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HomeMy WebLinkAbout0125 SCREECHAM WAY - Health FLC 25 Screecham Way - -- - -- - -- otuit1 107 __- _ - _ _ _ - ! .t 2 4-0 61 0(;�. COMMONWEALTH OF MASSACfIUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION C SW RECEIVE® _ f 2�. SEP 0 12004 T, TOWN OF BARNSTABLE TIT]_ HEALTH DEPT. I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS ENTV. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM Ln rn PART A CERTIFICATION Property Address: 125 Screecham Way r -o Cotuit -E�,RCEI, �'�'"��` 57 Owner's Name: John Buckley ,OT Owner's Address: Date of Inspection: 8/19/2004 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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 Section 15.340 of Title 5(31I0 CMR 15.000). The System: —ZPasses 1 Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: z i �� Date: F 616y 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 ****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. I. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D C. System Passes: 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: One or more system components as described in the"Conditional Pass"secti need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved b the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the following tements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic t�(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 lzy the Board of Health. *A metal septic tank will pass inspection if it is structurally soundffnot I aking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. f` a 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 pi�e(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping morg4han 4 times a year due to br ken 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: 6� r' i Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of WeXalth 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 determine�Jn accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will,irotect public health,safety and the environment: _Cesspool or privy is within 50 feet of a,sdrface 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 SA, 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 of a public water supply. The system has a septic tank and SAS and the SAS is within 50Wfeet of a private water supply well. _The system has a septic tank and SAS and the SAS is lessAan 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 thVwell is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen'Vequal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis"st be attached to this form. �I / r; 3. Other: r' i i I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ f 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 and 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 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 forma ./l.,,(-�Yes/No)The system fails. I have determined that one or more of the above 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: To be considered a large system the system must serve a facility wid a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the iteria above) yes no the system is within 400 feet of a surface drinkin 'water supply the system is within 200 feet of a tributary t a surface drinking water supply the system is located in a nitrogen sensi ' e area(Interim Wellhead Protection Area—I WPA)or a mapped Zone 1I of a public water supply well If you have answered"yes"to any questigp'in Section E the system is considered a significant threat,or answered "yes"in Section D above the large syst�6i has failed.The owner or operator of any large system considered a significant threat under Section E or fled under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should 6ntact the appropriate regional office of the Department. / Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 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) _ 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? _jZ_ 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 than 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 µ 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)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): -3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33© Number of current residents: Does residence have a garbage grinder(yes or no): N62� Is laundry on a separate sewage system(yes or no):&2jif yes separate inspection required] Laundry system inspected(yes or no): — Seasonal use: (yes or no): Yc.S Water meter readings, if available(last 2 years usage(gpd)): r n Sump Pump(yes or no): Last date of occupancy: r —� COMMERCIALANDUSTRIAL 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 _ Non-sanitary waste discharged to the Title system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: AZb Was system pumped as part of the inspection(yes or no): � If yes,volume pumped: l allons--How was quantity pumped determined? Reason for pumping: �r/ed', r.—<a�.•� �c �-��� �a<:t4s, TYPE OF SYSTEM AZ"§eptic 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 known)and source of information: Were sewage odors detected when arriving at the site(yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 BUILDING SEWER(locate on site plan) Depth below grade: Q 1 5 it Materials of construction:_cast iron /4'0 PVC_other(ex lain): 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: cy( Material of construction:_,,,�<—oncrete_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) e ®` I?Dimensions: l " x ��y x 15- Sludge depth: Distance from the top of sludge to bottom of outlet tee or baffle: Q 3" 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:=�,c— gr Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): L..' '<:SZ. cave '� v�e,.�—.-' •. o �w GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglas _polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet/etc.): Distance from bottom of scum to bottom ffle: Date of last pumping: Comments(on pumping recommendation tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of lea Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 TIGHT or HOLDING TANK: (tank must be /ss f inspection)(locate on site plan) Depth below grade: Material of construction:_concrete metal_fibthylene_other(explain): Dimensions: Capacity: gallons Design Flow: gallons/da Alarm present(yes or no): Alarm level: Alarm in worki order(yes or no): Date of last pumping: Comments(condition of alarm float switches,etc.): DISTRIBUTION BOX:—Z(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n" Comments(not if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): " PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,conditi of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 SOIL ABSORPTION SYSTEM(SAS):_�,�(locate on site plan,excavation not required) If SAS not located explain why: Type eachin its number: �� g P 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.): CESSPOOLS: (cesspool must be pumped as part of inspecti )(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 hy¢ aulic failure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of/hyraulic failure, level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 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. L4 O gt Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 125 Screecham Way Cotuit Owner: John Buckley Date of Inspection: 8/19/2004 SITE EXAM Slope Surface water Check cellar V Shallow wells Estimated depth to ground water>1 O 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 the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) (Accessed USGS database-explain: r_ r You must describe how you established the high ground water elevation: j �! G� f N R No._�.._- --�••-- r _........... _ THE COMMONWEALTH OF MASSACHU:SETTS ;r BOAR® OF HEALTH ..OF /9 n�i c� �/t C��— i Appliratiou for Uiivuiittl Morkii Tomitr i'U rrmit Application is hereby made for a Permit to Construct ( ) or Repair (f' ) an. Individual Sewage Disposal System at: C�� °,7. �— l�(11 tf Loa n- d es or Lot N ...J! 11� ts...........A. ..��g.S���.,p........................... ('1., L[c-ry^�. -f ar`''b-- j........ - q�° l�esi-� �2 Ad /7'r S� t✓�fLy Installer Address ,,ee,�, L d Type of Building s'F Size Lot._.l_3� .o......Sq. feet U Dwelling No. of Bedrooms.......................:....................Expansion Attic Garbage Grinder ) aOther—Type of.Building ...t[` it�,trn,. No. of persons...............::....... Showers ( ) — Cafeteria ( ) dOther fixtures .----------•------------------------------------•---....----------•------------------------....._..•-•-•...... .......... W Design Flow............ - ..:........f.........gallons per person per day. Total daily flow.................�........................gallons. cy Septic Tank Liquid capacity.-54 .gallons Length.X..G..... Width................ Diameter---------------- Dept h................ W Disposal Trench--No. .................... Width................... Total Length............ Total leaching area....................sq. ft. x 3 Seepage Pit No........-../....... Diameter...... ......... Depth below inlet..............•..... Total leaching'area..................sq. ft. z Other Distribution box ( ) Dosing tank ~' Percolation Test Results Performed by........................................................ Date........................................ Test Pit No. I................minutes perk nch Depth of Test Pit.._.._.....•........ Depth to ground water........................ Test Pit No. 2................minutes perAinch Depth of Test Pit.................... Depth to ground water------- ................ 0 -------------- .................. ............................................. Description� Descri rion of Soil.___._-._ :�' �^- x •p . ------------------------------------------------------------------------------------------------------- V � .:........ ._... •-------•--------•-••-...----•--•--•----•--•••-•---•...........................••••......---•...-------- W ••-••-••--------------------•----•...•••••-•--•••------•-•------ •-••---------•--•----••••-•••••............-••--•------ •••-•••---••---•-••----.....•--••••--•-•-••--•••-•••......-----•-•••--•-•-•••-- U Nature of Repairs or Alterations-Answer when applicable......................................•..._................_..___......_...._............_..... a: Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL U 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 / - - —u-------------------------- Signed1-.Date Date ApplicationApproved By................................................................................................... ........................................ Date Application Disapproved for the following reasons---------------••--...........------------------------------....-•------------------------ ------......_•--_.... .......................................................................................................................................................................................................... Date PermitNo......................................................... Issued........................................................ Date D" ._ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF......... .......... "' � s ��. ......... ..... ..................................... Appliratiun for Disposal lVorks Tonstrur#ion Prrmi# Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Zs- Scgeec FfftM U)A Colin r L % # ............ _..... .... ........--• ............. ................ _ -1134. ioqC ..I�!J.A9K— _. A .. T! .................................. P..) 1 Ga - P ,'& •�°`--.... kD64 ....Q r .a... .. G Installery�, /yy,� -Address / Type of Building /// Size Lot./t3_.iPp�_0...S feet �.. -------- Dwelling—No. of Bedrooms............................................Ex anion Attic g � g ., p ( ) Garbage Grinder , Pk Other—Type of Building ____...�No. of ersons.......,7?.................. Showers Cafeteriaq , dOther fixtures .............................................•-•----........---...................-•-•- - ........ W Design Flow.............X-17........._._._..._..gallons per person per day. Total daily flow........... 1,.�......_........._.galIons. Ir WSeptic Tank—Liquid capacity...�o�gallons Length•.&': /.... Width................ Diameter.................. epth_........__..... x Disposal Trench—No..................... Width.. _....._.___..... Total Length.................... Total leaching area...�.............sq. ft. Seepage Pit No------------/_...... Diameter........4........ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) I Dosing tank ( ) Percolation Test Results Performed bY........................................................ . Date.......................... Test Pit No. I.....Im....minutes per inch Depth of Test Pit......../z... Depth to ground water..........:............ PLO Test Pit No. 2................minutes.per inch Depth of Test Pit.................... Depth to ground-water............':.......... D Description of Soil.- -•---------•--....--•-•--•.............................................•-•--•----.....---._... .._...---.........-----...-------M•�---- V ! .............•-•-•-----......---••--- -------....---•---------...... •- - - UW ...........................................................--•-----•---•-•-•-•..::•-•-.....--•-•...••-•....:••-•••-----••-•••-•-•-•--••--••...--•--- Nature of Repairs or Alterations—Answer when applicable.........................................................:..:.................................. ----------•--------------------•--..._......._..........-.........-----.........-----•------••••--------•---•-••---------•-•------•-----....._............ = Agreement: e 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 been issued b the board"'of health. P P y 5 Signed- ie Application,Approved BY.................................................................................................. . Date Application Disapproved for the following reasons:.......:.._::.............•___•________-_._--•--........-.______.._--....._._.......__......_._______...._-- ......................••-•---•----.........--•--•--........-----..._....--------••----.............------...-----...--------------•-•---•------..•.:.......---•---•--•-••--•................................................... Date PermitNo................................•--•••••----------.. Issued..................................:.................. ... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............c/Guy: ......OF............................................................... ................. Trriif irab of Toutplianrr THIS IS TO CERTIFY, That-the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...... ..... r !;. %7�i�u �---.......--•--•..... . .. ........ •-........ .......------................................................ .. ._ ! / Installer at:. .:... :..- .). �?... .. *.............has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code--as des ribed in the application for Disposal Works Construction Permit No.___ ......... dated....-. .......... ! ? �' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE r SYSTEM WILL FUNCTION SATISFACTORY. _ DATE................ .... .l�...... .19 �.�._ Inspect .......................•------•---••-••........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH qq ...OF........ .......... .................................................. Fss........................ Dispos t arks funs#rur#iun rrrmit Permissionis hereby granted. ................ ................. ........._.... ........................................................... to Constru ( ) o Repair an I v dual Sewage is Sj�� Syst at N0.... ._. .�.� - .. ...._....Q Stre 'f.._. .... ...................................... as shown on the application for Disposal Works Construction Permit No......:.............. Dated.......................................... ............. . ----.....--••-----•••--.......---....._ Board of Health �. .. i a.8 DATE........•.:....... ......... �....- ---• ---._....... FORM 1255 A. M- SULKIN, INC., BOSTON �• � � � ���T' rL o� 'L IN 1 � PST 1�v do to 9 1 I' I � � I •: �� I �►� Z�G �'�`L6 t5•av WA y `H OF RICHARD ��F. � ?cTER N r A � ;, SULLiVA� BAXiER Rio No..297, " ,({Nm 24043 ,d . 37 �Pt-�►J V'I�w l��=lxa Vkrloa!;ttam `(3k5t�1> 01J N v . Wf'1'la 'CAI SP05,4L • t;�Nl L- T= - I I o x 3 = S rl G -rA-tk - )C 2rzo!- U5E tSOJ 4a4L `fi W1G. �U'..1.,. Pz- -F-- -PI FP (- Prr - v5a- IG!'AIQ(- AIL w,ac.L �42�A - IZ64 'Zloty �2•� = l�l�D 6PD V'C-rT M AP-r-A - I r74 rif - `j-o�b.L 'DESIGt�1 -814 GPn P -noel Sz�►T 1" 114 2 AV ti4 or-►. % V RICHARDA. SULLIVAll BAXTER No.24048 s Idp. 29/353a V' � w* Su f #• y �_✓_� r. �o FG• 50 �-FG � r- �'; MP - -oaiil l / BoX /.vim G,4G., 4Y L sEarrG �?f a PIT T.v.v�c ° W1 N .4 /it/✓. /Nt/ 3 ' GL��J .. � �1�_�� �+ �LP�Z �f�•d- G'.E.2T/F/EO PG OT pL4 A/ WA6LIE.D .• M�� , Cv Z)IF /Q 9.E / G-,E'T/iCy/ 7;4/,47 THE //o vS C S.yaw.v ,�/E,�Eov GOMPGY.,S !•v/T/,/Th��'S/O�'�ivE ,B.dX�.e�,t/YE /.uC. ,4M9.4ETI3AG` .e�4V/�'EkIE�C/rS d� 7y� ,2EGrsrE,2E�,C.4ivo.S�,e�Eya,Ps ' TDN/iV dF Z�42 iJ S T4 I: L 4� AlaT -eF ZSEO ::::)A/,4 LOCATION SEWAGE PERMIT NO. VILLAGE INSTA LLER'S NAME A ADDRESS V�1 �J'?Cv�,by ;Z5'iot�(4 k4ci�F 5 C5 d2!QL Eit c- k D S U I L D E R OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED -� �Z�a 6 J� � �'_ � � . �° 1 .2