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:: , BORTOL.UTTI CONSTRUCTION, INC. ,
45"1NDUSTRY ROAD, MARSTONS MILLS, MA 02648 ��
''-508-771-9399 508-428-8926 1_,4X: 508-428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATI ).rl
Property Address:
Date Of Inspection O In pector's Name: y4
_
i er's Name and Address:
CERTIFICATION STATEMENT:
I Certify that 1 have personally Inspected the Sewage Disposal System at this address and that the infornia-
tion reported below is true,accurate and complete as of the time of Inspection. The Inspection was perform-
ed based on my Training and Experience in the Proper Function and Maintenance of On-Site Sewage Dis-
posal Systems."T�Be system:
y Passes '
Conditionally. as -Sz . t -
Needs Fur er alua B he Local Approving Authority
Failure -
Inspector's Signature _Date: /
The System Inspector shall submit a copy of this Inspection Report to the Approving Authority with 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 the System Owner and copies
sent to the Buyer,if applicable and the Approving Authority.
INSPECTION SUMMARY:
A) SYSTEpvI PASSES:
' 1/ I have not found any Information which indicates that the System violates any of the fail-
ure criteria as defined in 310.CMR 45.303. Any Failure Criteria not evaluated are indi-
cated below. .
B) SYSTEM CONDITIONALLY PASSES:
One or more System Components need to be Replaced or Repaired. The System,upon
completion of the Replacement or Repair,Passes Inspection.
Indicate yes,nor,or not determined(Y,N,OR ND). Describe bases of determination in all instances. 11 "not
` determined",explain why not.
The Septic Tank is Metal,Cracked,Structurally Unsound,shows Substantial Infiltration or exfil-
tration,or Tank Failure is imminent. The System will Pass Inspection if Existing Septic Tank
is Replaced with a conforming 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):
SUBSURFACK:SEWAGE,�DISPOSAL SYSTEM, I.NSPEC,TION FORM
PART A
CERTIFICATION (continued)
Broken pipe(s)i replaced
Obstruction s removed
Distribution Box is leveled 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.isxemoved. _
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by.the Board Of Health in order to determine if
the System is failing to protect the.Public Health,Safety and the Environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HELATH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND.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,IVAPPROPRIATE)DETERMINES THAT THE.SYSTEM is'FUNCTION-
ING.IN.A MANNER THAT PROTECTS THE PUBLIC,HEALTIi'AND,SAFETY AND THI?
. . ..rENVIRONMENT: ,
The system has a Septic,Tank and Soil Absorption'Systehi and is'withi i'100 Feet to a Surface
Water Supply or Tributary to a Surface Water Supply.
The System has a Septic Tank and Soil Absorption System and is with a Zone 1 of a Public
Water Supply Well.
The System has a Septic Tank and Soil Absorption System and is within 50 Feet,of a Private
Water Supply Well.
The System has a Septic Tank and Soil Absorption System and is less than 100 Feet but 50
Feet or more from a Private Water Supply Well,unless a Well Water Analysis for coliform
bacteria and volatile organic compounds indicates that the Well is from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. _ ... ,.. _
D)SYSTEM FAILS:
1 have determined that the System violates 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.
Backup of sewage into facility or system component due to an overload or clogged SAS
or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool.,
Static liquid level in.the distribution box_above outlet invert due to an overloaded or clog-
?s ged SAS or cesspool s
car > ` Liquid,depth in cesspool is:less than 6"below invert or available;volume is less than 1/2
r7 iS.ey .z :P
day flow.
Required pumping.more than 4times in the last year NOT due to clogged or obstructed
i e s . Number of timespumped
PP .O ..
- 2 - .
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' }"SUBSURFACE `SEWAGE 'UISYOSAL'SYS 1`ENf'INSI'EC`I lON'FOR1V1`
PART A
(`N',It'I'f FICA'1'ION (coutiuucd)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwaler
elevation.
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 1 of a Public Well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. if the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 10,000 ggd 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 11 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 315 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further.information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the ff flowing have been done:
t/ Pumping information was requested of the owner,occupant,and Board of Health.
_None of the system components have been pumped for atleast 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 N/A.
he facility or dwelling was inspected for signs of sewage back-up.
he system does not receive non-sanitary or industrial waste flow.
1�rhe.septic
he site was inspected for signs of breakout.
ll'sysfent components,excluding the Soil Absorption System,have been located on site.
<1 t 4+ Y3tank manholes were uncovered,opened,and the-interior of the septic tank was in-
spected for�conditi6h of`baffles or tees;inaierial of construction;dimensions,depth of liquid,
_ -depth of sludge,depth of scum.
- 1'he size and location"of`the Soil Absorption System on the site has-been determined based on
existing information or approximated by non-intrusive methods.
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'.,'-,SUBSURFACE SEWAGE°DISPOSAL.SYSTEM,.INSPECTION FORM
7 , . ' PART B
f'''CHECKLIS'I'(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
/. FLOW CONDITIONS
RESIDENTIAL:
v
Design Flow:,�?30 _gallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder: ,w Laundry Connected To System:IV6 Seasonal Use:
Water Meter Readings,if available:
Last Date of Occupancy.
C'OMMERCIAL/1NDUSTRIAL QQ_,
+ 'Type of Establishment: `
------Design-Flow: gallons/day`Grease'Pr`ap Present:`.(yes or no)'-
f,
Industrial-Waste Holding Tank Present: - _.. .
Non-Sanitary Waste Discharged To TheTitle V System:,
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: (Describe)
Last Date of Occupancy:
GENERAL NFORMATION
PUMPING RECORDS any source of information:
System Pumped as part of inspection If yes,vo me pumped: gallons
Reason for Pumping:
TYPE O SYSTEM:
eptic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection'records,if any)
Other(explain):
ROXIMATE GE of al�COM n its, �te"
Sew ge odors detec ed eng at th
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SUBSURFACV SEWAGE DISPOSAL=SYSTEM!4NSPECTION FORM
PART C
GENERAL'INFORMATION (continued)
SEPTIC TANK:
Depth below grader// Material of Construction: concrete metal FRP Other
(explain)
Dimensions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle: ZL
Distance from bottom of scum to bottom of outlet tee or baffle: /
Comments: (recommendation for pumping,conditioin of inlet and out to or baffles,depth of liquid.level
in relati i to outl invert,structural integrityLeviden of leakage,etc.) L 7�
i"
/ H
GREASE TRAP:
Depth Below Gr de: Material of Construction: concrete metal FRP Of her
(explain):
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
_Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level
.,. m,relation to outlet invert,structural integr►ty;;evidence.of leakage,etc.)
TIGHT OR HOLDING'TANK:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain):
Dimensions: Capacity: gallons Design Flow: g.illons/day
Alarm Level:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
---V/
Depth of liquid level above outlet invert:
Comments: (no level and c istri utio_n is a al,evidel of solids carryover evidence of leakage into or
ou(pf boEiz it
etc.
PUMP CHAMBER
w Pump�s inlworkiu order• -
...
Comments:(note condition of pump chamber,condition of pumps and appurtenances,etc)"
5 -
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SUBSURFACE`SEWAGE`'DISPOSAL SYSTEMI INS PEC'FIO.N,FORM
MART C
SYSTEM/'INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS): y
(Locate on site plan,if possible;excavation not required,but may be approximately by non-intrusive
- methods) If not determined to be present,explain:
Types
Leaching pits,number: Leaching chambers, number: Leaching galleries,number:?
Leacahing trenches,number,length:
Leaching Gelds,number,dimensions:
Overflow cesspool,number:
Co ments.(note comdtf not soil signs of hydraulic failure level of onding,condition of vegetation,etc.)_kAro/
CESSPOOLS: -
of liquid to inlet invert:
Number and configuration: —Depth-top
g 9
Depth of solids layer: Depth of scum layer:a''. 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
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hyddraulic failure,level of ponding,condition of vegetation,
etc.)
- 6
-
�rSUBSURFACK'SE WA'GE,DISPOSAL•:'SYS'I,EM,,INSI'F('TION*FORM
"PART C
.,SYSTEM ,INFORMATION (continued)
SKETCII OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references,landmarks or benchmarks.
Locate all wellsrithin 100 Feet.
1' •
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Meth of Determination or A proximation:
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- 7 -
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TOWN OF BARNSTABLE 9, -ZZ�
LOCATION 2-0 12�,1,I1lel ✓!,oll SEWAGE#
VILLAGE / �l'b7' ��� ASSESSOR'S MAP& LOTa -eO,73
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 4aaa GnL
LEACHING FACILITY: (type) (size) // X 32 x ,2
NO.OF BEDROOMS 3
BUILDER OR O R/
PERMITDATE: �/ Z COMPLIANCE DATE: C
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Jrf Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. ....a._i Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
2pprfcation for &.spool *p5tem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair( wi/an On-site Sewage Disposal System at:
Location Addressor Lot No. Ow is arne�,Address
ssjandd Tel pNo.
Tei/;,Y
.,,. Ins;al 'sN��QAd s, Tel.No *71 Designer's Name,Address and Tel.No.
/ Z d
Type of Building:
Dwelling No.of Bedrooms 13 Garbage Grinder(✓�v
Other Type of Building^ P 9) By�-eNo.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //® gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
t
Description of Soil
Nature of Repairs or Alterations(Answer when pplicable) )! 47
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue y t ' Health.
Signed Date
Application Approved by
Application Disapproved for the following reasons
Permit No. � Date Issued /
No. (.._.._ ,, Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH{DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS _
0(pplication for i5pozaY Permit
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Application is hereby made for a Permit to Construct.O or Repair( n On-site Sewa t
ge Disposal System at: 1
Location Add res4 r Lot No., > t O e-r Name,Address and,Tel.No. �,�� �ZZ 4319oV
,r
In l r DNarrle�'A1"ss,air��� 7 7// /' Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder(r�/o
Other Type of Building /Ge 5)W e-,►'C'e No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow //® gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer whe licable) J�AI, Pl - _
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and"notrto place the system in operation until a Certifi-
cate of Compliance has been issue by ',§Bo'ardzo-Health.
1`"lz. �
Signed Date ,
Application Approved by
Application Disapproved for the following reasons
Permit No. Date Issued""_
fi{ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
u Certificate of Compliance -
THIS IS TO CERTIFY,that the On-site Sewage Disposal System instal, (/ )or repaired/replaced on
by 4/` for `��0�'✓�' �4��r®
as h e constructJee in accordance
with the provisions of itle 5 and the for Disposal System Construction Permit No. dated.,_ — .Z
Use of this system is conditioned on compliance with the provisions s rth belo :
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No. Fee
t THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
�iopogal *pgtem Construction Permit
Permission is hereby granted
to construct( )repair( an On-site Sewage System located at 2-,! /9
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be,c mple 'd w'thin two years of the date below. -
i
Date: Approved by +_
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CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONS HIUCTION rEloll-1'JIVT ROUT DESIGNED PLANS)
hereby certify that the application for disposal works
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construction permit signed by me dated �� /�� ; concerning the
property located at ZQ �el�%Q' /� meets all of the
following criteria:
There are no wetlands within 300 feel of the proposed septic system
/Thcre
P � In
arc no private wells within 150 feet of the proposed septic system
observed groundwater table is 14 feet or greater below the bottom of the leaching racliity
T ere is no increase in now and/or change in use proposed
There are no variances requested or needed.
SIGNED: DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
IAttach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan,
this plan should be submittcdl.
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
...... --- ---_OF.................. ----- --------------------
Apphrativit for M_qpwial Works Tonotntrtion Vrrnfit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at
194........ --- --------------------Z,0...................................... ........................
a i ;-"dress or Lot N
o -----
Owner Address
-------- Installer . ................................ .............................................Addres.s•...........................................
Type of Building Size Lot----------_---------------Sq. feet
Dwelling—No. of Bedrooms.._._..._ .Expansion Attic Garbage Grinder ( )
Other—Type of Buildii ------ No. of persons___________________________ Showers Cafeteria ( )
Otherfixtures ...... ----------------------------------------------------------------------------------------------------------- -----------------------------------
Design Flow--------------------------------------------gallons per person per day. Total d ily flow....... ----------------------------- ------gallons.
Septic Tank—Liquid capacity/0,00--gallons Length----9......... Width__ ___-_._.. P iameter---------------- Depth----------------
Disposal Trench—N P-e
. .................. Width.......�_,C_V�al er (W,04---dqtal leaching area--------------------sq. f t.
nle
Seepage Pit Nc t e / Total leaching � ea...--------- Diameter... t e nlet
A--- XV
Other Distribution b x Dosing tank ( )
x ,
Percolation Test Results Performed by------------------ -----------------------------------------------je--.... Date----------------------- - 4—
Test Pit No. I................minutes per inch Depth of Test Pit-.---_____________-- Depth to ground water.._.-. -—✓---------_-
Test Pit No. 2-----------------minu per inch Depth of Test Pit.-__________________ Depth to ground water__._-._-___.-___-_--__
------------- --------------*4-------- ......
0 Description of Soil------------- ---- ------ -------cxj -
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------- --------------------
---------------------------------------------- ------------------------------- ................................................................................................... ...... --------------
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------- ---------------_
---------------------------------------------------------1�..................................................----------------------------------------------------- ------------------ -------------------
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 further agrees not to place the system in
operation until a Certificate of Compliance has been,,igs3ed b the hoird of>e*h
X 7 L/lFrI 61 1
ed . .. ... ...... ------------ �IfA�e4------ _-4-71-,
Date
Application Approved By...... . . ..........
• Date
Application Disapproved for the following reasons:......................................... ------------------------------------- ................................
........................................................................................................................................................................................................
Date
Permit No......................................................... Issued.....7 5-
/ Y.....................
Date
---------------------------------------- -- --
N ...1.67 Fl s.... .mot
THE COMMONWEALTH OF MASSACHUSETTS
�B/ OARD QF HEALTH
`4
.���firtttirrn �fnx �i���a��t1 �ark� C�.an�trnrt�n�t rrntit � '
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
103o-----•--- ----- 4 .�---- ....................g2o---------------------------------------------------------------------
at' n- dress or Lot N 9
---------•=- -•-- Wit' � �---------------------------------------- -•• iw--------1 A 1s.._.._......
Owner Address
(S� - ..
Installer - Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.-._ ....._.-_.Expansion Attic al Garbage Grinder ( )
Other -,-Type of Building _.:.. - _Q�,_--___ No. of persons............................ Showers ( ) — Cafeteria ( )
a A._;r
04 ', Other fixtures ------------------------------------------------------
W Design Flow.............................................gallons per person per day. Total d ily flow..................._........................gallons.
WSeptic Tank—Liquid capacityrlQOQ•.gallons Length_--- Width____ _________ iameter_._._..._..___ Depth
x Disposal Trench—N ------------
Width- 1 e Dial leaching area
-------sq. tt.
Seepage Pit No Diameter �... nlet................ _. Total leaching< ea.-
Other Distribution bbx Dosin tankt'
Percolation Test Results Performed by-------------------------------------------------------------- Date
�,�,1
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....-f -__.-._._._..
1:14 Test Pit No. 2..............__niinu s per inch Depth-of Test Pit..------------------ Depth to ground water......-----..-----_--._.
------_--- •-•---•-••------•-- _____
Description of Soil------------- ---- - --- ----- . .. � .--------
U ---------------------------•--------------•-----•--•--......•••-•--•-•••--•-•--•-•-----••--•-•••-----•----------------•---_- ........... -----------------------------•-`--•=`-------------
W
U Nature of Repairs or Alterations—Answer when applicable..--------------------------------------------------------------------------- -----------------.
-----•=-------------•--------•---------•------------------•------------=-----------....-•---•--...._....._...........----------------Agreement y
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ' s ed b the d of h.
igned_._
Date /
Application Approved By......
,r ="
Application Disapproved for the following reasons: 7
----------------------------------------------------D-te--••---••••••- '
•---------------------------------------•-------•----- ------------- - =-----------------•----------------•--•-••-----------•---••-•---•--••---••----••-
Y Dat
Permit No......................-•--•-
Issued...
7/- Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
. Lf ............OF......... ......:...................................................
Trxtif iratr off om4fianr
` ry THI TO CERT Y -iat the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----- -- - -------------- --- - •••-•---- --=----....---•--- - -------._...-----------•--------------•---------...-••---•-.._••-----•-
` nstaller
at a ---------. -Y'-- -:� :•-•= ----f-----•---'`�=`------ - ---- -- - -
has been installed m accor nce with the provisions of Artic I of The State Sanitary ode descri ed in the
application for Disposal Works Construction Permit No--------- _7 5z" -_--____ dated.. ..�rL�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ANTE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ----------------•-•••--•-_----- Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
s..► .... 1r2......OF............ �
No._.AP7J..•-----••-- FEE .
Ririvnlitt gxk QITu nr inat Vrriti#_:
Permission 's reb ranted --- r=--._.......•---•-------•-••••-----------------------.......
Y g
to Construct i( r Repair,,( ) an. ndivi ewage Disp s
at No.oZl1 - --- ----- s -
as shown on the a�pplicatio for Disposal Work-s'Construction Pe ito______ __ ____ __ ________.
------ - - - -- - -- - --l✓�✓�
M�..
oard of Health
DATE -- . ------
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