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HomeMy WebLinkAbout0089 CARLISLE DRIVE - Health S Carlisle Drive )sterville P A = 122 141 lull i �I UPC 12134 2.15, Lr�►+ iuet��ur► 36� by �✓ zoc � • ° - ; � • kt �' ;�. " ,.• "i:• y. q� My' ''t✓4 '� •. • , ,a • ,Yr •._; _.� JLLr iF. ��.6 } F4� �.yr`ry ..w o3 + i y �-. a [•r.- � .i F � y 3. .+a•. - -' ,e....,' a A 5: a y. .:�.,.. " v + - a •"a • a S�� •� .. v a 5 - e-4 y� .E 'r-� F G,. �- •*'4�;�''' F„,.Y''x'' ,� -� P• ��.a..f' ,€, 'v'- ., "R, .T - are'r .a". ;• 3 . .•i.�"'�:� s N;�, � + N r ••/ /', �.�"1� ��: Yam/ \ ,V�� n�lS� �S�.' , � �_ ..- ., _ . , # L .. r, * -. a _, •. � - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION MAP PARCEL. ; TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION _ RECEIVED . Property Address: 89 Carlise Drive nstPrvi l 1e Owner's Name: Willet Bennett OCT 2 1 Z003 Owner's Address: TOWN OF BARNSTABLE Date of Inspection: Th d y —5-3 HEALTH DEPT. Name of Inspector:(please print) Wi 11 i am E_ • Robi nson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported . below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to SS`ection 15.340 of Title 5(310 CMR 15.000). The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ' FaiZ s , Inspector's Signature: Gu �i� \ — Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeatthDr 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 approxing 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. Title 5 Inspection Form 6/15/2000 page 1 S r Page 2 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued). Property Address: 89 Carlise Drive Osterville Owner: wi 1 1 Pt- Kennett- Date of Inspection; Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. le Passes: 1 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.'section need to be replaced or reps ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answ yes,no or not determined(Y,N,ND)in the for the following statements.if"nat determined"please explain e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsoun exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A me I septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicati g that the tank is less than 20 years old is available. ND ex,lain: Observation of sewage backup or break out or high static water level in the distribution box flue to broken or obs eted pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with app oval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND a plain: The system required pumping more than 4 times a year due to broken or obstruKled pipe(s).The system will pass in pection if(with approval of the Board of Health): broken pipe(s)are replaced obstr uctinn is mrmovod ND xplain: r S Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 Carlise Drive Osterville Owner: Willet Bennett Date of Inspection:-/�--1 w C. F rther Evaluation is Required by the Board of Health: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. S tem will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the Sys em is not functioning in a manner which will protect public health,safety.and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh 2. S tern will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a ` pr vate water supply well•• Method used to determine distance •• his 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 )1hpresence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other ure criteria are triggered.A copy of the analysis must be attached to this form. 3. her: 3 f Page 4 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 89 Calrise Drive Osteville Owner: Wilett Bennett Date of Inspection:1tY tf�-0'3 D. 3-stem Failure Criteria applicable to all systems: You hiust indicate"yes"or"no"to each of the following for all inspections: Yes o 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 an 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 I00,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. ]This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (YesfNo)The system fails. 1 have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E Large Systems: T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gp Yo must indicate either"yes"or"no"to each of the following: (lit following criteria apply to large systems in addition to the criteria above) yes o 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 If you h ve answered"yes"to any question in Section E the system is comsidered a significant lhrcat or answered . "yes"in Section D above the large system has famed.The owri r or operator of arty large system considered a significa:t threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. he system owner should contact the appropriate regional office of the Department.- 4 i ' Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 89 Carl i se Drive Osterville OwnerWillet Bennett Date of Inspection:_�,,_ Is-o 3 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 V Were any of the system components pumped ouf"in the previous two weeks? Has the system received normal[lows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection 7 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? _✓_ 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 7 _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on-'the site has been determined based on: Yes no ✓Existing information.For example,a plan at the Board of Health. �✓ e D termined 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)) 5 ti Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 89 Carlise Drive Osterville Owner: Willet Bennett Date of Inspection: 42 S•-c, 15 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): lam' DESIGN flow based on 310 C 15.203(for example: 110 gpd x It of edrooms):/ Number of current residents: Does residence have a garbage der(yes or no):/-0 Is laundry on a separate sewage system(yes or no):1 0 [if yes separate inspection required] Laundry system inspected es or no):L� Seasonal use:(yes or no):Y1 Water meter readings,if available(last 2 years usage(gpd)): 2 0 01 -5 4 , 0 0 0 Sump pump(yes or no): A-0 2 0 0 2-6 4, 0 0 0 Last date of occupancy: 3' /u- ,s COMM RCIAL/INDUSTRIAL Type of a tablishment: Design fl w(based on 310 CMR 15.203): gpd Basis of d sign flow(seats/persons/sgft,etc.): Grease tra present(yes or no): Industrial aste holding tank present(yes or no):— Non-sani waste discharged to the Title 5 system(yes or no):_ Water ter readings,if available: Last da of occupancy/use: OTN R(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):/L If yes,volume pumped:_gallons--Now was quantity pumped determined? Reason for pumping: TYP 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) _Innovative/Altcmative 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):kc) 6 I'agc 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 Carl i s2 j2Live _Osterville Owner: Wi 1 1 at- B nnett Date of inspection: BUILDING SEWER(locate on site plan) Depth below grade:-- Materials of construction:_cast iron _40 PVC_other(explain): Distance Gom private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): f SEPTIC TANK:-(locate on site plan) Depth below grade: �G �/ . Material of construction _concrete 'metal fiberglass_polyethylene _othcr(explain) — _ If tank is metal list age:_ Is age confinned•by a Certificate certificate) of Compliance (yes or no):_(attach a copy of , Dimensions:_' A- Sludge depth: Z-g: " Distance Gom top of sludge to bottom of outlet ice or baffle:'o m Scum thickness: Distance from top of scum to top of outlet tee or baffle: / Distance Gom bottom of scum to bottom of outlet tee or battle: How were dimensions determined: c3 � - • lie �rt s Comments(on pumping recommendations, inlet and outlet tee or baffle conditicn,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): A GREA TRAP:_(locate on site plan) Depth bolo grade:— Material of onstruction:_concrete metal fiberglass_poly ): ethylene other (explain — —' — Dimensions Scum thic ss: Distance Go top of scum to top of outlet tee or baffle: Distance Go bottom of scum to bottom of outlet tee or baffle: Dale of last umping: Comments on pumping reconunendations, umlet and outlet tee or baffle condition, structural integrity, liquid levels as related I outlet invert,evidence of leakage,etc.): 7 Page 8 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 Carl ; se Drive Qstesrille Owner: 1.7;13el; Bouaett Date of Inspection: TIG Tor HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: ' Mater al of construction: concrete metal Fiberglass__polyethylene otlter(explain): Dime sions: Capa '4" gallons Desi n Flow. gallons/day AI t present(yes or no): Al level: Alarm in working order(yes or no): Dat of last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Z(/irp'rcscnt muss be opened)(locate on site plan) Depth of liquid level above outlet invert:4�)-- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,ctc.); PU iP7working R: (locate on site plan) Pum srder(yes or no): Al s in working order(yes or no): Co n cnts(n ote otc condition of urn cltambcr,condition P p of pumps and appurtenances,etc.); R Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89,)Carlise Drive Osterville Owner: Willet Bennett Date of Inspection: 4—1$-cj 3 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,ezcavation'not required) If SAS not located explain why: s Type y. leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: - overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): // D orlaz CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number an configuration: Depth-top liquid to inlet invert: Depth of solid layer: Depth of scum layer: Dimensions ofcesspool: Materials of co struction: Indication of oundwater inflow(yes or no): Comments(no condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of onstruction: Dimensions: Depth of solids. Comments ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 89 Carlise Drive Osterville Owner: WillettBennett Date of Inspection: 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. y�b 7 „' 3 10 Page l l of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM' PART C SYSTEM INFORMATION(continued) Property Address: 89 Carlise Drive Osterville Owner: Willet Bennett Date of Inspection:ljVr IJ O 3 SITE EXAM Slope Surface water - Check cellar Shallow wells i Estimated depth to ground water 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 ho)e within 150 feet of SAS) r. Checked with local Board of Health-explain: C 4I' Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must dgscribe how you established the high ground water elevation: r , . 11 OON LOCATION ° SEWAGE PERMIT NO. Poo (� s o(�A./i RY lIXD,y I/n A A i 4 l9" r7' z VILLAGE � 22 ` 4- 1 A= INSTALLER'S NAME i ADDRESS BUILDER OR OWNER o J DATE PERMIT ISSUED DATE COMPLIANCE ISSUED c./_ ? � P67- r•. �2 r 3a . 3l Ic No......�.� :.. Fps....- ..p a........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................OF.....J&I.rn-.a5zr,1.S.._.------...........--------- Alip iration for 11ispas al Works Tnnitrurtivat Frrutit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: .[..... " ........JrsX:SAY l�I.L`.:1 ,C.�sT... ........ ..................•--•. c/ Lo lion- ddress or Lot No ... -�-r� .......... - - .- a.d�..m.�.. ................ .. __C .r...l�..... �. p/e Da y1 r Own r� V X.�•. ......... IL � Address Ll .......................rlf.szg.h/p—., Installer Address Type of Building Size Lot_ �.®.fV.......Sq. feet Dwelling—No. of Bedrooms--------,-----•____________________•_-•Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of ersons:::..._................... Showers YP g ---------------------------- P ( )'— Cafeteria ( ) dOther fixtures .---.....---••---•-•--•••--------•-•-----•-••-•-••-•-•.-••-•---•-•----------•...--:....:........•--_...._....._......_...--..............-•-•.----- W Design Flow...............:............................gallons per person per day. Total daily flow----- :?-O...........................gallons. WSeptic Tank—Liquid capacity./O.dW..gallons Length................ Width.]_........... Diameter.............._. Depth-._..__......... x Disposal Trench—No. .................... Width ....... Total Length_......_....r...... Total leaching area.....................sq. ft. Seepage Pit No......../---------- Diameter..e :_/4... Depth below inlet...... Total leaching area.A�4;......sq, ft. z Other Distribution box ( ) Dosing tank ) Percolation Test Results Performed by.._, ,._..A 4i4L C.tcI."............................:... Date....B��.��............. ? � Test Pit No. 1__/...._.�2!minutes per inch Depth of Test Pit...............::... Depth to ground water........................ Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit.....................Depth to ground water........................ -••••-•-••-•----------------------------------•---••-•••••-........•----:.....:...•-------::..........•-•---------••---......•-----...............-----•---_. . ODescription of Soil................................. ......................................................:•-------.................................... U ............................................... ---•••-•-•••--••-•---••-••••--••••-•-••--•-••......................................................................... .........• --•-•--•-•-•...--•= .... VW --•----------------------------------------------------•------•-----•--------------•---...-------------•---------- ............................ - ......................... 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 4been , uedby the boar of l lth.. Si ned._ g .- • q Date Application Approved By ---------•------------------------------•------- --------- "G,.........Date Application Disapproved for the following reasons:..*•-•------•••••-••••--••-•--•-••-•••-•------•-•..................•---•-.-----=•----•---•..... -Date �f� Permit No.... � ----------------••--........_.__. Issued---- ......� •- -- Date t +No...`...... /'1........ Flss.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Win..............:....OF..... rn. _ w.----•..................•-- Appliratiun for Bi-opuual Works Tonstrurtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal System at: Location- ddress "� or Lot No. - ---...----•- ''A. ...Z .0d.. es---------------- Owner Address a ".1/is!1.._....., .....V............................... .... :Jr.i2_5.1AA!f`C--•--1­0 �%t. +"....................... Installer Address Type of Building Size Lot.,+ ,r..49 ......Sq. feet Dwelling—No. of Bedrooms........j_------•-----•--.-•--.-___-Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Building No. of ersons...._.......•............... Showers — Pa YP g -----•---------------------- P ( ) Cafeteria ( ) Q' Other fixtures .----•-•------•-•--•------------- . W Design.Flow............................................gallons per person per day. Total daily flow----Z!N2.......................... { W Septic Tank—Liquid capacity./ -_gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... WidtlV................... Total Length..._............_. Total leaching area...................sq. ft. Seepage Pit No........ Diameter..�_....� }- Depth below inlet... ........... Total leaching area.A��---.--sq. ft. . Z Other Distribution box ( ) Dosing tank ) z Percolation Test Results Performed by... a... ! _.X p.....A................................. Date...50.11-�--..__.__.... dcs + Test Pit No. 1___._..._..'��minutes per Inch Depth of Test Pit.................... Depth to ground water........................ (T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---•---------------------------------•--------•-----------..........-----................--••--•----.......................................... ODescription of Soil............................=-----------------•---•-•---•----•--•-----------...---------------------------------------..........................•-•---......-••---•.... 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 rovisions�of'TI p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i sued by the oar f he lth. Signed. r.. -----' .- ate Z Application Approved By..........I,A/--•--------------------•----------------.................••...••• Date Application Disapproved for the following reasons:--•-------------------••----•----------•-----------•--••---•--------------------------------------------------- ---•-----••------•--.....--•-----•------•---•---•-••----•-------••-------•-••..................•....----...--•------•--••---•----•------- ............................................................... Permit No._... rr_ Date .-zr.-•--•---•-----------•------•----- Issued.-- ----- ..................................... Date t`JTH'E COMMONWEALTH OF MASSACHUSETTS z BOARD OF HEALTH ............t. .ads'".............OF.... .................... fTrrtifiraft. of Tomplianrr 'A "4 y THIS IS,_'0 CERTIFY, Tha the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by---------------------- .........� ... ...... ................................................................................................................................... ,r �/ t Installer at.....`!1 " ` '�rj-----------------------------------------------------------•-------•-•--•--......----•----------------.....-------------•-- has been installed in accordance with the provisions of TIT F - j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------- --_-__.' "� ._ dated......tf Off'"_ af................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM 11.1.1. FUNCTION SATISFACTORY. 0��? DATE...... .:....p��. .... .. --------------------•------------- Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAI,.TH Voo �r ............O F........ .......... ..:;C 2 FEE.. Elispouu�ll Mork u Ton irudivit rrmit Permission is hereby granted........1C.- ""....... -------------•--••------•-------••--•--•-------....-•----.......------....... to Construct ( . ) or Repair ( ) an In ividual evt�age Dis osal System atNo....... , •-•••...OX4.......A ------------.---•-----------------------•---•-••---•----------------•-d:17" Street. as shown on the application for Disposal Works Construction P 't N .'__ ted.... ....�................. ........ Boa DATE---._Q-:-`I(,e .:`.-• i Boar of Health --- ----------------••------•----•--•----•----... 4 1 FORM 1255 .HOBBS & WARREN. INC.. 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