HomeMy WebLinkAbout0003 CAPTAIN ALDEN'S LANE - Health 31CAPTAIN ALDEN'S 44PSTERVILLE
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Commonwealth of Massachusetts
Executive Office of Enviromnental Affairs
Dept. of Environmental Protection
John GradOne winter Street,Boston,Ma. 02108
D.E.P. Title V Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
(508)564_-q8-ffl F.WELD G
Governor `
ARGEO PAUL CELLUCCI
U.Governor
/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
9 •
Property Address: 3 Captain Aiden jtoad Osterville Address of Owner: ON
Date
Date of Inspection: 4120198 (If different)
Name of Inspector: John Oraci Lisa Dabre:14 South Broadway 12-2113 Irvington J
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and Telephone Number. $ V�
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 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:
x Passes This Inspection Is based on criteria defined In Title V
Condi Iona Pa5585 code 310 CMR 16303.My findings are of how thesystem Is
performing at the time of the Inspection.My Inspection does
_ Need Fu her Evaluation By the_Local Approving Authority not Imply any warranty or guarantee ofthelongevhyorthe
Fail septic system and any of its components useful life.
Inspector's Signature: / Date: 41211e8 ,
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
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,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
Conpliance(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 conforming septic tank
as approved by the Board of Health.
(revised OW7197)
One Winter Street is Boston,Massachusetts 02108 • FAX(617)556-1049 is Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 Captain Alden Road Osterville
Owner: Lisa Dabre:14 South Broadway 12.2E Irvington NY
Date of Inspection:412019tt F
_ Sewage backup or,hreakout.or, hiah.static water level obser.Yed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is 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 is removed
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 HEALTH 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,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply 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 the SAS 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 free from pollution from that facility and the presense.of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must Indicate either"Yes"or"No"as to each of the following:
I 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.
Yes No
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to nn overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 0412747)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION (continued)'
Property Address: 3 Captain Alden Road Ostervilie
Owner: Lisa Dabre:14 South Broadway 12-281rvington NY
Date of Inspection:4120198
D]SYSTEM FAILS(continued)
Yes No
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
— — Numbers of times pumped
— — Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater 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:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
i
(revised 04127187)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 3 Captain Alden Road Ostervilie
Owner: Lisa Dabre:14 South Broadway 12-213 Irvington NY
Date of Inspection:412019a -
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the 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.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_x_ The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x 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.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants,N different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x _ Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)]16.302(3)(b)]
(revised 007197)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
r
Property Address: 3 Captain Alden Road Osterville
Owner: Lisa Dabre:14 South Broadway 12.28 Irvington NY
Date of Inspection:412orgs
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 9•P•d.lbedroom for S.A.S. .
Number of bedrooms: 4
Number of current residents: e
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: 1 week ago
COMMERCIAL/INDUSTRIAL:
Type of establishment:
hment:
Na
•
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No,
Non-sanitary waste discharged to the Title 5 system:(yes or no)No
Water meter readings,if available: nfa
Last date of occupancy: Na
OTHER:(Describe) Na
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)Yee
If yes,volume pumped: 1000 gallons
Reason for pumping: Maintenance
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
a
APPROXIMATE AGE of all,components,date Installed(if known)and source Information:
1979
Sewage odors detected when arriving at the site:(yes or no) No
i
(revised 04127197)
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Captain Alden Road Ostervilie
Owner: Lisa Dabre:14 South Broadway 12-213 Irvington NY
Date of Inspection:412019&
SEPTIC TANK: x '
(locate on site plan)
Depth below grade: 1"
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age Na . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: t.g•6^H57^w410^
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle: 24^
Scum thickness:2"
Distance from top of scum to top of outlet tee or baffle:S"
Distance form bottom of scum to bottom of outlet tee or baffle: te"
How dimensions were determined: measured
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.)
Septic tank and all components are structurally sound and functioning property.Recommend pumping ever year..
GREASE TRAP:
(locate on site plan)
Depth below grade: rda
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: We.
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum 10 bottom of outlet tee or baffle:rda.
Date of last pumping;v.
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.)
nfa
BUILDING SEWER:
(Locate on site plan) 'S
Depth below grade: r'
Material of construction: cast iron_40 PVC other(explain)
Distance from private water supply well or suction linePwri
Diameter: 4••_
Qmments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 0412797)
Ili
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Captain Alden Road Osterville
Owner: Lisa Dabre:14 south Broadway 12-28 Iry ington NY
Date of Inspection:4120198
TIGHT OR HOLDING TANK: "
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nfa
Capacity: r" gallons
Design flow: He gallons/day
Alarm level:_rda Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rft
DISTRIBUTION BOX: x
(locate on site plan)
Depth of liquid level above outlet invert: oquldlevelwithbo8omofpipe
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
D$ox Is structurelly sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
da
(reWeed 04127 97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 3 Captain Alden Road ostervlile a
Owner: LisaDabre:14 South Broadway 12.2B Irvington NY -
Date of Inspection:4120199
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
He
Type:
leaching pits,number: an*1000 gallon leach pit
leaching chambers,number:Na
leaching galleries,number: rda
leaching trenches,number,length: rda
leaching fields,number, dimensions:rJa
overflow cesspool,number:We
Alternate system: nra Name of Technology:_nra
h Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
Leach pit and all components are structurally sound and functioning property.System has l'of leaching left.
CESSPOOLS:_
(locate on site plan)
Number and configuration: roa
Depth-top of liquid to inlet invert: rda
Depth of solids layer: roa
Depth of scum layer: nia
Dimensions of cesspool: nla
Materials of construction: Na
Indication of groundwater: nla _
inflow(cesspool must be pumped as part of inspection)
nfa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
rda
PRIVY:_
(locate on site plan)
Materials of construction: rda Dimensions: nla
Depth of solids: rda
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
rda
(revised 0427)87)
i
o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
3 captain Alden Road Osterville
Lisa Dabre:14 South Broadway 12.26 Irvington NY
4120198
y
I
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
AA
01) fops
4
Page ! of 10
(nv1oed04I MT)
r--
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
3 Captain Alden Road ostervllle
Lisa Dabre:14 South Broadway 12-213 Irvington NY
4120198
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers 4
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS maps and charts
(revised0ar27197) page to at 19
L0CAT10tPC�P` � SEWAGE PERMIT NO. ..
l-zia ,a 79> 6 79
s VILLAGE
A- 14-6 ob I
INSTALLER'S NAME & A.DDRESS
OR OWNER
tz
i
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED 7
1
i
r PIT
S cn M
►�- �y�
No.......... -7�..... ...... �� a Fss... ......_...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF. 'HEALTH
?o c_-A)................OF.........6A.9A).S'�.r RL-fir....._.......---.............
-
a9 Appliration for Uiipnsal Workii Cnnnti rnrttnn Prrutit
Application is hereby made for a Permit to Construct (V or Repair ( ) an Individual Sewage Disposal
System at:
. .r_............ tE IA:k.4r.•.......• -•-......4®-�•--•.---•-f a------- --- ................
ocation•Addres or Lot No.
........----•--------------.......----------
.......... _ G_. Q� ------•--•------•----------------•---------- ----•----•-----
�` O �r Address
a ................. ........................... •.........-•••-•-----•-•-•-•.....-••••--•-............----••••---•--•--•-•----•-•--•----•--•---..
Installer Address
dType of Building Size Lot../_._73_>., ..... feet
U Dwelling—No. of Bedrooms...................•....._......____.__.Expansion Attic (��) Garbage Grinder (era)
a
p, Other—Type of Building .......1-4/4......... No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures --------------- ------------- -
<W ------------------------------------------------------------------------------------
Design Flow.......ll.d...........................gallons per n pe�day. Total daily flow.._...-3Q.......................gallons.
WSeptic Tank—Liquid capacityloo-xt..gallons Lengthd7.._d_ ... Width. Diameter................ Depth. _B.._--
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------/------�. ---- P g q•
__.... iameter...,6.... Depth below inlet___..._ ...._._. Total leaching area. O_�....s ft.
z Other Distribution box ( Dosing tank ( )
Percolation Test Results Performed by._1XAVA4l?....A ...�AIA�D ....i�.4 t. Date...l�L/_��_...�-_��.1_���
aTest Pit No. 1.,_-a._minutes per inch Depth of Test Pit---- . ._'...... Depth to ground water_JU�ial
Gi, Test Pit No. 2....:...........minutes per inch Depth of Test Pit.................... Depth to ground water........................
---•.....•---•--------------•--•••••••-•••••----••••-••••••••••••-••-...._........_..------.._....0.........................................................
O Description of Soil Q" 1. e-Z fV.L? ,0. ..............
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 ilTia 5 of the State Sanitary Code— Th er igned furth not to place the system in
operation until a Certificate of Compliance has been iss y t iea
Signe ... .... .......................................................... ............ ------ ......................
Date
Application Approved BY •............. = �T` -`- .
Date
Application Disapproved for the following reasons:-:.. ------•-••--. ......................................... ..............•------..._....._...._---.--
..............................................••••-•---......._._........-----•------.....••---....•--•••--.._..........--------- - ••---------------•...---
Permit No.......................................................... Issued---.�..
No.........G 77 Fss..............................
C%P
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......-_......oF. ..r. a. .1 t-............:.....................
Appliratinn for UiivnoFal Workii C onvitrurtion ami#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
� „ :.. ' ............ ".
------•-- --...---?r 5 � � ! �cf • - •... or Lot Location Addres�
No.
O r Address
............................................
Installer Address
Type of Building ;, Size Lot.1.73-2.K.....Sq. feet
Dwelling—No. of Bedrooms...________.................................Expansion Attic (.v0) Garbage Grinder (n+o) \
a. Other—Type of Building .......&444......... No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ..._..-----•-•---------------------•--.... i.vu;�--•-----•--•--•---....------•---..........--••-------•-•----------...........................
W Design Flow.......Z/.+a._---•-•••-----•_-__----_gallons per?"-son per day. Total daily flow------ -,—�?I2-----------------------gallons.
WSeptic Tank—Liquid*capacity QA�._gallons Lengtha...'d. Width.Y...i!.O".. Diameter_______________ Depth_5__A_`/
Disposal Trench—No..................... Width.......:............ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...... ............. Diameter... _''..__�' ..._ Depth below inlet.....6____________ Total leaching area_a�..±!'?.a.sq. ft.
Z Other Distribution box (W Dosing tank ( )
Percolation Test Results Performed by:AgN_ A!h....A.�.. _a...... 5:. Date...1
,al Test Pit No. Le, ..;_..minutes per in Depth of Test Pit...Z—............ Depth to ground water-_.Mp
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' .............••••••-- ••••-------•....:....................-•------•--••------•---••..............-•----.....--••--..................••••......-•-•-
"of
O Description of Soil------------.n ' ''....._:_ >•raft-�-----•...4-�•p--------��1���t�-------------3.0.�......-i'���-�.------.
------------------------------------------------•---------- --------------------------------------•---------------....------------------------------------_....
V 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 iIT1E 5 of the State-Sanitary Code— The igned furth of to place the system in
operation until a Certificate of Compliance has,been iss th rof iea
.. + '
Signed..... ----- --•--- --------- --------- --------- ..... ........... ................................
D to
Application Approved BY....... --- �'' ��.� ., .
7 Date
Application Disapproved for the following reasons---------------•--= ........................................................................................
-•-----•--........--•------------------------------------------------------------------------------•-------•••••-•---••----------------•---••-•••------•--•---••-••---•-•------••-••-••-------...._....
Date
PermitNo........................................................... Issued........................................................
Date
THE COM*ONWEALTH OF MASSACHUSETTS
BOARD O . EALTH
.�. ........OF...:. .. ..........
Turrtifiratr of Tompti anrr _
THIS IS TO CE TIFY, That the Individual Sewage Disposal System constructed ( epaired ( )
bY----------
n ller
,�,e
has been installed in accordance with the provisions 5 of The State anitary Code as described in the
application for Disposal Works Construction Permit No. ._ -___.......7.�_-___--_-. dated.._............................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE / .. Inspector ........- rr THE
�•
COMMONWEALTH OF MASSACHUSETTS
"""""' BOARD ®F HEALTH
9
N ........ FEE........................
,•.M
Disposal � n��nr�iinaT eranit
Permission is hereby granted------------- r�� ai ``'+�--------•---
to Construct an Individual Sewage Disposal,,�ystem
at No... ••. ---•--.----E`'�./ !' � }� t ' ............
j Street
as shown on the application for D sposal Works Construction Per o.___..__._., Dated..........................................
000 ----------X
Board oalth
DATE.. t ................. / ,, • }
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