR HOLDING TANX-Jb ie (kcal+on$ite plan) • Depth below grade: IJ,4 Material of 490onemw_metal,FRP_otir(explain) - A� I Dimenskas: Capacity ns / Design flow: nalday Alarm level: N Comments: (condition of We tea,condition of alarm and float switches, stc.) Iignt or Ho-Ling tanX. Not preSent DISTRIBUTION BOX: 4*W, (locate on site plan) Depth of liquid level above outlet invert: .U.)9 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,atc.) Tl; et,+; bi,ti nn bnx i a nnt. nracant. PUMP CHAMBER:_✓QVe— (locate on sit*plan) Pumps in working order:(yea or no) /i Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) ump am er is not present, (revised 11/03/95) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontiaued) p�p.rty ,e,� 142 Oceanview Ave Cotuit,Mass . owner: William Burgess D&W of Inspeetton: 3/5/9 7 SOIL ABSORPTION SYSTEM (SA9k Ooca"on site PLUk if possible;e uir4 but may be approximated b7 am.iatruslw methods) If not daterminad to be prwat,explain: e Type: �. l..ralns P ts,aumber� leack, ehambus,aumbar: w.rni..,aumber.� 1eeehin8 trvnehea,aumb.r,I4n8tb 6"M" S.1ds,aunaw, anion,: ovardow owspool,aumber Coasmaats:(note condition of soil, 4ps of hydraulic Ugure,level of pondiaz condition of ve8etat1on,etc.) None of the above are present CESSP004- (beats as site Plan) Number and ooa18uration / Dopch-top of b4uW to inlet invert• Depth of eolWa Lgar Depth of scum layer. Dimaanioas of mspool: ldatwi.j.of ooast:uctim. L_ Indication of pwadwater. inflow_(oaespool must be u of a pumped Part inspection) 4¢ Command:(note condition of 64 sips of hydmulie Ullurs;level of pondin8,ooaditioa of vegetation, etc.) oamy Tan or pon in All vegetation is normal. PRM:Aj,4 (beat.an Site plan) Matasial,of Al/* Dimanrious_ i11A Depth of aoH&?_A� Commaata:(note Condition of Soil, 48as of hYdrauhc failure, Ievel of poadin& oondition of re8etatioa,itc.) Privy is not presen (revised 11/03/95). 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B ` SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties t s e o a t least two permanent references landmarks or benchmarks locate all wells within 100 ' Cotuit Water Company 428-2687 3Y' CP C I DEPTH TO GROUNDWATER .1+ depth to groundwater r+ckthod of determinesion or ,approximaticn: nnnmoSr: :Pns. a �d-4Q&M*issib.= titer table Contours 301 to water s rw,n.•..-n,r��--r+r..►. anr•ne.w�-art e�.rrs.srr.�.•r+�►�r�*Rnn•,nerwy�n�n,� 7 7 77r-rn—....-.r..., TOWN OF Barnstable HOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED 1 2 0 nv' wAveT RE ¢ea le A e Cotuit Mass . STREET ADD SS _ 4 , ASSESSORS MAP, BLOCK AND PARCEL i 33-28 OWNER' s NAME William B�zrgess PitR.T—D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr . COMPANY NAME J. P.Macomber & Svvrr -Inc . COMPANY ADDRESS Box 66 Centerville ,Mass. 02632 Street Town or Clty state LIP COMPANY TELEP14ONE ( 508 ) 775 - 3338 FAX ( 508 1 790 -1 578 - CER'fIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the 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 with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : 'XXXXXXXXXXr,Systeoi�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 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con acted has found that the system fails to protect the public health and the environment in, accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . e , - Inspector Signature Date 3/7/97 One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or•.I.operator shall u d within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 CMR 16 . 305 . partd .doc - Sbj1f 3��1 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 5 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. June 8, 1995 ' Acting Director of the ' ion of Water Pollution Control .7 G No........,Z ..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .L' Q............OF......6 ACkk.q;7Vl4A_1._C. ---------------------------- Appliratinn -for 'Nip oal Workii Cnnntrnrtinn Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .............................. ................... .....................................................`-`'-"......----- Location-A dress or Lot No. fi aw r �_....� Address I q�. -1-0-------- ------------ nster Address t d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms._.___ ----------------Expansion Attic ( ) Garbage Grinder (k)2 aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Q, Other fixtures .....................--------------------------------- W Design Flow.....�®--------------------------------gallons per person per day. Total daily flow----------�17Q......._.............gallons. TrenchL tNo capacityth..s Length Total Lengthidth--------------Total leaching area.. Depth--------------- Disposal Seepage Pit No..'.-Z-_..../------ Diameter../..0P0.. .�e th below inlet____________________ Total leaching area--_-- _...........sq. it. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of "Pest Pit----------------_... Depth to ground water------------------------ p4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------ ----------------------- ---•--------------------•-----. . . ODescription of Soil-...........Am....... ----------------------------------------------- --------------------- ---- 1---------------- U ---------------------------------------------------------------------------------------- --------- -----•. ----- - W ------- --------------------------------------•-----------•--•--•-•-...---•------•----. .. �'. --�-t/ . . - -------- U Nature of Repairs or Alterations—Answer whe pplicable---- ---- - ._ ,------ __. ----------------- ---- --------------------------------------------------------------- n� --- -- - ----- -------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned fCertergrees not to place the system in operation until a Certificate of Compliance has been issued the !doad o h Sig .---- -- � . ----- ------------------ f�z� D/?L Application Approved By---... 1 ------------------------- ----- �':.7 � �✓ Date e Application Disapproved for the following reasons:............. --------•----------------------•----------•--------•-----------•-----•----------- --------------------------------------------------------------------------•-••------•--------------•••.._...------------------------------------------------..............------------....-----------•--- Date PermitNo........................................................ Issued.-------- --------- ................................ Datete -- --- - - ��. --......—_---------------------------------------- :.. �...... Fwic— .................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH VOW— ., OW. . _ ..:_.........OF...... 04..Kk.S;-VA ,.C.L.................................•--- ApVtiratiun -fur Di,spuott1 Workii Tonstrur#ion Vanift Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal ' System at: (�1RR((ff�SSdd � . N_oLcaton or Lot +ti- �_._ A� WL . MC. ........................ Ow er Address Z,•. ff .. aV Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms----J :_.,7-----------------Expansion- Attic ( ) Garbage Grinder )Z•-. e g a ' g --------------------------- No. of pei-sons Other—Type of Building ---.--- ------------- Showers ( ) — Cafeteria ( ) 0.' Other fixtures ------------------------------------------------- - :.....•-••--...... W - Design Flow:.:....................:.:........gallons per person per day: Total daily flow-__--_--=�QQ--_. --___-.--.--.--gallons. WSeptic Tank=Liquid capacity - allQpns Length________________ Width................ Diameter................ Depth................. x Disposal Trench No "" idth-. --•-._. Total Length------------ __--- Total leaching area-----------------.-_sq..ft. Seepage Pit-No-Z.._ ;_.____ Diameter.1_QQQ_� -at th below inlet____________________ Total leaching area_.'-------------Sq. it. z Other Distribution'box ( ` ) Dosing tank aPercolation Test,Result Performed by-------------------=----------------------------------------------------- Date---.----------------------- -------- -- Test Pit No.11------_---------minutes per inch Depth'..of, "hest Pit---------------------- Depth to ground water............... ..._... (14 Test Pit No. 2................minutes per inch Depth of Test Pit....................... Depth to ground water_..--------------------- -------------------------- ...... = ' ODescription of Soil--------. ► 4- -•--------------------------- -------=------- -------- ---=---------------- v ---- W ----------- ----------- ------------------------------------------------ - V Nature of Repairs or Alterations—Answer wh pphcable._..__ - ------- ---- - ------- --- ...._ .... . . _.__ .__.___. -• ---------------------------- - ••------•- -• -----. C?' i" ---------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—'The undersigned fu liter not to place the system in r operation until a Certificate of Compliance.has been issue�d�1 .tho d h It �r Si . -- .. -'`....'"' ---- l Application Approved BY - -------- --•-1�----- �..r•^" Date 4. Application Disapproved for the following reasons------------- ;--.-------------_-----•---.---_---.--.---------._.--------------:- . .........--•--....-•---- -----------------------------------------------------------------....... ......................................................................................................... Date PermitNTo....................=........................... -------- Issued........................................................ Date THE.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Ol ........`.....OF.......:: ... ..�i .. ................................ .. IT , firate of Tom Iitturr THIS IS TO CERT Y That the nd Ntdual wAg �,i,gposO. S stem constructed or Repaired!; Y ( ) P !; ) -- Installer atQ L� ......" t:._ _ 0' ►_ _ "� � t ' '"---•-----------=----------------------•---•--•-----..._._._....._...--- has been installed in accordance with the°:provisions o _ c9e XI of The State Sanitary Cocir asPescribed in the application for Disposal Works Construction Permit -------------- dated------ '+ ....... .......... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUE© AS A GUARANTEE THAT THE w SYSTEM W L FUNCTION SATISFACTORY. � , -..... E ------ ------•............... Inspecto = THE COMMONWEALTH OF MASSACHUSETTS BOARD O HfEA TH ...... ... ..O F::... �'. �!�' .........C...... / No.--- ---------- i . FEE//................. %rV0qitt1 u k-q it rrtn'# • 4 Permission ' reby granted s- -----•••-- - ... to Constr ( ) or epair ( In tdual wage Disposa tem at No""� vC as shown on the application for Disposal Works Construction Per o.-._... D ... .. -- ---7 __ .......... Y oard of Health DATE............................................ -------- „. FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 13 ot&TION ' 060 SEWO CtE PERMIT UO. VILLAGE 1W5T&LLER S W&ME ADDRESS BUILDER 'S Q &M - ADS--DRESS DILATE PER"1T 155UED 7--76 — — — DATE COMPLI W-ICE ISSUED : ' _ _. � � d''� � �.y '/ �\ Y �. .� � � i � ;� / .[`l \ '' � ��' / � � .\ 76 � V `\ �� ��Na``\ MAP NO. PARCEL NO. oa H~\� 1. DATE . C��s „a ail 1793 2. SEPTAGE HAULER: 3. PROPERTY OWNER'S NAME: 4. ADDRESS (PUMPING LOCATION): 5. VILLAGE: 6. VOLUME (GALLONS PUMPED): 7. TYPE OF FACILITIES PUMPED: (CIRCLE ONE) gam; COMMERCIAL: A) SEPTIC TANKS (HOW MANY?) B) CESSPOOLS (HOW MANY?) C) LEACHING FACILITIES (HOW MANY?) D) GREASE TRAPS (HOW MANY?) 8. REASON FOR PUMPING: (BY CHECK (✓) MARK) A) MAINTENANCE ( ) B) SYSTEM FAILURE ( ) C)OTHER ( ) ,, 3y� ��s.' �� �� - � � _ - � � J ���i � � � � C.P �� �i�, � � �� m Y .. ,. �; ������� ��3��7 �-