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HomeMy WebLinkAbout0022 SPICE LANE - Health �2 Spice`Laie J 65-107 Ostervill f COMMONWEALTH OF MASSACHUSETTS to EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION r V TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: ZZ S,o r Owner's Name: - .as t ,aeh Owner's Address: fJc �rvi/li "MR Date of Inspection: 7.- :2 o/_ o y Name of Inspector: please print Yokn Company Name: Mailing Address: a l!/ b, Sy' ) t yar ins h1l"lli M�7 N _ Telephone Number: 509-'`12 0.7779 .._ LS CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the info ation 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 maintenanceof 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7-.Z(O 41 The system inspector shall mit 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 P Pg Page 2 of 11 OFFICIAL INSPECTION FORM—N41'C)`T OR VOI UNTARY ASSESSM M,S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , ; ' PART'A CERTIFICATION(continued) Property Address: 0:2 S ice ,�,,V_e Owner: ¢Sf ♦N Date of Inspection: 7- —O Inspection Summary: Check A,B,C,D or E/ALWAYS complete`ala'ot$e�11o�.i� A. System Passes: ✓V&T I have not found any information which indicates_that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. . Answer yes,no or not determined(Y,N,ND)in the 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 faihae 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. ND.explain: Observation of sewage backup or breakout 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 pi*s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more thatt 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 obstruction is removed ND explain: 2 Page 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A; : CERTIFICATION(continued) Property Address: .2 2 S,pi ce Zan z r v: i ryf f7 Owner: w n 8s'f / Date of Inspection: 7—26-01y 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 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 froni 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: i 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT,FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM:INSPECTION FORM>.- PART A CERTIFI CATION.(cmtinued) Property Address: -S,o.�e Os trvi /lo /a Owner: 116 ho t A" Date of Inspection: — m-D y 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 ti 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 ''/2 day flow !/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. v 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 thait'S0'feeCfromaprivate water supply well with no acceptable water quality analysis. (This system passes if.theA"N water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this foray.) lUd (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 facility with a design flow of.10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the miteria above) 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. 4 Page 5 of 11 OFFICIAL INSPECTION'FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Pr v� IY17 Owner: okilyst fp04 Date of Inspection: 7— 26—0'y Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health V Were any of the system components pumped out in the previous two weeks? ✓ _: Has the system received normal flows in the previous two week period? t✓ 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? 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 jSAS)on the site has been determined based on: Yes no tl _ Existing information.For example,a plan at the Board of Health. (P _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] f 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOROIIJNTAIY ASSESSMEA"�'S , SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM. PART.C SYSTEM FORMATION Property Address: ;2Z S ice 4ov,,- _ Owner: .do�;M-es wa Ph Date of Inspection: 7—?6-041 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):. Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: I IO gpd x It-of bedrooms): 30 Number of current residents:_ , Does residence have a garbage grinder(yes or no):,Vv Is laundry on a separate sewage system(yes or no):,j/a [if yes separate inspection required] Laundry system inspected(yes or no) Seasonal use: (yes or no):kL Water meter readings, if available(last 2 years usage(gpd)): *of a e",.1-e -k,a f, -�. sQvvinkli�r Sump Pump(Yes or no): No I Last date of occupancy: occ a ,.cd COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): �d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):'_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION + Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM i/Septic tank, ' be*•,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attat:h'a copy of the current operation.and maintenance contract(to be obtained from system owner) ) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1,7 Were sewage odors detected when arriving at the site(yes or no): /1O 6 Page 7 of I 1 OFFICIAL INSPECTION.FORM,—NOT•FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL';SYSTEM INSPECTION FORM PART C : SYSTEM INFORMATION(continued) Property Address: �c� H Owner: r.,:tsf th Date of Inspection: Oki BUILDING SEWER(locate on site plan) Depth below grade: " Materials of construction:_cast iron 4ZPVC other(explain): _ Distance from private water supply well or line: :,,r ,' , Comments(on condition of joints,ventimg,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: W.Material of construction: concrete_metal_fiberglass_polyethylene M —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: �- Sludge depth: 2�' Distance from top of sludge to bottom of outlet tee or baffle: 29 Scum thickness: Or" Distance from top of scum to top of outlet tee.,or baffle: 6 Distance from bottom of scum to bottom of outlet tee or baffle: 13" How were dimensions determined:-4Q,s a r►K a rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): `tCGN? k 5ae�±ArS .YA GREASE TRAP:_(locate on site plan). Depth belowgrade: Material of construction: 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:. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 x� OFFICIAL INSPECTION FORM—NOT' _OR.F VQLUNTARY_ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM: SYSTEM INFORMATION(continued) Property Address: 22 1C-z Owner r,,es7R �H Date of Inspection: 7-2G=U4t' TIGHT or HOLDING TANK: (tank must be pumped at time of utapeq.Wn)(idtatc om site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no):• Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:Ncn (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc. . o Page 9 of I I OFF_ ICIAL.INSPECTION,FORM.--.NOT.,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 2:2 5 ,�'4 �an Owner: f 'f *, Date of Inspection: —g 6—o If SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explainwhy::. y . Type ✓' leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: irtnovatMAlternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): /040 oc,� ��acl, .�i�f �Q.s y�'• �,cui� �.vv1 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 or no): ' 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.):. 9 Page 10 of 11 t1., ''r:.: OFFICIAL INSPECTION�.ORM W-FORVOLVn- AY-ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL'SY4'£EM iNSPECTION FORM ' • SYSTEM INFORMATION(continued) Property Address: c e tan 4 v , Owner: n/(f W '" Date ofInspectlon: SKETCH OF SEWAGE DISPOSAL'SYSTEM.F 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. .,..„.. -37 i 27 29' y 3f' 17 /3 Q /��� TD tBYIr RS+•� G _ 10, ,r Page 11 of 11 , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SZWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 lc* n-e Owner. Date of Inspection: SITE EXAM a Slope Surface water Check cellar Shallow wells ` Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation.hole:within 150 feet,of SAS) ✓ Checked with local Board of Health-explain: .QSSttfSelS ,faun a1 doll Checked.with local excavators,installers—(attach documentation) Accessed USGS database-explain: Maps r, 11o4/fl,. srf: You must describe how you established the high ground water elevation: - hor of cW,%' y- i T{ Uh �� Oh/ G y /.' ,. .. iZ t ut 9' ru s� _o , I1 , rMA.TERBEDROOM IS'-0° CL _ —_ CL 1000 GALLON CESSPOOL - 1000 GALLON SEPTIC TANK _ — — r �. — .' — — CL � � � a Bathroom waste feed - Y - CL . Kitchen and laundry waste feed _ CL - CL 27, 2° 1 ENTRY 29'-0° 1 i CL t LIVING ROOM � 0 t CL xdx. xasn nun uexFxa oo« BEDROOM 02 DINING ROOM CL 0. o KITCHEN NEW FAMILY ROOM CL 22'-9°X14'-2° \ UP °E _ xw I ❑a anm I I xa.nrte I _ _ EXISTING �,_a Hpn x�aaMri ENTRY Te x 7a1 NEW ATTIC 22 SPICE LANE OSTERVILLE,MA -axaeemxnw ooe - (Light walls are existing) (Light walls are planned addition over ge) TOWN OF BARNSTABLE LOCATION S Se'c4 L#,4 SEWAGE':#, VILLAGE 0$-Mt-V 1-P ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /d00 LEACHING FACILITY: (type) (size) 6 �� NO.OF BEDROOMS BUILDER OR OWNER Avnesf PERMITDATE:2 COMPLIANCE DATE:,2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 9� q 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .Tetin IV. 144It, 0y 04 Nail 17 24 6" yz' 3S' 27' 3 o c �.Ip t45-t°1 No.---.. a- - Fux..,0?.-..•-.Q-.- ..... THE COMMONWEALTH OF MASSACHUSETTS 7 BOARD OF HEALTH ............ / D LC/........OF....... �`'2 +- �C.�......... .................... Appliratinn -for 13itipwial Workii Tnnitrnrtinn Vrrmit Application is hereby made for a Permit to Construct or Repair ( }"an Individual Sewage Disposal System at: X ..f ic�_...L `� ------.... GSrEir�«c ------•--•------••-•--------•--•-.......--•-- Loca ion-Addr;ss or Lot No. f/ �zQ�. ...: �C °$7�.�c/GG� O ner Address Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms___�...................:................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons...........,---------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures - d w Design Flow........... .fie.......................gallons per person per day. Total daily flow__--,0,0_......._____•_------------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..10,06 '�'-#'�iatl�leAr................... Depth below inlet.................... Total 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 Test Pit.................... Depth to ground water.-.----..-----.--..--.-. f1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth, to ground water--.- .._-.-_-.__-_---- a' ---------------------------•------------.._......-----••-••---------•--•---._.....-----•--------•---......................................................... 0 Description of Soil.........................:-------------------------------------------------------------------- U ......................................L .4 �ZZ--------4ea/ ...... 44t...........avl �e 44v.. ----------------------------------.......------------. w ----------------------------•----_ . .. l� _.... --..__..... 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 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 y oard alth. Signed- � ---- ---------- ----- Date Application Approved B © A = '�:L S =Lj.h19_ ....D..d�•._RE(r�vLQ ------...4---- -/.?---7:j---- Date Application Disapproved for the following reasons----------------•--------.....-------------------------------------------------------------------------------•--• ---------------------------------------------------------------------------------------------------------.•-------••---••--•-------••---------------------------•----•--------•------•----•----•--•--••-- 11 Date / Permit No.-------1 ........... Issued......6---- 4 Dace �J No.•••5�Q.Al••--• FEiz............................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......._ ...,�4.,GI...+ ....--......OF....... � r . r °. ......:.................... AVVliration -for BitiVmal Workfi Tottotrurtiott Prruid Application is hereby made for a Permit to Construct (7<) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or Lot No. I Owner t Address Installer Address UType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms__-,.....................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ________________________-- No. of persons....___-_,.__----_-_.-----.- Showers ( ) — Cafeteria ( ) dOther fixtures --------------- ------------------------------------------------------------------------------------------------------------------------------------ W Design Flow.............'.(r----______:-__-.-_-_.--gallons per person per day. Total daily.flow___.34i_ ...........................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.. ' , ! . Ifbia4et ____________________ Depth below inlet_____________-_-___. Total 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 "lest Pit.................... Depth to ground water.-.-_--.._-__-.-----_--- Gtq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.-.--____---__-_-..._. --------.--•-------- --------- -----------------------•-----•---------•--------------------------------------------•------------------------------------- ODescription of Soil--------------------------------------------------------------------------------------------------------==-•---------•. ----------------------------------------- V -------------------------------------•--- ------------ ------------------------------------------------------------------------------------------------------------------- W •---••----------------------------- e f--------- --••-•---•-•-- 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 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�yoardpf.health. Signed =` """ ' --•- ---•-•-------------•------ Date Application Approved B ` ! ' h'&0je't - 7y {' �_ - " � ' Mz' Date Application Disapproved for the following reasons----------------•------------------------------•---.--.-.------•------- -•-••--•-----•----------------------•---- •..................•••..........-•-------••-•----------------•-••-----------•-------•--•--•--•••••--••-••-----•--•--•----••------••----------------•-----------------------------•----..._------ •••••- Date Permit No------- - - -- ................................... Issued.........------z----- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........................... .. . .. .....O F........ . ... .. ..... .. .. ... ........................................ Q'Irrtif iratr of QW.1,11mplionrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) f' ,p' 8�/ r�r Installer reg le fa lee 5� at ------ ----- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as .described in the , - application for Disposal Works Construction Permit No.___-_._� �':...................... dated......r THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector------------------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ... .......OF........................... .. ..' No. �� ------. FEE........................ Dispoottl Workii Tomitrurtion ramit Permission is hereby granted = , "! w Via' --------------------------------------------------------•-----•---•---•. to Construct ( ) or Repair ( ) an Individual Sewage Disposal System . . ---------------------------------------------- Street as shown on the application for Disposal Works Construction Permit No.._ ___... Dated__ _:-:`_ _"_ --- -------------------------------------------------------------------------------------------------------- Board of Health DATE...................................................................••-••-•-•---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS --