HomeMy WebLinkAbout0024 NUTMEG LANE - Health 24 NUTMEG LANE, OSTERVILLE
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TOWN OF BAIMTABLE
VILLAGE-0 579''`VI /4375 ASSESSOR'S MAP & LOT
S NAME&PHONE NO. \7-1 . ,W
SEPTIC TANK CAPACITY 16Ad
LEACHING FACILITY: (type) � /�`v (size)
NO.OF BEDROOMS
BUILDER OR OWNER
-PhWUPDATE: �� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Le ching Facility(If any w dands exist
within 300 feet f 1 chi cility) Feet
Furnished b
� � � �\. Sy,
eo �
Soo
DATE: _3/1.7/07 9 8
PROPERTY ADDRESS: 24 Nutmeg Lane
Osterville ,Mass . A F/�/�C-�
8
02655 - ) OFF 4 199,
ITy�FpSTAe�F ti
On the above date, I Inspected the septic system at the above ad tip"
This system consists of the following: t
1 : 1 -1500 gallon septic tank.
2. 1 -Distribution box.
3 . 2-1000 gallon precast leaching pits .
Based on my Ins.-section, I certify the following conditions:
1 This is a title five septic.:system. ( 78 Code—).- _
2. 1 -pit cover is broken. Must be repalaced.3 . 1 -pit cover must be raised 3111 below grade . _
4. Septic heavy with solids & Scum layer. Must be pumped. "'7"�7
5.. Distribution box is cracked and broken. Must be' replaced:
6. The septic system is in proper, working
order at_the- present time .
ISIGNATURFF:
Name:_J-P Macomber Jr•
Company:_J. P_Macomber & Son-_Inc
Address:
Cente?rvi1leLM ps__02.632
Phone:---S0.&__77,,_3338.....
__ • 1
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER, & SON, INC.
Tanks-Ceupools-Leachfields
Pumped & instslled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
775-3338 7754412
U
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
t3a.+rnor
F.Weld Trudy Cox*
ArW Paul Calluocl
arld B. strum
corm�..brw
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
24 Nutmeg Lane Ostervi5Te I�IassoN
Property Adds.,[Hurley & O' Connor Address of owner.
Date of Inspection: 3/17/9 7 (If different)
Name of Inspector.. Joseph P.MAcomber Jr.
Company Nance,Address and Telephone Number.
J.P.Macomber & Son Inc .
Box 66 Centerville ,Mass . 02632 508-775-3338
CERTIFICATION STATEMENT
I cartify that I have personally inspected the sawage 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-sits sewage disposal systems. The system:
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails c �y
Inspector's 8lgnature:C/��` % �-/ Date: j�14�/cG
The System Inspector shall submit a copy of this inspection report to the Approving Authority 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.
INSPECTION SUMMARY:
Check A, B. C, or D:
A) SYSTEM PASSER:
have not found aqy information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
_Al�, One or more system components used to be replaced or repaired. The system,upon completion of the replacement or repair, passes
Indicate yea, no, or not determined(Y, N,or ND). Describe basis of determination in all instances. If"hot determined",explain why not)
The septic tank is metal, cra;kod, structurally unsound,shows substnntial infiltration or=Mtration,.or tank faflure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Conforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Wlntor Street a Boston,Massachusetts 02108 a FAX(617)55&1049 a Telephone(617)292-5500
��Pnnld on Racyckd Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Prop.rtyAddreesc 24 Nutmeg Lane Osterville ,Mass .
owns. Hurley & O ' Connor
Date of Inspection: 3/1 7/97
B)SYSTEM CONDMONALLY PASSES (continued)
Si a e backup or,braakas£'or h b static watar level observed in tba distribution bos L dw_to broksa or obstructed pipes)
or dw`tb i bsok n�Wtlid'or unevia'distssbutioa box. The ta eysm will passspection if in (with approval of the Board of
Hwlth)— W bsok. pipe(s)are placed G fZ hpQ
a is removed
distribution boat is levelled or replaced
The system required pumping more than four times a year due to broken or obetruRtad pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTHr
—gd/Z Conditions exist which require Anther evaluation by the Board of Health in order to determine it the system is tailing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
)BANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
yQ Cesspool or privy is within 60 feet of a surface water
dV Cesspool or privy is within 60 fset of a bordering vegetated wetland or a salt marsh
3) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Qm Tba system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
,a The system has a septic tank and soil.absorption system and is within 60 fast of a private water supply walla
The system has a septic tank and soil absorption system and is less than 100 feet but 60 feet or more from a private water
supply w4 unless a well water analysis for coliform bacteria and volatile organic compounds indicator that the wall is tree,
hom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 24 Nutmeg Lane Osterville ,Mass .
Owner. Hurley & O ' Connor
Date of Inspeotlon: 3/17/97
D) SYSTEM FAILS:
•
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
failure.
(�d Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the 4istribution box above outlet invert duo to an overloaded or clogged SAS or cesspool.
,t,p�a�1t ,ts
Liquid depth in eeaspeel is less than 6"below invert or available volume is Is"than U2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
�Q Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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 analysed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
ll The following criteria apply to large systems in addition to the criteria above:
/VO The system serves a facility with a design flow of 10,000 gpd or greater(Largo System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions grist:
'ILY the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinldng water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Anther information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 24 Nutmeg Lane O s t e r v i l l e ,Mass .
Owner. Hurley & O ' Connor
Date of Inspection: 3/1 7/9 7 •
Check if the fo have been none: `
J_/ Pumping information was of the owner occupant,
requested �,� and Board of Health.
Nona of the system components have been pumped for at least two weeks and the system bas been reosiving normal flow rates
that period I.a:ge volumes of water have not been introduced into the system recently or as part of this inspection.
As built plans Law been obtained and examined. Note if they are not available with N/A.
ZThs facility or dwelling was inspected for signs of sewage back-up.
"The system does not receive non-sanitary or industrial waste flow
, The aite was inspected for signs of breakout.
system components,4waluding the Soil Absorption System, have been located on the site.
-,Ae septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baIDes or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
, �size and location of the Soil Absorption System on the site has been determined based on existing information or
ace ted by non-intrusive methods.
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
L
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
P11pe1tyAddrvss: 24 Nutmeg Lane Osterville ,Mass .
Owner. Hurley & O' Connor
Date of Inspectiow3/17/97
FLOW CONDITIONS
RESIDENTIAL•
Design flow: gallona
Number of bedrooms:_
Number of current residents: Z
Garbage grinder(yes or no):_Ao
Laundry connected to system(yes or no):IL� `
Seasonal use(yes or no): A(
Water meter reading,, if available•
Last date of occupancy:
COMMERCIALIINDUSTRIAU
Type of establishment:
Design IIow:_,eejgallons/day
Grease trap present: (yes or no)If-V
Industrial Waste Holding Tank present: (yes or no)/VV
Non-sanitary waste discharged to the Titls 5 system: (yea or no)A2,31
Water meter readings, if available:_�/�
Last data of oavpaaq:_ /i>X)
OTHER. (Describe) .4/.4
Last date of occupancy:
GENERAL INFORMATION
PUMPING ORDS and so of information:
1
System pumped as part of inspection: (yea or no) $
If yes,volume pumped: ns
Reason for pumping _�� 1 Ss Aj ,4 SC1✓sy , Leo �c
TYPE O,$SYSTEM
L' Septic tank/disUilnrtioa boa/soil absorption system
Z,"h Single cesspool
VQ Ovsrtlow cesspool
_0� Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all oompoaents,date in.rtalled(if known)and source of informatioa: �l�f�.OX/f"�� �iy�/
C �971 7zo,
Sewage odors detected when arriving at the site: (yes or no)�a
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C-
SYSTEM INFORMATION (continued)
Property Address: 24 Nutmeg Lane Osterville ,Mass .
Owner: Hurley & O ' Connor
Date of Inspection.-3/1 7/97
SEPTIC TAN K:1 fe0 pwd.v
(locate on site plan)
/P
Depth below grade;_f0
material of construction: concrete _metal _FRP _other(explain)
Dimensions:&4
Sludge depth:
Distance from top of s dge to bonom of outlet tee or baffle:,._
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:_
Distance from bonom of scum to bottom of outlet tee or baffle.
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle,. depth of liquid IPvel in relation to outlet invert, structural
riry, eyidence of leakage, etc.) Pum se tic tank ever 2-3 years : Inlet & outlet
_ tees are in lace : Te—ptic tank is structurally Sound-'. o evidence o
f 1 a
CREASE TRAP. i �
(locate on site plan)
Depth below grade:,44
material of constrrrrtion, ?zoncrete _metal _FRP _other(explain)
XA-
Dimensions'
Scum thickness.
Distance from top w scum to top of outlet tee or baHle:_Af f
Distance from bonom nt srtrm t^ honnm of outlet tee or baltte•/V�
Comments.
(recommendation for pumping, cond+r•^rt of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, et
Grease traA is no present.
(revised I/iS/9$1 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Propei.t,Addres 24 Nutmeg Lane Osterville ,Mass .
owner. Hurley & O ' Connor
Date of Inspection:3/1 7/9 7
TIGHT OR HOLDING TAN&_&�tfe.
(locate an site plan) •
Depth below grade:. !
Material of oonstructioa: oonesete_metal_FRP—other(explain)
AM
d111
Dimensions: AA
Capacity: A)R asllonr
Design flow: A)R gallons/day
Alarm level: A)4
Comments:
(oaadit; n of inlet we,
condition of alarm and float switches,etc.)
Tight or holding tank not present.
DISTRIBUTION BOX-Z
(locate on site plan)
Depth of liquid level above outlet invert: NO
Comments:
Box iis�not ievet IS 0: ox`viIs°•csolids
c-ke9yoan'c roV1"n US of
replaced.
.
Ther� ,u�� f solids narry over: There is evidence of leakage in
an�ou o Rev }�ag -hpen sea ea��1 R f�7
PUMP CHAMBER.-&LVe-
(locate on site plan)
Pumps in working order:(yes or no)•&
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Pum= chamhPr is not present
(revised 11/03/95) T
' U
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oonUnued)
ProperVAddre" 24 Nutmeg Lane Osterville ,Mass .
owner. Hurley & O' Connor
Date of In'P*O ow 3/1 7/9 7
SOIL AMRPITON SYSTEM(SABk,z
Oooste ea site plan,if possib ;aseavation not required,but my be approximated b7 aoa-iatrus)w methods)
If not detsrmiaed to be present,ssp3aia
TSP«
k"hin pis., number
Lachia�chambers,"umber Z)
galleries,anmber—T
1whin tr*wjwf,numwjsz8tL-
leachir
fi&W number,
overflow cesspool, number.f °a':
�N eisum sa°n ° o` ine'sank`:�11�"osigns or pon ing�—
All \TAgPt.At.l nn is normal . Cover On # 1 nit must be raised 3111 below
_er_a.d.g e:p.:Vtid:ire- r4;nlnPaH RPr�"ire T)nne 18/97
U-
CESSPOOLS:&d4�&.
(locste on site plan)
Namber and conaprati= A1/1
Depth-top of liquid to inlet invert: A)4
Depth of solids lyer: AiA
Depth of scum lyw.
Dimensions of cesspool: W
Material of construction:_ &4
Indication of gsound..atsr: Ar/f
inflow(cesspool must be pumped u part of inspection) gZ4
&4
k
Comment,:(note condition of soft,sues of hydraulic failure,level of pondiv&condition of vogwAtion,etc.)
AA-
PRIVY:,/ v ;I �-
Goca"on sit.Plea)
Mat sill,Of oonstruction:-- ,vim ,, AJ
Depth of solids:
comments:(note condition of s4 suns of hydraulic&Durs, level of pondin&condition of vegetation,itc.)
Privy is not present
(revised 11/03/95)- g
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM
_ PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE L'_SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
Centerville Osterville Marstons Mills
Water Company
428-6691
rzewr
i
G /
DEPTH TO GROUNDWATER
y201 + depth to groundwater
r+pthod of determin on or a p matron
No werY2neouned. at, .,,wen• s s£em -was installed. ( 1971 )
Jy
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V
Jos �r
- sbj1f 3�71�
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Department's qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the
General Laws. Issued by The Department of Enviromnental Protection.
June 8. 1995
Acting Director of the �' -ion of Water Pollution Control
_ .. � •
No. ... Fps.. ........
. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF !-I ALTH
:.......-OF......A.... ... ---- -------•-----------••----------••-----------•--•-
Allp ira#ion for Disjuan1 Works Cfonstrur#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair (jel) an Individual Sewage Disposal
:.... -a--- • • ... .....--- - --------- ----- •• ----••... •----•--------••• •...---
O rkE"s; ------------------------ .. Address
Wl
v � -+
Inst lIer+ Address
Type of Building tc-`wn7 `�� Size Lot_.__1� ------Sq. feet
U
�.., Dwelling—No. of Bedrooms_________________ ..._.___.__..__..__..Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons....................... Showers ( ) — Cafeteria ( )
as Other fixtures ----------------------------•-
W Design Flow............................................gallons per person per day.. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.__---_-___gallons Length................Width................ Diameter.-_ _-._--_ Depth................ !
x Disposal Trench—No.................... Width.................... Total Length Total leachingarea....................s . ft.
Seepage Pit No..................... Diameter____________________ Depth below *nle .. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) —cam �t t,r
Percolation Test.Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to groundwater........................
---------•-
D Description of Soil...............ty �___............
x
�
U .............................................................. •....------•-•--•-•--•.......-----•-•-•------------•--•------••••-------•-------•-••--•---•-•-••-•--------------------•-----.............
---------------------------------------------------------------------------------------•-•--------------•-------------------------------------------------------•.�.� ----------
U Nature ofWReairs or Alterations—Answer when applicable..•___--___-�---_____.j�P.��._._.. �le�iL,......5. ._..
Agreement:
The undersigned agrees .to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 board of health.
Sipne ............................ sue
b 9-`-'•_ .y Date r'....
Application Approved BY. �- . ------------
.:.............•---- Q � D e-:7.7._
Application Disapproved for the following reasons:----•---------------•-•-----------•----------------------- ---•----------------•---............................
-•------------•----------------------•--...--•------•--------.....------....-----•--------•-••-------------•---------------•----••--------•--•-•---••••-------••-•-------•----••----•--................
Date
e
Permit No......................................................... IssuecL......................'...............................
=
Date
THE COMMONWEALTH OF MASSACHUSETTS 16e
BOARD OF HEALTH
.. .............O F........... ..........................
Trrtifirate of Tong hatirr
THISJITO CER IFY hat the Individual Sewage Disposal System constructed (� or Repairedby .------------------------------------------------------------------•--------------- ....................................................
Installer
�d7L at I S v l a ..�, .>- - -------•--------------•-----------•---••-----•--••
has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. ._..._ ................ dated---!Q_-.2.:7-_77..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector..=•-••----•-----------------------------------------------•-•------••-••----._•---
`, ���; �� ,r' ,: mow. •� � � �t►-� �
No......... .... Fss --"".................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H ALTH
•-----...f -----------.OF ... •
%• `,pfiration fur �ts�tits�� sxk� Cns�slrl�rtiun Pruttt
Application is hereby made for a Permit to Construct ( )` or Repair (AoO) an Individual Sewage Disposal
k Systems at
................ ... .....: .---- .....•-• ---••--- •---------------• ........................................................
oc�t�n-Address or Lot No.
_-•----------•--=-._.....-•---• gLA44.qz. y f9ztL...AbJ :
O r y Address
a ' ... :.. . .. .........5'&.6WA 1 ..::--•---•--••................................•---...
/Insta er "' Address
..
Type of Ruildin ��c4 44 3 Size Lot......... .......Sq. feet
U
�., Dwelling--No. of Bedrooms.____ ________________Expansion/—Attic ( ) Garbage Grinder ( )
_.. No. of persons _.___�P______________ Showers
a Other,—Type of Building ________ ______________ p _ ( ) — Cafeteria ( )
Otherfixtures .---=•------•----•----------------•-----------•---••-----.-.••-------------------••••--=:._...-.-•-•--•-••-••-•---•••••-•-•-•-•-•--••.....-......•---
WDesign�Flow__............____......... _:_:._gallons per person per day. 'Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity .:____gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. _______________ Width_._ _......... Total Length __--__.. ......... Total leaching area....................sq. ft.
Seepage Pit No. Diameter' ._:______________ Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( ) ,.-e -k
Percolal"ion Test Results' PerformedtTby------------------------ ---••- ------ . Date .
---_.-.
Test Pit No 1 ._.¢ minutes per inch Depth of Test Pit____________________ Depth to ground water........................
Gz, Test Pit;No 2 ,:_;:_......minutes.per,'nch -Depth of Test,;Pit................... Depth to ground water_....................
O
Descriptionof Soil -•-- ---- v i----------------------------•••--•-------------------------.....................
s ,
W ... .
u .__ _____ ______ _____ ________ _._._._ ._._____________. .__ ____ �__ __ ____-__
U Nature of Repairs or Alterati ns—Answer when ap�liCable 3C/la.L�._ nwa. .
/�> QQ ;` •• D, tk€---...•------ ------ -------- •------------•-----..-.•...--•---•._...-..•------.........
Agreement --..
' "The undersigned agrees`,-to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL L 5 of the„State Sanitary Code— The undersigned further agrees not to place the system in
t
operation until a Certificate of Compliance has been issued by the board of health.
Signed
a e .
lication Approved*B Y
PP PP E � ----------------------
A .e. j �tr�... -*fir,_.
z � ae ,
`Application Disapproved for.`tlollowang reasons_______________________
j
y
' Date .
+ ------ Issued_
Permit No.......-•--•----=. ,-------- ------------ --------- -------•-•----...-----•-- -----------
Date
THE CeMMONWEALT,H OF MASSACHUSETTS _
;"` 4 BOARD OF HEALTH
a %.F�rrftftratr of 111"i t�a�tr�e
TH 1S 0 C RT Y, Tl}&i!t)he Individual Sewage Disposal System constructed�( �or Repaired
,Y by �: .�.n �..........ddtt.��✓.... --------_-__- __-___----•------------------
_ ..
Installer
has been installed in accordance with the provisions of T r of The State,"Sa.nitary Code as described in the
application for Disposal Works Construction,,,T it No. „ .______________ da.ted___./�O^t : 7. +.__.____,-_-.
a.
THE ISSU NCE OF-THIS CER.Til'ICATE. SHALL NOT. BE CONSTRUE® AS A GUARANTEE THAT THE
STSTEVI WILL FUNCTION SATISFACTORY,.' v
w ..
DATE.......... .....................................-- -------------------. Inspector { js
1 THE COMMONWEALTH OF MASSACHUSETTS
BOARD" OF' HEALTH
(7) ........OF..... .. ...................................................
No._._X_�,.�_....... ��af° SFEE..1r.. ......
� = ;.
Permission is-.hereby granted;:_.1 .-4-._r.u^�- /1`'.��% .___ µ...
to Construct ( o Repair ( ). a Individual .Se age 'i'sp sal System
- �. 7 ---------------- •--------•-r_-•--
Street ?'.
as shown on the application for Disposal Works Construction Permit :o. :.__._ :__ Da t --eZ-_"Y.-
....................
_ ti �
...................
PATE........ {
h 7e 7 7 x Board o xgalt
t
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS fy 5d�•� -
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