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HomeMy WebLinkAbout0130 OLD KINGS ROAD - Health 1130 Old Kings Road . j COW it P A = 022 093 - - -- ---- -- --- - - - - REG'-. ]ABLE COMMONWEALTH OF MASSACHUSETTS F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRSDEC DEPARTMENT OF ENVIRONMENTAL PROTECTIONN OF B� PHEALTP MAP PARCEL LOT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 130 Old Kings Road (Cotuit)Barnstable,MA Owner's Name: Catharine Locke Owner's Address: c/o Marjorie Harvey,Guardian 116 Old Kings Rd.,Cotuit,MA 02635 Date of Inspection: November 13,2003 Name of Inspector: Gary J and/or Jane E Rabesa Company Name: Rabesa Subsurface, Inc dba Warren Cesspool Service Mailing Address: 72 Sandwich Rd East Falmouth,MA 02536-5602 Telephone Number:508-540-7143 CERTIFICATION STATEMENT I certify that 1 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 Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature Date: November 21,2003 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health 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. Notes and Comments:Title V system,currently unoccupied,in good condition. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 130 Old Kings Road (Cotuit) Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: YES X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: NO 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 determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Warren Cesspool Service 508-540-7143 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 130 Old Kings Road (Cotuit)Barnstable.MA Owner: Catharine Locke Date of Inspection: November 13,2003 C. Further Evaluation is Required by the Board of Health: NO Conditions exist which require further evaluation by the 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 accordance with 310 CMR 15.303(l)(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 system 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 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: Warren Cesspool Service 508-540-7143 ci,)nnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 130 Old Kings Road (Cotuit) Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool —X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. _X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. —X_ 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.[ NO (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: N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gad to 15,000 god. 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Warren Cesspool Service 508-540-7143 r;.io c r-., +;,.., G,.,..,,A/I cnnnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 130 Old Kings Road (Cotuit)Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x — Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x Were as built plans of the system obtained and examined?(If they were not available note as N/A) x Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x Were all system components, including the SAS, located on site? x_ 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? x Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no x — Existing information. For example,a plan at the Board of Health.. x _ 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)]. Warren Cesspool Service 508-540-7143 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 130 Old Kings Road (Cotuit)Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n/d Number of bedrooms(actual):three DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): n/d No design plan available at the health dept. Number of current residents: none(previously two) Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): n/a Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)):2002 averaged 145 gpd,2003 averaged 173 gpd Sump pump(yes or no): no Last date of occupancy:July. COMMERCIAL/INDUSTRIAL: N/A Type of establishment: Design flow(based on 310 CM 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: (town) February 2001. Was system pumped as part of the inspection(yes or no): no If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM x Septic tank,distribution box,soil absorption system —Single cesspool Overflow cesspool _�Privy _no_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 known)and source of information: 1985"as-built"on file. Were sewage odors detected when arriving at the site(yes or no): no Warren Cesspool Service 508-540-7143 f Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Old Kings Road (Cotuit) Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 BUILDING SEWER: locate on site plan) ( P ) Depth below grade: 16" Materials of construction: cast iron x 40 PVC other(explain): Distance from private water supply well or suction line:town water line 28'. Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: YES(locate on site plan) Depth below grade: 14"/12" Material of construction: x 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:standard 1000 gallon septic tank Sludge depth: 10" Distance from top of sludge to bottom of outlet tee or baffle: 23" Scum thickness: none 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: onsite Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):The tank appears to be in good structural condition with no failure criteria. The sanitary tees are concrete. The DEP recommends pumping every three years,depending on use. GREASE TRAP: NO(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or 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.): Warren Cesspool Service 508-540-7143 7 r Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Old Kings Road (Cotuit)Barnstable.MA Owner: Catharine Locke Date of Inspection: November 13,2003 TIGHT or HOLDING TANK: NO(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: YES(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: none 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.): Viewed by remote camera,no failure signs observed. PUMP CHAMBER: NO(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.): Warren Cesspool Service 508-540-7143 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: 130 Old Kings Road (Cotuit)Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 SOIL ABSORPTION SYSTEM (SAS): YES (locate on site plan,excavation not required) If SAS not located explain why: Type x leaching pits,number: one 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.):The 4' by 6' leach pit was dry at time of observation with no previous failure signs. The cover is 32" below grade and should be raised for future access. CESSPOOLS: NO(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): no Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: NO(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Warren Cesspool Service 508-540-7143 T;+io c i—,.o,.+;— V,,,..,,4n 1;11nnn 9 Page 10 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Old Kings Road (Cotuit) Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 SKETCH OF SEWAGE DISPOSAL SYSTEM NOT TO SCALE 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. 130 Old kin s R� v BACK Warren Cesspool Service 508-540-7143 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Old Kings Road (Cotuit)Barnstable,MA Owner: Catharine Locke Date of Inspection: November 13,2003 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water is greater than 11 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: x Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: records on file Checked with local excavators, installers-(attach documentation)Engineer's certification x Accessed USGS database-explain:town topography maps,USGS survey maps You must describe how you established the high ground water elevation: Grade to bottom of leach pit is 8'. Besides the elevation from USGS and town topography maps,the elevation of the land in back is lower. JUL 1d. i; 5 Rd ts.4 'MSL. V' fii rnst. Warren Cesspool Service 508-540-7143 No Z4 Fes ............... THE COMMONWEALTH OF MASSACHUSETTS ' BOAR® OF HEALTH ot� ......................OF...........Ai2.c� .._... Applirta#iou for Disposal Works Tnnstrnrtinn Prrutit Application is hereby made for a Permit to Construct (V_11�or Repair ( ) an Individual Sewage Disposal System at: ...........................•---------••-- -•---••---•-. ... ......-------- Locatio -Address or Lot NO. W Owner Address ..:....�.tl.0 4.alQ...................................... --- ----e� .........N-14A...................... Installer Address dType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons........_--------------- Showers ( ) — Cafeteria ( ) a' Other fixtures __________________________ W Design Flow..................... ............gallons per person per day. Total daily flow_______.._........s_�.©.............gallons. WSeptic Tank—Liquid capacity./ gallons Length__ !...... Width.4!P7.___ Diameter................ Depth..,�..!71..... x Disposal Trench—No..................... Width-------j............ Total Length............�.......Total leaching area............_..__.__sq. ft. Seepage Pit No........ --_-._.__.. Diameter.../z._C.__..._. Depth below inlet...._._��..-......... Total leaching area..M...._.._sq. ft. Z Other Distribution box (s/f Dosing tank ) Percolation Test Results Performed bGf . IN .................................... Date___ a Test Pit No. 1.....Z-------minutes per inch Depth of Test Pit..144_'.... Depth to ground water.........._._-'----------- (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------ ....--- -•--- - 0 Description of Soil...f�alUl _.....SRy� C7.®� �.¢ y t V ...••-•-•-••--••----••••------•-------•..............•---......-----•---•------•--•---------•...-••••-----•--•----•----------•-•••---•--------•••---•-------•-------•---••----------•-- -------------------------------------- ? -----------------------------------------------------------------------•------------------------------------------------------------•--- U Nature of Repairs or Alterations!Answer when applicable.___________________________________________________________________________________•-.-.--.___. ----------------------------------------------------••-•-...........................................-•--...---•-••-•----------•---•----------•--••---•-----•--•-•-•-••---••--•-••-•---•-••........---- Agreement: The undersigned agrees to in tall 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 Co m liance has been issued by the board o iealth. ,` u� C� t- Si ned.........- Application Approved y------ :---- -•-•----•- .............................................. � Date Application Disapproved for the following reasons---------------------•------••-------•----------------------------------•...------ ............................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date w + y 41 No......................... FEB..........................._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tJ..._-------------------OF...... A/��.?S% cC_..------------------...------•-------- Allpfir�ation fur Uiupoual Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct (V_1�or Repair ( ) an Individual Sewage Disposal System at: - or Lot No. ......................_.......................................................................... ..........-•...................................................................................... Owner Address W -----•---•------------------------------•-...............----------._..__._._...----..........---- Installer Address 3 dType of Building Size Lot_______/_/___Q____D____O.........Sq. feet U Dwelling—No. of Bedrooms................ .......................Expansion Attic ( ) Garbage Grinder ( ) per, Other—Type of Building ____________________________ No. of persons......... __.____.___.____ Showers ( ) — Cafeteria. ( ) a' Other fixtures ____________________________ _ W Design Flow..................... ____....:_.._._gallons per person per day. Total daily flow.................. 3_0..._.........gallons. WSeptic Tank—Liquid capacitvA�_gallons Length__jg_."G____._ Width.:4'!Q..____ Diameter________________ Depth_S_.�.l..�..... x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......A----------- Diameter_:_!?_.�.......... Depth below inlet.... ........... Total leaching area__4. .....sq. ft. z Other Distribution box (� Dosing tank (� ) SG.A���JSK�----•-----•-•----•----------- Date._./__0::•3/:�3'' 77 Percolation Test Results Performed by_________________________________ _._____._______. aTest Pit No: I.....Z-______minutes per inch Depth of Test Pit__/c1'-4_`----- Depth to ground water..................... fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_____:_______________- ------------•--------------•------••----•-------------------------------•---•------•---..._...------........................................................ O - cow Description of Soil._L` O�!J�T-------=SAS------ e ..... --•--•• ¢ y U -------•----------------•----------------•---------------------•-----------------------•---•--------_____---------------------------------------------------------------•-------------•----------------- W ------------------------------------------------------------------------------------•-----------•-•---•----------------------------------------•----------•------•-•----••--•---•---•-•---------------- y 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 TIT iZ 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. C`'� ?L 0_ a •_ __1/1 I `fate r �AppicationApproved By..................--............................................................................... Date Application Disapproved for the following reasons:_____________________________________________________________________________________•__.___._.:__.._...._______ --------------------•------------...----------------------------------------------------------------••------------•---•---•-----------•-----------•-----••---•-------•-----••-----•••-•-----•--.._._.... Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................................OF................... .................. (IrrfifirFa#r of Tlrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( . ) by............................................................................................................................... Installer at........:.....................•-••--....---•------•- ----------------------------••-----•----------•-----------------------•-------•--•-•-•-------•--•-=---.-------------------• ZL;- -T •--•------------- has been installed in accordance with the provisions of 'IT Ih-j 4*..Sanitary Cgdo/de r- e ;in the application for Disposal.Works Construction Permit No......................................... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED AS A GUAR TEE THAT THE SYSTEM WILL FUN TIO SATISFACTORY. DATE..................... ..� .... ................................... Inspector....--------------•----- • - --•--- - ....... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH —_ ...........................................OF..................................................................................... No... FEE:`-"`................ Diu ouWorks (9onotrudion rranit Permission is hereby granted------- = ---'-.A-•---••--.----------------•--•--••----------•-----------------------.........-------_...._.............._ to Construct ( ) or Repair ( ) an Individual Sewage Disposal System y stye t4-,6rt ,.,4I 2 .,<s� :,t as shown on the application for Disposal Works Constr etion Per eirli NO.______�_____________ I�at "y 1 PP P ', . , .� .� .r.... -•--------•-----•-_---•- .... - ,. z.. J ..:...........,...----t _. . Board of Health DATES , �1 f E3. ........................... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS L O CATION SEWAGE PERMIT NO. 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