HomeMy WebLinkAbout0058 WHITMAR ROAD - Health 58 WHITMAR k D' � OIL
�I
COMMO. WEALTH OF NLkSSACHt;SETTS
r,. EXECUTB E OFFICE OF EN IRONMEITAL AFFAIRS
-= DEPARTMENT OF ENvIRONMENTAL PROTECTION
ONE RI\TER STREE". BOSTO\ KA 0210E (617) 292.550o
TRUDY C0
Secre:ar,
ARGEO PAUL CELLUCCI A�I'IDiBS R: 1>~
Governor Conu=s :e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION 1(�/
�rt s�(j Wh�Tyvt►avt t Name of Owner vlek ` O
Property Address: � -
Co Address of Owner:
Dane of Inspection:. L l i7�c( �+ - L / o� 99`9
. Name Oi.;;,�;:s...`..•/weds!Pri�)[,� C.i}Q C"G �F�EL./�CU � ._ � — � �'e�
I am a DEP approved//system Inspector pufauant to aecucA :Y•� �: •saes !37:...+"R 15.000)
Company Name: 14& _)`-r?
Mai3ing Address: /L„ L t��5 I�ln I/N- dL�i 4-�1 z
Telephone Number: /S:O-
CERTIFICATION STATEMENT
1 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system.
Passes
�� tr®n�tLlo(11111Y i a'a:�:
_ Needs Further Evaluation By the rote?Acproving Authority
_ Fails
inspector's Signature: Date t 1 5
The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be sent to t1Te
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
j
revised 9/2/98 :pY 1oru
v(tip •:t•.='1'tj. ..`}l.�'•�•'its L
`= Primed on Recy W riper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (e—b—ed)
',ropertyAddress: 5� (rc�r�l�rVL►`tK.�
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
�•: :P
B. SYSTEM»CONDITIONALLY PASSES:
On_e or ore 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.
Indicate 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 is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is Imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to d ermine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDAN WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEA AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetlan or a salt marsh.
21 SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PU LIC WATER SUPPLIER.itF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC LTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption s stem(SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
_ stcm and the SAS is within a Zone 1 of a public water supply well.
The system has a septic tank and soil absorptio sy
_ The system has a septic tank and soil absorpti feet but 50 feet or more from a
n system and toe SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorp on system and the SAS Is less than 100 sis for coGform bacteria and volatile organic compounds indicates that the
private water supply well,unless a well wat r analy presence o(a ammonia nitrogen and nitrate nitrogen is equal to or less
well is free from pollution from that facility nd the
than 5 ppm. Method used to determine d' tence roximation.not valid).
3) OTHER
I _
r
j:
revised 9/2/.98 Page3orll
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspecti
D. SYSTEM FAILS:
You must indicate eith r "Yes" or "No" to each of the following:
I have determ ed that one or more o1 the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination i identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
_ Backup sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid le el in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in c sspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping ore than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times p ped_.
_ Any portion of the So Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspo I or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool r privy is within a Zone I of a public well.
_ Any portion of a cesspool or rivy is within 50 feet of a private water supply well.
Any portion of a cesspool or p ivy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analys . If the well has been analyzed to be acceptable, attach copy of well water analysis for
•coliform bacteria, volatile organi compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either'Yes" or "No- to each of the [lowing:
The following criteria apply to large systems in ddition to the criteria above:
The system serves a facility with a design flow o 10.000 gpd or greater(Large System) and the system is a significant threat to publi
health and safety and the environment because on or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to surface drinking water supply
the system Is located In a nitrogen sensitive are (Interim Wellhead Protection Area-1WPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system 1 accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information. ,
revised 9/2/98 pM���ertl
I�
✓ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Noperty Address:
Owner: j
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ygs No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow
rates• during that period. 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 NIA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered. opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid,depth of sludge..Depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
tA6 Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
115.302(3)(b)) f
�( The facility owner(and occupants,if different from owner)were provided with information on the proper maintenaaco of
SubSurface Disposal Systems.
revised 9/2/98 J..page sofII
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
Iroperty Address: Sb
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: ?30 g•p•d./bedroom. .
Number of bedrooms (design): Number of bedrooms lactuall:E.S
Total DESIGN flow >�
Number of current residents:C
Garbage grinder(yes or no):_k�,_3
Laundry(separate system) s or not: h3; If yes, separate inspection required
Laundry system inspected CyeVor no)
Seasonal use (yes or no):t
Water meter readings, if available (last two year's usage(gpd):
Sump Pump(yes or no): tJ
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment;
Design flow: qpd ( Based on 15.203)
Basis of design flow
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:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:.
System pumped as part of inspection:(yes or no)_ f
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,•attach previous Inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date Installed(if known)and source of information: j• ,(�I.4j rl C ; •�w r.► �� �—
Sewage odors detected when arriving at the site:(yes or no)("`J
J�
reVis d 9/2/98 .. .�Y,7".:PYQt60(tl f.'+,•.�41..,�j3 '•:'•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
+roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction:a cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line T_
Diameter
'Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
Depth below grade: f'k=tttl
Material of construction: )(,concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank 1s metal,list age_ Is age confirmed by Certificate of Compliance_(Yes/Nol
Dimensions: MO Sv.CA
Sludge depth:---q"_ 6
Distance from top of sludge to bottom of outlet tee or baNle:� r
Scum thickness: 01- � rt
Distance from top of scum to top of outlet tee or baffle: _ ��
Distance from bottom of scum to bottom of outlet tee or baffler_
How dimensions were determined: enu.._._"i
comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles.depth Df liquid level in relation to o tle invert, st ctural int rity.
evidence of leakage,etc.) w t dr
GREASE TRAP•
(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 battle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet Invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 rage 7ot11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
jperty Address: � `T
Jwner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order:Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches. etc.)
DISTRIBUTION BOX:4ITj
(locate on site plan)
Depth of liquid level above outlet invert:&A i(tN wr s'wUAA�
Comments:
(note if level and distribution is equ 1, evidence of solid� yover, eviden t t boz, etc.)
t leakage into r� Q _
\
f
PUMP CHAMBER:,
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,-condition of pumps and appurtenances,etc.)
revised 9/2/98 P���aaril
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/ SYSTEM INFORMATION (continued)
4operty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):,t'
(locate on site plan, if possible: excavation not required.location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
Inoue condition of soil, signs o��draulic failure, level�of ponding. damp soil, Condit n of gelation, etc.)
i
CESSPOOLS-
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
9epth of solids layer: -
)epth of scum layer: t
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:AA'?
(locate on site plan)
Dimensions:
Materials of construction:.
Depth of solids:
Comments:
(note condition of soll, signs of hydraulic failure,level of ponding,condition of vegetation, ate.)
revised 9/2/98 ps;c9orIii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t�
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Jwnef:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
VIA
� s d
y.
revised 9/2/98 Page to or it
� A w
V
SUBSURFACE SEWAGE DISPOR SAEC SYSTEM INSPECTION FORM
P
SYSTEM INFORMATION (continued)
roperty Address:
Owner:
Date of Inspection:
V`4 - — -------
NRCS Report name
Soil Type_
Typical depth to groundwater_____ --
USGS Date website visited
Observation Wells checked Deep
Groundwater depth: Shallow Moderate -----
SITE EXAM Slope
Surface water l fa
• Check Cellar 01�1J�
Shallow wellseg4v
Estimated Depth to Groundwater Feet
Please Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
r"
Determined from local conditions -
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators. installers
,(_Used USGS Data
Describe how you established the High Groundwater Elevation. (Mustbe completed)
revised 9/2/98 11 of 11
TOW -4 OF BARNSTABLE
QAO SEWAGE #
q v iiLAGE ASSESSOR'S MA3 & LOT
INSTALLER'S NAME&PHONE NO.
SEP`nC TANK CAPACITY
LEACHING FACILITY: (type) (size) t
NO.OF BEDROOMS
f
BUILDER OR OWNER
DATE: .4COMPLIANCE DATE:
Separation Distance Between the: f
Maximum Adjusted Groundwater Table
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) _ ��`�' FVe'
Edge of Wetland and Leaching Facility(If any wetlands exist F_
within 300 feet of leaching faci - �+)
Furnished by l�Qr�JL
77
LA
3a.(
q7'
TOWN OF BARNSTABLE
' "OCATION lz �j f/1�/11 P�. �� SEWAGE #
f io
f1ILLAGE ,C 0�rG[ / ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.. ll ILC A 1CffC-1eS-0A) Y32- -Z<<f
SEPTIC TANK CAPACITY 1 U 0 0tL
LEACHING FACILITY:(type) 6 )� 6 h t (size) 546AfF
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER jWAJ
BUILDER OR OWNER I M J-0K DA-IJ
DATE PERMIT ISSUED: ?°7
DATE COMPLIANCE ISSUED: IN,
VARIANCE GRANTED: Yes No Ll-l-'
���M
1/Ya��
����� ' ��
4rT o � ® o
��� ���
No... ....r'.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........... d-w .. .....oF:.... �� A Q .S'J" 13[.E.......
Appliration for 11ispos al Works Tonstrnrtiun ramit
Application is hereby made for a Permit to Construct ()() or Repair ( ) an Individual Sewage Disposal
System at:
................__......_.w.�!.1 T M !� .o A..D......_.... o T /_ Z
Location-A dress -.• � Lot No..
. ...... .......J A• F�...............
........-:�9. ?,fl ...._......_.... f15 �✓.a r._ ............ ✓sh -
�j.� �` /►l Owner / A/d 1 ess
G1✓a1�-----------------•-------..... ?J�_. .R�f.,....
Installer Address
d Type of Building Size Lot...``../. J S2 .Sq. feet
,., Dwelling—No. of Bedrooms.............3............_..._..__.....Expansion Attic ( ) Gar age Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Other fixtures .....................___.._..
W Design Flow......................... ........gallons per person per day. Total daily flow.............. ...................gallons.
WSeptic Tank—Liquid capacity.1.10...O.0).gallons Length..�._-.4.._ WidthA.-1 q. Diameter....—... Depth..:...-4
x Disposal Trench—No. .................... Width ....... Total Length........�__..__:.. Total leaching area....................sq. ft.
Seepage Pit No.............I..... Diameterl?.'_ ___.. Depth below inlet.&.._-.!2----- Total leaching area... PP
Z Other Distribution box ( ) Dosing tank (Performed by......J54-K_,-)
`-' Percolation Test Results •._ .N e_ Date....___At c._Z 3 ! yes
,.1 ....---•-- -- - s.._.....
Test Pit No. 1...........2 9.....minutes per inch Depth of Test Pit.. ___ ..�.. Depth to ground water.___"../t�'.....
fs, Test Pit No. 2________Z__minutes per inch Depth of Test Pit... _ . Depth to ground water._____.I...../Z c
Description of Soil.....--- _. r-T66-'�e�. _5 c� �J •--` /_ C�_.._.__1....._._.
.........--
x
W
UNature 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 iITLL 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 th oard of health.Signed... _ .......P�,,,,,a,,,
Date
Application Approved By............. � ''--- ---------------------------------------- -••-•-...
Date
Application Disapproved for the following reasons:----•----------•----••-•-------•------------------------------------------------•------......--•........-••--••.
--••--••--••--•---•-•-•-•...........•--•...............••---_-•••-••--•--•-•--._......_..._..-•----•...-••••---•--•-----•----•--------- -••--•......----•-•-•--•-••-••----•--•----••------•-••-•••......
Date
PermitNo......... ._7..--- -----•-• -------•----.... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
WV...........OF.... ..............................................
Appliration for Kiopoiittl Warks Tomtrnrtion thrmit
Application is hereby made for a Permit to Construct (, ) or Repair ( ) an Individual Sewage Disposal
System at......... .. -..... -
r Location Address �p+ pr Lot NoA g
~pu` _t. B D ra A ?.'.5'...®. ... [#w 6.1,4 R 3 k
o owner Address
Ac9 4;:4W.-•".................
Installer Address +
Type of Building Size Lot._...:1 .................Sq. feet
aDwelling—No. of Bedrooms............3...........................Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures _--------------_--------------•-------....•-
.........---------------------------------------•-.....•••••-•--............__.-----•.........------
d
W Design Flow.........................5_ _..gallons per person per day. Total daily flow.............. `" gallons.
WSeptic Tank—Liquid capacity. f?_..gallons Lengthf 4'.____
x Disposal Trench—No..................... Width........... g g q..._.._... Total Length Total leaching area $�..s ft. �
Seepage Pit No-------------I...... Diametero� -..O. Depth below inlet;,.-":�_.._.. Total leaching area_g-A_
Z Other Distribution box ( ) Dosing tank
~' Percolation Test Results Performed by..... . . .::.'�.... .. V_l :_____________________ Date.._--- � ' ..Z-3
aTest Pit No. I........ .....minutes per inch Depth of Test Pit_:/ e/._ --- Depth to ground water...,o 4A.K�:......
(i Test Pit No. 2......._ ._..minutes per inch Depth of Test Pit., . M....... Depth to ground water....... K.5:_
,; - ,; ......... I
� `./ ;;-O Description of Soil----.
..................................................
r
------------------------------------------------•-----------------------•-------------------------------------------------------------------•-------------------------------------------................
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 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 by the boar of health.
Signed ...... .... ....
Date
Application Approved By........---. ^- _ .-'."`"`'-'.
......................... Date
Application Disapproved for the following reasons:..............................................................................................................
--.....-•-•-.........•-•--••----------------••--•-•....--•-••-------------•-------...-••---•-----............................-----•-•------------------------....................--------.....•---
Date
Permit No......... ..�...... ..��.....a.....-'--•---.» Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(9rriifirate of Tamwhana
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..............M_�.1 "�-'�-�''�-•-••-....... •------•------•-....• --••- -----•---...--•-----•'•----•-•----••----••••••.......••---•....__..._
- -•-- -----
Q Installer
... ...---•-••...........................'-------------------------......
has been installed in accordance with the provisions of TITS, S,-fGTl-g State Sanitary Code as described in the
application for Disposal Works Construction Permit No....._....................../.____.__._-_ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. t
DATE................ .............................. Inspector...-•-•--•-•--.... ..-t. ................................;........... II
4 h
`^4
THE COMMONWEALTH OF MASSACHUSETTS .
BOARD OF HEALTH
i .. �
....... .� ..............OF..., J
..........................
No... .Z .., 6..� FEE........................
Disposal Worho . ......
to Construct ( *or Repair ( ) a In vidual Sewa a Dispo�l �_y em .
at No..-•-••••--�c<-_-7-•. '�' w tit! ' 1 C �
......................'-----....-----•----------------...... ...........................................................
Street
as shown on the application for Disposal Works Construction Permit No--------- t/__OV Dated.--------------
:..........................
.....--•...-•--.-'-- .... -------------------•---------.-.....__:.-------
-
DATE----------- ..^._ .....
l --•.'....................... Board of Health
-F---�•--'--�--�: ��..7
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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