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HomeMy WebLinkAbout0014 JANES WAY - Health 1.4 JANE���WAY, OSTERVILLE s_ - A= 146 046 s a Commonwealth of Massachusetts 4 1 �1 Title 5 Official' Inspection Form ' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „; M 14 Jane's Way e Property Address V Ellenor Letterie Owner Owner's Name information is s ' required for every Osterville Ma. 02655 09/18/2017 I } page. City/Town State Zip Code Date of Inspection' . ; to-"f Inspection results must be submitted on this form. Inspection forms may not be altered_ in any way. Please see completeness checklist at the end of the form. - Important:When filling out forms A. General Information / ,w on the computer, use only the tab 1. Inspector:, key to move your cursor-do not Michael T Bisienere ` use the return key. Name of Inspector Cape Septic Inspections teb m Co an Name Company 624 Old Barnstable Road . Company Address Mashpee Ma. 02649 City/Town State ` ' Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification 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 15.340 of Title 5(310 CMR 15.000). The system: ® Passes,, ❑ Conditionally Passes ❑ Fails „ ❑ Needs Further Evaluation by the Local Approving Authority 09/19/2017 Inspector's Signature Date 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 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. 4. ""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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 onin 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: This 2 bedroom home has a H-10 1000 gallon septic tank feeding a leaching pit. At the time of the inspection there was appx. 2 feet of ponding water in the leaching pit. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code bate of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts . Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system 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 a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent 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. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 1/2 day flow t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name - information is required for every Osteryille Ma. 02655 09/18/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no".to each of the following, in addition'to the questions in Section D. 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 If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Jane's Way M Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection C. Checklist 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 ❑ ® 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 N/A) ® ❑ Was the facility or dwelling.inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? I ® ❑ 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? 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® El approximation 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): < 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments GSM 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: In 2016 114,000 gallons were used and in 2015 89,000 gallons were used Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes .❑ No Industrial waste holding tank present? ❑ Yes ❑ No, t Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts N rz Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma: 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information- Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes n No 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) and a copy of latest inspection of the I/A system by system operator under,contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 19" Depth below grade: = feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 611 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No t Dimensions: Standard H-10 1000 gallon septic tank Sludge depth: 1 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The Barnstable Health Dept. has a list of local septic pumping co. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: µ ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle' Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins.doc•rev.6/16 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts - w - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): Pump Chamber flocate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: One ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: El 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.): At the time of the inspection there was appx. 2 feet of ponding water in the leaching pit. Cesspools (cesspool must be pumped as part of inspection) (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 inflow ❑ Yes ❑ No t5ms.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i 'I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition 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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Jane's Way �M Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 PY LOCATION 5EW[�GE PERMIT MO. -LL�- - - -- - - - = - VILLAGE. - - - -- - - - - IWST&LLER 5 U&ME 6 ADDRESS BUILDERS ►J&ME ADDRESS pQTE PERMIT DATE COMPLI WLACE ISSUED - - _- •ti, � II �DT IL7 r • Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Jane's Way Property Address Ellenor Letterie Owner Owner's Name information is required for every Osterville Ma. 02655 09/18/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 13 plus feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: I augered a hole to 13 feet to show four plus feet of seperation Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 14 Jane's Way - Property Address Ellenor Letterie Owner Owner's Name information is Cisterville Ma. 02655 09/18/2017 required for every , page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater " ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file �3 Frei 96TTom t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 DEQ'2 i i998 COMMONWEALTH OF MASSACI-IUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPAIMLENT OF ENVIIRONMENTAL PROTECTION i ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL C L LLUCCI DAVID B. STRUHS Governor /'Xl !!! � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner t 1( ( PART A td `� ® CERTIFICATION Property Address: /y rQners W191 4/Pr(///fie NameofOwner /dl// /. 0/Connell Address of Owner- t' Date of Inspection: �[ /a'7 Name of Inspector:(Please Print) A eel �' 144Y-1�17-C C&I77'el-w //e j MA 1 am a DEP proved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: c o m S G A eC /- Mailing Address: i 7 / e Telephone Number: _170S_ 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: '� Passes Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: C '/�v Date: The System Inspector s all submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 y ~ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 14 Jane's Way, Osterville owner: 11/28/98 Date of Insp ection: Dorothy O'Connell Estate INSPECTION SUMMARY: Check A, B, C, or D: A. SYS PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: /SJDi/l7 ri ��OtUS Q.C�/P A DI�SC�iI tic- 4/ /l�/O�l7�Lt 7 j? B. SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y,N,or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2of11 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 14 Jane's Way, Osterville Property Address: 11/28/98 Owner: Dorothy O'Connell Estate 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 if`the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEAL ETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHI LL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is wi ' 50 feet of surface water Cesspool or privy' ithin 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPL R,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH ANDS AND THE ENVIRONMENT: The system has a septic tank and soil absorption system S)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 soil absorpti system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil ab tion system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and s ' sorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unles well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution f that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method d to determine distance (approximation not valid). 3) OTHER at revised 9/2/98 Page 3of11. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 14 Jane's Way, Osterville Property Address: 11/28/98 Owner: Dorothy O'Connell Estate Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: _ JO I have determined that one or more of the following failure conditions exist as described 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/ f/_•/ Backup of sewage into facility or system component due-to an overloaded or clogged SAS'or cesspool. _v Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or A 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 thara 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). / Number of times pumped_. v 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. v 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 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" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Lar System)and the system is a significant threat to public health and safety and the environment because one or more of th ing conditions exist: Yes No the system is within 400 fe a surface drinking water supply the system is wi ' 200 feet of a tributary to a surface drinking water supply the sys is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped Zone II of a public w r supply well) The owner o operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 i f . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 14 Jane's Way, Osterville Property Address: 11/28/98 Owner: Dorothy O'Connell Estate Date of Inspection: Check if the following have been done:You must indicate either "Yes" or "No" as to each of the following: Yes_ No Pumping information was provided by the owner, occupant, or Board of Health. �A - _ None of the system components have been pumpe&foret least two weeks v' rs•es a--•i^^lhaL.Imriad. 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. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of LKeakout. t/ All system components, xeitV�'� y p azoladir+g the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) The facility owner(and occupants,if different from ownerl.were.provided with information on tha.propermaintanance of SubSurface Disposal Systems. revised 9/2/98 Page sorii i .1 . SUBSURFACE SEWAGE DISPOSAL SYS7 EM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 14 Jane's Way, Osterville owner: 11/28/98 Date of Inspection: Dorothy O'Connell Estate FLOW CONDITIONS RESIDENTIAL: Design flow: 6M g.p.d./bedroo At if bal6�Q J/UfO Nt>/ atJ Number of bedrooms Idesign):A0 Number of bedrooms(actual): CPI Total DESIGN flow Number of current residents:- Garbage grinder(yes or no):-( d Laundry(separate system) (yes or n Po; If yes,separate inspection required Laundry system inspected ..(zes or no Seasonal use(yes or no): ND ,�,,c / Water meter readings,if availole(last two year's usage(gpd): 67 f/�I.S U, C�Q1�aS Sump Pump(yes or no)- A V Lest date of occupancy: 9Fj IOU 64 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present:(yes or no)_ >te aste Holding Tank presen • s or no)_ waste discharge a Title 5 system: (yes or no)_ readings vailable: oc ncy:scribe) occupancy: GENERAL INFORMATION PUMPING RECORDS and sourcy,of information: ND 11Pce�d e^t� G�yrr�oi � �►Pr S S/S /PCq�<-f System pumped as part of inspection:(yes or no)_O If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM We ,&Aox OA/I;K eGl1 q p/t_,,1o,,*A JL0000' Septic tank oil absorption system Single cesspool Overflow cesspool Privy , Shared system(yes or no) (if yes, attach previous inspection records,if any). I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date installed Of known)and source of information: ye, S a -Z97 > V% .*V6 Reeoa Sewage odors detected when arriving at the site:(yes or no) revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Jane's Way, Osterville Owner: 11/28/98 Date of Inspection: Dorothy O'Connell Estate BUILDING SEWER: (Locate on site plan) Depth below grade:1-2 � Material of construction:_cast iron V40 PVC_other(explain) Distance from water supply well or suction line Ill Diameter 11 Comments: (condition of joints,venting, evidence of leakage,etc.) C SEPTIC TANK:_ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ .Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: '7 /(7 Gt/ X d /6 d 4 X �/7 l/ 000,5JOn) Sludge depth: rl Distance from top of sludge to bottom of outlet tee or baffle: CA? Scum thickness: � -7'/ Rom /-i b LwP L Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle:—L E dA, //4 4e1/f How dimensions were determined: ra G a77eki S'/v�e JV f� Comments: (recommendation for pumping,/c ndition of inlet and et tee or baffles,depth of liq id level in re etion to outlet invert, tructur integrity, evi ence of leakage,et-) Ale P�oMm�nsf ✓n ,, / �f ., h / r -e Q GREASE P• (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyeth a—other(explain) Dimensions• Scum thickness: Distance from top of scum to top of outlet tee affle: Distance from bottom of scum to botto outlet tee or baffle: Date of last pumping: Comments: (recommendation of umping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity, evidence of le ge,etc.) revised 9/2/98 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Jane's Way, Osterville Owner: 11/28/98 Date of Inspection: Dorothy O'Connell Estate TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass ethylene_other(explain) Dimensions-: Capacity: gallons Design flow: gallons/d Alarm present Alarm level: rm in working order:Yes_ No_ Date of previous pu mg: Comments: (condition o ' let tee,condition of alarm and float switches,etc.) f .S A4A DISTRIBUTION BOX:_ l (locate on site plan) /V U oX D/V r) Depth>liquidabove o invert: Q �o � ° N d A60X Fo v IV/d Comm(note.iribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or N Comments: (note condition of pu amber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 14 Jane's Way, Osterville Owner: 11/28/98 Date of Inspection: Dorothy O'Connell Estate SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,if possible; excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Type: / / leaching pits,number. ((/x(O 612OWE-77 T- 6d177'M leaching chambers,number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic fail re,level of ponding, damp soil, coition o vege ation, etc.) C121L / / U(r /S O om , CESSPOOLS:_ (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: inflow (cesspool m e pumped as part of inspection) Comments: (note condition 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 soil,signs of hydraulic f ' e,level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 h r' • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Jane's Way, Osterville Owner: 11/28/98 Date of Inspection: Dorothy O'Connell Estate SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Lawn +20 �"f�2 OF /foys� � � I ` o C , 17 �IST�ouc s AC = 35.5 � 3 C Zs ' o � 8� = 2-8.5 � . hE_7 = 55 '/0 revised 9/2/98 Page 10of 11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 14 Jane's Way, Osterville Owf 1 : 11/28/98 Date of Inspection: Dorothy O'Connell Estate NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater_Feet A) Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed SiteiAbutting property, observation hole, basement sump etc.) Determined from local conditions I-1"'Checked with local Board of health �(,va �. COno�v✓ M✓1&j Checked FEMA Maps Checked pumping records Checked local excavators,installers ✓Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Us.G. S Cow 746vr so ' �9• s. L .2. Grou•-c/K.�t�� Co., /r�,q-� Q ,2 Z 3 . ��9 z 3 Y So (--z 2 f 7. 3 t 8.)= /0 , 7 revised 9/2/98. Page 11 of 11 a , ( f Fj /A r o I a { 4 • 1� , I f L l - anc�.a�.®.v,..+.—•.w..-...—.�.�.�..w x,.�..n s.rry{arnr�asawaw •w:iPtstCY�us.Ae'Asr7xck=4^nN[iY.+,PiV+++!' 4 YN IN . h r� �r�'�C;gR,J� ' ��' ���d+i0/� R-l��°��'O6�! .Cd A./� 7'.�d�Y •/'�", ��b��rie�,� � L 3.:. 1s o` f ft H Iwo LOCATION 0 1 SEW&C;E PERMIT UO. IWSTQLLER'S U&& AE ADDRESS BUILDER 5 Q &MF- ADDRESS DL-s,TE PERM VT 15SUED D ATE COMPLI W-acE ISSUED : — — 3l ���� :� _1�S �o� �� ��� 0 � � ,�S �� THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALT . _C)..GI .r .OF......... ....... .. � ..:..C ....d�� . Appliratinn -fear Biiputittl Workii T>anMrnrtion Vrrntit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Syst ••••--- - ----- - � 2 �.__ :cation- !Y. r. _,•............................ 7fJ2 C w erAddress • U ._._..... jC _ if/ .-/Z......................... Installer Address ......� � O_ S feet U Type of Building Size Lot.. ............... . q. I �-, Dwelling—No. of Bedrooms--------a...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .......Ali__&-(E..-------------------------------------------------------------------------------- ----------- W Design Flow..__...._._(570________________________gallons per person per day. Total daily flow.................�.��.�............gallons. WSeptic Tank—Liquid capacitV-��N� allons Length................ Width................ Diameter_-.--_-..-_-__ Depth................ x Disposal Trench—No_____________________ V'6�' th ................. Total Length.............. Tot leaching area....................sq. ft. Seepage Pit No...... �D t� ...... in TCHeachin area.......-_--•......sq. ft. Z Other Distribution box ( ), Dosing tank ( ) 0A4, ^e�4ftd* 74 aPercolation Test Results Performed by------- -----------------------------------------------•----------•--•---- Date_------------------------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ Li, Test Pit No. 2________________minutes per inch Depth of Test Pit.................... Depth to ground water....................... G Descri$tion of Soil ��°' `�` Z_...-vcc< - o u_ ����'�'1�--mot'- �--------------------------------------------------------------------------------------------------------------- W U Nature of Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------........_.............. ----------------------------------------- -------------------- .................................................................................................--------- ---------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI 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 board of health. Sign � ���sr� 2''"-•• V�w �� •- � � �at Application Approved B PP PP y------14��4 !1/J_- -- - ----------------- Y -, .74-------- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------- ---•-••-••--•-•-----•--------------------------------------------------------------------------------•------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS �_-- BOARD OF--,,HEALTH, /a_ 46/A�OF......... ....... ..���-spa .�:.................... Appliration -fur Biapviial Workii Towstrnrtion Prrmit Application is hereby made for a Permit to Construct (G.) o�pair ( ) an Individual Sewage Disposal System at ........._................. ! Location-Add-ss re or Lot No. - r // O(w(_+}ctr % Address ........................... Installer Address f'/ YP g /t✓ �0 0 Sq. feet U Type of Building Size Lot_._______,e.............. . .-� Dwelling—No. of Bedrooms---- ..............................Expansion Attic ( ) Garbage Grinder ( ) aa,,, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) p'' Other fixtures --------y -A-e-------_ Design Flow-__-_-_-___:°?.^ �...................... Mons per person per day. Total daily flow------------------- w g P P P y Y gallons. WSeptic Tank—Liquid capacitv/° allons Len-th---------------- Width................ Diameter______-..--__ Depth_.--__-__--- x Disposal Trench—No_ _______________ ____ Width-------------------- Total Length-_-.--._-..______---/To�taa A'eaching area........------------sq. ft. Seepage Pit No......Z _GO Di?h t/,Z�2` ------ �ptV0beo nlftt-'_ fi-a+-leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank aPercolation Test Results Performed bY.......................................................................... Date------------------------------------._.. Test Pit No. 1----------------minutes per inch Depth of "Pest Pit-------------- ..... Depth to ground water----.-_.___--_--__.... (14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--..-.---_-----__.-_-._. 9 ---------)----- ------ --...--------- •••.•------ = G Description of Soil �G li`1.�• !�r __��'.?.�_ u.•,.._.. �cc -------- ---- U ------ ? 1 -`---- r. -- -? t +.5 ,/ ---._.... ---------........................................ .......... 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 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 issued by the board of 7. health. Sign - «�.=+ ��1 �{y / 1�%i%�"�" r.�/-_� � .j�� / Date Application Approved BY------- -----------:� � -C ---- - ----------------- ------- . Date Application Disapproved for the following reasons:................................................................................................................ ....................................................... ••••------_..._...•------------•-•--••••••---••--------------............._.._...------------. ....._----------_._....._......------•.----•-•... Date PermitNo......................................................... Issued.........------------------ ............................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f Q..�fi... .......OF......... 1. /�/ xr/.fT .. ,.............................. Trrtif iratr of fI'limpliatta THI�S TO CERTIFY That the Individual Sewage Disposal System constructed ( or Repaired ( ) by..---••---/- :t- .U-�& -------`�-------�e---%•----•----- ----------- ---- • / Installer /� at....X..a....... ..7------------ -------- V•-------- •--•l d- ..... has been installed in accordance with the provisions of Arcle XI of The State Sanitary Code as descr}'bed in the application for Disposal Works Construction Permit No... �______`)-�_J ............... dated...... "_ 4-_............__.... THE ISSUANCE OF THIS CERTIRCATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE °_.......... / ------------• Inspector - --- --------- - -----•• . ... ..................... THE COMMONWEALTH OF MASSACHUSETTS 7� BOARD OF HEALTH 71_��.. ✓..../1L...OF....... ... fr i'�....�... d.....-.............................. /G No.........L.( < FEE... Di-sp aiittl irk ��n nrti tt rrntit � e Permission is hereby granted------------ -e�--1 V----------�--)C--------------_y....................................................................... to Construct )or Repair ( ) an Individual Sewag Street r as shown on the application for Disposal Works Construction Pe nt�}� No._. 2 ��G ated - -- --- -- ` `'r - -- -- ----- -.�<c�lil. '----------------------_ DATE. l d ` `/ Board of Health FORM 1255 Hoees % WARREN. INC.. PUBLISHERS ' .: - `- I zx,. A Fti,` �+t]xy'i"'t�'s'eR' .. e x t - c m 4r3. :.>,...w �: j ,. 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