HomeMy WebLinkAbout0031 FLOWING POND CIRCLE - Health 31 Flowing Pon i Ci roc?e
Osterville
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- C 01VIMOIN'WE�L. OF SA E S
EXECL"I` vE OFFICE OF N-V'IRONTMEN-TAI,AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TTI'LE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 3 L 6uJ i t
Owner's Name:
Owner's Address: . f
Date of Inspection: 1 Ix L 3��-y C70
(AD
Name of Inspector•1please print) i ( e�, '�• co } "'
Company Name: &rAyy r(G kV i r0A h►t c
Mailing Address: p Ki� ha P CG c
'a► OC`�6tE�
Telephone Number: SOSs�As""-760$
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system:
Passes .
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
C
Inspector's Signature: Date: l6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
r
Page 2 of 11
OFFICIAL INSPECTION POKE=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE I3ISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ( 4jullle. aot
Owner:
Date of Inspection: 196 e7,)'
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
AI have'not found any information which indicates that any of the failure criteria described in 310 CMR
03 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"sectio to be replaced or
repaired The system,upon completion of the replacement or repair,as approved a Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the folio g statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic i as approved by the Board of Health.
*A metal septic tank will pass inspection if it is cturaliy sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years of is available.
ND explain:
Observation of sewage bac or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a bro ,settled or uneven distribution box.System will pass inspection if(with.
approval of Board of Health):
broken pipe(s)an zqAaced
obstrucrcn i s removed
distrubu on box is kwied or replaced
ND explain:
The syste required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection (with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL IN SPEC$ION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3Pc��Q
S�kl►v.l
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 determine ' he system
is failing to protect public health,safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR .303(1)(b)that the
system is not functioning in a manner which will protect public health,safety an 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 t marsh
2. System will fail unless the Board of Health(and Public Wa r Supplier,if any)determines that the
system is functioning in a manner that protects the public h th,safety and environment:
_ The system has a septic tank and soil absorption sy em(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water su ly.
_ The system has a septic tank and SAS and th AS is within a Zone i of a public water supply.
The system has a septic tank and SAS the SAS is within 50 feet of a private water supply well.
_ The system has aseptic tank and SA and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method us to determine distance
"This system passes if the well wa r analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic com unds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrog and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. opy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DWG SYSTEM INSPECTION FORM 3
PAR'T:A
CERTIFICATION(continued)
Property Address:
Owner:—gmul yy
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X 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
0/ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
-g(- Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone I 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 i00 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 ea3iform bacteria and volatile organic.compsn3lds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equatto or less than 5 ppm,provided that no other-failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I 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:
To be considered a large system the system must serve a jwith a design flow of 10,000 gpd to 15,000
Ypon must indicate either"yes"or`no"to each of Vdition�
wing:
(The following criteria apply to large systems' to the criteria above)
yes no
the system is within 400 of a surface drinking water supply
_ the system is wit ' 200 feet of a tributary to a surface drinking water supply
— ` the system' ocated in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 a public water supply well
If you have ered"yes"to any question in Section E the system is considered a significant threat,or answered .
"yes"in S tion D above the large system has failed.The owner or operator of any large system considered a.
signifi threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
(( CHECKLIST
Property Address: 00vi`t Ot 'C6 cl
vt 4
Owner. � (x`�u►I�
Date of Inspection: i t s o 5
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
of _ Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as NIA)
Was the facility or dwelling inspected for signs of sewage back up?
i 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
L—baffies or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_,k _ 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.
/� _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
'4s`imacceptable)[310 CUR 15.302(3)(b)]
5
Page 6 of i
OFFICIAL INSPECTION FORM—NOT FOR VOLU-1-TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM(INFORMATION
Property Address: 31 car% C� ,`,�
Owner: ( h�
Date of Inspection• sk "a b-5'
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): -
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): a�
Number of current residents: b
Does residence have a garbage grinder(yes or no): 08
Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required]
Laundry system inspected es or no): ibD
Seasonal use:(yes or no): Na
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: 03
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based'on 310 CMR 15.203): —` apd
Basis of design flow(seats/persons/s tc.):
Grease trap present(yes or no):
Industrial waste holding tank sent(yes or no):
Non-sanitary waste disc d to the Title 5 system(yes or no):4
Water meter readings,i vailable:
Last date of occu /use:
OTHER(des e):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): t�.0
If yes,volume pumped: gallons—How was quantity pumped determined?
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)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, to installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
6
Page 7 of I I
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: oaJcza-.e
Owner: 794--4,w yt
Date of Inspection: Al.[a
BUILDING SEWER(locate on site plan) .
Depth below grader
Materials of construction:—cast iron JL40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:bC (locate on site plan)
Depth below grade:
Material of construction:_C concrete metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: Loda G arc
Sludge depth: ,2 " C.,
Distance from top of Mudge to bottom of outlet tee or baffle: v?d
Scum thickness: I
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 140
How were dimensions determined: lykezuS y,-Ck
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rela d to outlet invert,evidence of leakag etc.): o ( L c
ww(4 G�vt�
R&t `
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:_concrete_metal_fiberglass olyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet t or baffle:
Distance from bottom of scum to botto outlet tee or baffle:
Date of last pumping:
Comments(on pumping recomm lotions,inlet and outlet tee or baffle condition structural integrity,liquid Levels
as related to outlet invert,evid ce of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: E C,,,.�(,e
Owner: CSLN vL
Date of inspection:
TIGHT or HOLDING TANK: (tank must be pum at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete etai fiberglass___polyethylene other(explain):
Dimensions:
Capacity: Ions
Design Flow: gallons/day
Alarm present(yes or no):
Alarm Level: in working order(yes or no):
Date of last pumping:
Comments(conditi of alarm and float switches,etc.):
DISTRIBUTION BOX:K(if present must be opened)(locate on site plan)
Depth of liquid IeveI above outlet invert: eVC4.
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,etc.): /,� ! _ ('
6 FPC uJt,,6 L" 6t8 (.[�d l�K I?Q S ZS Yl cs T 'Cltl'f�(iS
PUMP CHAMBER: (locate on site plan)
]Pumps in working order(yes or no):.
Alarms in working order(yes or no):
Comments(note condition of pum chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUI[fYACE SE*AOE DISPOSAL SYSTEM INSPECTION FORM
PART C
�" SYSTEM INFORMATION(continued)
Property Address:——3�r(�-��tQ-W� av& C,4,nGkp
Owner: y�y`
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
K leaching pits,number.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): ( �
I UY �0
6 a
;?0IVI i 4t,N 100'
CESSPOOLS: (cesspool must be pumped as part of in pection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer-
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater igKow(yes or no):
Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of so' ,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page IO of I I
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE ®ISPOSAL SYSTEM INSPECTION FORM `
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 L
Owner:
Date of Inspection: J
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.
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Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2;
Owner: �Smu;;�
Date of Inspection: is 57(65'
SITE EXAM
Slope S L C,"
Surface water 00
Check cellar l�S5
Shallow welts Njo
Estimated depth to ground water 010 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
A Accessed USGS database-explain:
You must escribe how y g you established the hi hg round orate elevation:
II
LOCATION SEWAGE PERMIT NO.
VILLAGE �
Q..F e;� ire 8e 1�
IN.STA LLER'S NAME & ADDRESS
BUILDER OR OWNER
DATE PERMIT 'ISSUED
-DATE COMPLIANCE ISSUED
ja
; '
k
—-e7�v
No................_...... F�$..P3. ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H 'A T
Appliraiiun for Disputial Workv nstrnrtiun ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sy at: ?! , j`
--
Locatio Tess or Lot No. f
Ins aller Address �r
Sq. feet
T oftingSize Lot .._ .-��
Dwelling—No. of Bedrooms...........-3............................Expansion Attic ( ) Garbage Grinder (" )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ....... -................
W Design Flow..........j`'V.......................gallons per person per day. Total daily flow.............. _o__...._............gallons.
(� Septic Tank—Liquid capacity/ ons Length................ Width-----------_.... Diameter................ Depth................
Disposal Trench—No...................... th ------- __-: Total Length--- ._._._ Total leaching area....................sq. ft.
Seepage Pit No..... .............. r-�__1%� � b 'y Total leaching area.? _ -----sq. ft.
Z Other Distribution box Vr Dosing tpk 2 7� 7o'-'
Percolation Test Results Performed by__ ?. -- Date..... ? .
Test Pit No. 1.....�minutes per inch Depth of 'Test Pit--------------��-ept��,o ground water.................
44 Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water........................
0 •---•--••---•---• ••• ....• - - - !..................
Description of Soil-------------L)_-.rZ `- --: �'y'�A..I� -••---- -------If ,----------- �
:...........
V .....----•-•--•-•---------•-----•-----••-•-•----••-•------------------•---------...........---•----•-----
W
VNature 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 boaWl of health.
Si ned.� �- ----•----- �y
ate
Application Approved By---- --.. • -- ! A--•-•-•f--------•-••• -----
Date
Application Disapproved for the following reasons-------------------------•------••----------------------•--------------------•------------ ......................
..---••-•-•---------------------------------------------------•--••-------------••------....-•-----------•-•---•----------•--•--•-----•-•-------------•-•--•----•--•---••------••-•-••-----•-----------
Permit No......................................................... Issued.--��l-�-- -- ......... Date---------
Date
No---------------- ----•:: F%s.. .��_..............
THE COMMONWEALTH' OF MASSACHUSETTS
BOARD OF H A T
- ---......i .....OF......
Appifirutiun for Bispuiital Works unitruriion-ramit
Application is hereby made for a Permit
ttto' Construct ( ) or Repair ( ) an Individual Sewage Disposal
y a5: . .1 .
.......... ......................... ----------------------
+
> . Locati � •dfress
er ,a ¢ .or Lot No T
, ......................
w r... ..
i / �/ Addre
L f
�a
::.-- • Y. . ---•-• 7.. -�
Installer �irAddress
Q Tylp�of Building Size Lot _ _..Sq. feet
V Dwelling—No. of Bedrooms---------- _________________ ___Expansion,Attic ( ) Garbage Grinder ( )U
a 4 Other,—Type of Building ............................ No. of persons............................ Showers
( ) — Cafeteria ( )
Other fixtures .-----..-o ....... ................................................
Desi n Flow....._ ._ `. .....................gallons per person 'per day. Total daily flow____---_ ......___..........
W g �'--- - - g P P P Y• Y ------- gallons.
Gd Septic Tank—Liquid capacity/___. _ra ons Length................ Width:................ Diameter__._____.___.._- Depth................
Disposal Trench No .................... dt _.._f .17ek.. Total Length L. Total leaching area..... ___..sq. ft.
Seepage Pit No: rA pag Z M b e Total leaching area-*.7. A......sq. ft.
Z Other Distribution box ( Dosing t ( � ` 2 7 7A
`" Percolation Test Results Performed by.:-~_ `4. c:; �. ? $.__ Date:..:_.,l`. .2.-.?�r-'S...........
,� Test Pit No. 1..... _-:.-:.._minutes per inch Depth. of est Pit____________________ Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' . -•-- -- ..............••-•-_-----
O Description of Soil....... 1 '" -----'4rf C .............................'
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 TITL iE 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 theboaql of health.
se-
9 � ate
Application Approved By..... r 4.`..�'i 1-[ ....................... -------2_n 4....... p-'---
�f Date
Application Disapproved for the following reasons:................................................................. -
..................................•------------•-------------•--...---•-----------=--•-•- ..................-.........................................................................................
Date
.Permit No......................-•---•--••-••--------------------- Issued----.....------.................... ...........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFZ
AL H
'
.#.., ......OF..:O. .. . ..
TrrtifirFatr of TompliFanrr
TH IS TO CERTIF Thh he Individual Sewzg 1"'Di al System constructed or Repaired ( �'
by .._. * --------------
Installer a rt
at•. • ..... ...... ......................... _ ....-- - --------- ! ._.... - --------------------•-••------
has been installed in accordance with tlprovisions of T 5 of The State Sanitary Code as'described in the
application.for Disposal Works Construction Permit No. �; dated.... , Ate '
THE` ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS GUARANTEE THAT THE
SYSTEM `�VILL FU CTION SATISFACTORY •� f> `
DATE. ;•-= = •� 7 .. -------- ---------- Inspector •- �! __. r
..-pry�P 7a•
• -� a..�i+u'S'r:mis<»yK his..+;.: �,r f.,.,. �
JM
THE COMMONWEALTH,. O MASSACHUSETTS C WEALTH F MASSAC SETT•� S
.BOARD OF HE L H
-wr
No...........:........... % FEE.- g_.............
. vosttl Works (to #r win Prrutit
Permission i reby granted --• / •- } ............
to;Construc or Repair n Individual Se ;g Dispo #st(Rn
at No: '" , ------ ...............
••. --•• ------•-•-
/ Street
j;' as shown on the application for Disposal W s Construction Pe it o._ _-___- Dated_._ .'__ _`-� -----.---•__..___
�„� �.rM ,.r.rj /`� ;. -----• f Boar f�He ...................................—
r 4
y
DATE..-•- ---------•-...............................
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