HomeMy WebLinkAbout0189 AUDREYS LANE - Health —A A A._ew%ffl .•••.. --
189 AUDREYS'LANE;MARSTON MILLS
� ti
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
' A DEPARTMENT OF ENVIRONMENTAL PROTECT,ION
ONE WINTER STREET. BOSTON. NA 02108 61 7.292•550 '
RECEIVED
WILLIA\I F.WELD' .J
Govemo: ' c J U L 4 1999:TRU CORE
S cretar
ARGEO PAUL CELLUCCI
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTI TO1rYst TMp�Avl UHS
ON FO issioner
PART A
4 ,4 CERTIFICATION £ ti
Property Address: 1 !I U`^v�
Address of Owner:
Orate of Inspection: 7 - (If different) q/W-e
Name of Inspector:
II am a DEP approv sy tem ins ec r pursue t to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: 'a s�
Mailing Address: d_
Telephone Number: _a
CERTIFICATION.STATEMENT
' I certifythat 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
-I maintenance of on-site sewage disposal systems. The system: ,
passes.
._ Conditionally Passes
Needs Further aluation By the Local Approving Authority —
Fa
IlkInspector's Signature: Dater
The System Inspecto all 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:
AI, SYSTEM PASSES: ;
/ 1 have not found any information which indicates that the system violates any of the failure criteria as defined in 3 0 CMR 15.303.
Any fai crite is not evaluated are i4cated below.
COMMENTS: C t t
.04
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 ND). Describe basis of determination in all instances. If"not determined", explain why not.r-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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:l/www.magnetstate.ma.ustdep
0 Printed on Recycied Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i
PART A -
1
CERTIFICATION (continued)
Property Address:
Owner:
r .Date of Inspection:
Bj SYSTEM CONDITIONALLY PASSES(continued)
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). Describe observations:
broken pipe(s) are replaced s
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
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 HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within SO feet of a bordering vegetated wetland or a salt marsh.
2); . SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
:ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
i tributary to a surface water supply. 1 . % .
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
(revi,mod 04/25/97) Page 2,o[ 10
• 4;
' t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
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.
y. Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
_ e 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.
i liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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 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.
Any portion of a cesspool or privy,is.within alone 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.
i
E) LARGE SYSTEM FAILS: i
You must indicate either "Yes" or "No" as 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 (Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No t
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'll 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 further information.
(raviaod 04/25/97) Page 3 of 10
r - -
''f' i.. 'i•ir 1,}�r.'4 of .
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a' PART B.
r;. r, i';• ''..1, CHECKLIST
":`
Property Address:
. P Y
Owner:
,�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 th(owner)occupant, or Board of Health.
f/ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow,rates during that period. 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 industrialwaste flow.
The site was inspected for signs of breakout.
All system components, excluding 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:
The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface.Disposal System.
Existing information. Ex: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) (15.302(3)(b))
i
(revised 04/35/97) Page 4-of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
j SYSTEM INFORMATION
Property Address:
Owner:
Date of,inspection:
REStD_ ENTIA FLOW CONDITIONS
Design flow:_41,3d s.p,d./bedroom for S.A.S.
Number'of bedrooms:
Number of current residents:
` Garbage grinder(yes or no):_ j)
Laundry connected to system (yes or no):
Seasonal use (yes or no):ko 7—
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump(yes or no):—\a
- Last date of occupancy:.-- ccu ,c
COMMERCIA �trunt)cTQ�A�.
Type of establishment:
Design flow:_gallons/day
..Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no) '
Non4anitaay waste discharged to the Title 5 system: (yes or no)
Water,meter readings, if available: —
--------------
Last;late of occupancy:
OTHER. (Describe)
Lust date of occupancy:
GENERAL INFORMATION
PUMPING !RECORDS and source of information:
System pumped as part of,inspection: (yes or no)
If yes. volume pumped: _,____gallons
Reason for pumping
TYPE.O STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared iystem (yes or no) (if yes, attach previous inspection records, if'any) ;
VA Technology etc, Copy of up to date contract?
Other
APPROXIMA AGE of all components, date installed (if known) and source of information: I
Se age odors detected when arriving at the site: (yes or no);
(s toed 04 2 .7
/ !/! )
• Page 5 of 10
i
5. .. .A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
',:.. PART C
SYSTEM INFORMATION (continued)
Property Address:,,-".., "
Owner:
Date of Inspection:
BUILDING SEWER:
(locate on site plan)
Depth below grade:
Material of construction: _cast iron ✓40 PVC_other(explain)
Distance from private water supply well or suction lint. r q , v S vc-, W e-
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
.s
SEPTIC TANK: --=
(locate on site.plan)
Depth below grader.
Material of construction: oncrete _metal _Fiberglass _Polyethylene _other(explain)
i if tank!is metal, list age_ Is age confirmed by Certificate of Compliance ._(Yes/No)
Dimensions: -0X
Sludge depth: Lis
:Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: �•
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet to or baffle:
How dimensions were determined: a .rc�`� �k q.;�C �g pG
.Comments: i
(recommendation for pumping, conditio of inlet and outlet t or baffles, d pth of liquid level in relation to outlet invert structural
integrity, evicl nce of eakage, etc) v- �
1 ,
GREASE TRAP: Iq Pik Yi
(locate on site plan)
Depth below grade:
Material of construction: _,concrete —metal _Fiberglass _Polyethylene —other(explain)
;Dimensions:
Scum thickness:
Distance.from top of scum to top of outlet tee or baffler
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:'
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 0.4/35/97) Pago B'of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
�'. PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection: .
TIGHT OR HOLDING TANK:_ L<_-(lank must be pumped prior to,or at time, of inspection)
(locate on site plan) ,
J
Depth below grade:
Material of construction: _concrete_metal Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order Yes; No
Date of previous.pumping: _
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on'site plan)
"Depth of liquid level above outlet invert:____,_,.
Comments:
(note if level and tstribution is `u\, evidence of soli s carryover,eviden of leaks a i`nt�o 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:`
(notecondition of pump'chamber, condition of pumps and appurtenances, etc.)
Irevisod 04/25/97) Tags 7 of AC
rt "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r e PART C
SYSTEM INFORMATION (continued)
Property Address,
Owner:
Date of Inspection:.
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain-
Type:,!
leaching pits, number:
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 h raulic failure, level of pondi �o dition of vegetation, etc.)
L+2r)
CESSPOOLS: 1/1 b�
(locate on site plan) V t
Number and configuration:
Depth-top of liquid to inlet invert:.
Depth of solids layer;
Depth of scum layer;
Dimensions of cesspool:
Materials of construction: F
Indication of groundwater:
inflow (cesspool must be.pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIM
! (locale on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments: .
tnote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8, of 10
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address-
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
•
o,
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(revised 04/35/971 Page 9 of 10
a
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
\. PART C
. SYSTEM INFORMATION (continued)
.Property Address:
Owner
Date of Intpectioni
Depth to Groundwater feet
Please indicate all the methods used to determine High Groundwater Elevation:
Ohtained from Design Plans on record
Ob ervation of Site r s (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
i/ Check with.local Board of health
CheckIFEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
.Describe in your own words hcw you established the High Groundwater Elevation. Must be completed)
l
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0
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(revised 04/25/97), Page 30 of 10
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ASSESSOR'S MAP NO. PARCEL 0 S
LOCATION SEWAGE PERMIT NO.
INSTALLER'S NAME i ADDRESS
B U I L D R 0R OWN[It
0
DATE PERMIT ISSUED --5�
DAT E COMPLIANCE ISSUED
Q �-
� A
� �,
� �
i
� - �j w � �_
` � �°� �-
s v 6-
� �
��
IT6S�Ts--,r 3-7
<I "7 Fps .........
THE COMMONWEALTH OF MASSACHUSETTS
_ BOAR® Off' HEALTH
I-.. .w_A.................OF.... .q..r...n.s.- - .�a..l- .....
Appliratiun for Iligpniial Works Tuntratrtiun 1hrutit
Application is hereby made for a Permit to Construct (e<) or Repair ( ) an Individual Sewage Disposal
System at:
s
............. ... .... .5: �c.----- �! �ls..
Locat1 n-tTd;res or Lot o.
e------------------------------- -•---...-•----------...••-----•----................---................------------.... ----...
Owne ...
a ............. .. .........................................
P s�� .. ddress C
nstal ` Address
U Type of Building Size Lot---ZJ 75?7�Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------•-•-----------------------•-•-•-------•••--------------
W Design Flow......................... ......gallons per person per da . Total daily flow-;_-•:_.:...._....`33. ........gallons,
WSeptic Tank—Liquid capacityl"Doallons Length�__:......... Width_V..:,42_. Diameter________________ Depth_.7 -T._.
x Disposal Trench—No..................... Width........._...... Total Length................�. Total leaching area....................sq. ft.
Seepage Pit No......./ L_.--_____-- Diameter.� ..-__�.-... Depth below inlet..Y�___.je..... Totaf leaching area..Z-BOsq. ft.
Z Other Distribution box ( k) Dosin tank 7. 5786
Percolation Test Results Performed by ____W-O.;
� 4i
Test Pit No. I......7......minutes per inch Depth of Test Pit.... epth to ground water.-
Test Pit No. 2......4.....minutes per inch Depth of Test Pit.... Zo..a- Depth to ground water-----
Oa #� Q "; T-F•P--s.0_J.........sM 1�.?A.1............... -----------#g;--------------------------
Description of Soil....----- - L6.........C7.ra.e!+,(---. -'�F-U!t-d---•---------------'��a t ---------•----
....... .
-----------------"--------------------------------------------------.Nn------ ........0 1 g'r9..c..V_W..&I...- •. - ---------
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 TL 1 5 of the State Sanitary CO.d — The undersi u tl:er agrees not to place the system in
operation until a Certificate of Compliance as been u d by the rd of h h.
S d ------ R 71 ....
..-
Date
Application Approved B
PP PP Y ..... :..... ......�.-- ............
Date
Application Disapproved for the following reasons----------------•---------------•----•------------------•------=...............................................
•--------•••-••---------------------•----...-•----•------•-•--------••-•--------•------•-•-•---•-•-------••---•--•---•-•------•---••--------•-•--•--•-•--------•---•-•---------••-•---•----•••-------•-
Date
Permit No.-------... . .......... Issued.......................................................
Date
No---- 4'%... ! Fims. �...........
THE COMMONWEALTH OF MASSACHUSETTS
"'"�� BOAR
D Off' HEALJT- H
1..1�1 1..y!..................OF.......�.e_-7 r 4--�•••4-" k✓._'•
Applira#ion for Uiipusal Works Tumitrurtion Vautit
Application is hereby made for a Permit to Construct (sC) or Repair ( ) an Individual Sewage. Disposal
System at:
t .41-7 _4
.... ....._...-•.........._... .. .� .............. ....................... .......................................................................
--------•---------•------•._..........-••-
Locatyi�t-Address or Lot No.
.............. ......... �F__= `�' .................................. .................................................................................................
Owner Address
........................................... --...._..........__........_........_..............-----....--•----•--••••-•-•••----•.._....----•-
Installer Address
Type of Building Size Lot.... -3,__i'___��Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
G" Other fixtures ------ ----------------------------•--------------------------------------------------------•--------•---•-----------•------------------....---------
d
W Design Flow......................... ...gallons per person per day. Total daily flow__.__......_._...__- �'___C _._.___gallons.
WSeptic Tank—Liquid'capacity_`'09_C*allons Length e.._....._. Width-��t__U_�biameter________________ Depth_ 7_'__7_�
x Disposal Trench—No. .................... Width_.._.._...._._._.. Total Length.................... Total leaching area........__....._....sq. ft.
Seepage Pit No------- ........... Diameter./Z--___a..._. Depth below inlet-.`K.. ...�..... Total leaching area.......-.� sq. ft.
Z Other Distribution box ( ) Dosing$ tank ) 7 -7eF6
'-' Percolation Test Results Performed byc.4 f. /s�•`��</f Su{��� Date-zA!,t`n<.._
14 Test Pit No. I...... _.._.minutes per inch Depth of Test Pit....... to ground water.._. l%r✓. :._�_-
(i, Test Pit No. 2__..._. _....minutes per inch Depth of Test Pit-___f.��'_ Depth to ground water.....
---•--.... r -••--
D Description of Soil G G-.__..... .Y y";P---•----------------='G.....b v...................................................
er
W /!fu e��r!_+r.N�r�r-c. . �-F,c_ v_a. 7L�•r cr-------------------------
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 TIT �:
p 5 of the State Sanitary Cod —The undersi u ther agrees not to place the system in
operation until a Certificate of Compliance as been u d by the rd f h h.
i
......... .......I ........ .............. ....7/ -,5,..............
r,.�- -• at
f.
Application Approved By........ `_ -------------------------�-_.>_...... .. ......... ......=���
Date
Application Disapproved for the following reasons:................................................................................................................
-----•----------------------••---...--------•--------------•-•-----•---.......-------------•--------...--••--•---•••-•••-•••-----•-------•----•-••-------------•--------•••---••-•--•-•••-•----....--•--
Date
PermitNo........ ••• :- ......... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....................... .. ..��1
... ..................................................
(InfifirFa#r of ToutpliFatta
THIS IS TO CERTIFY T�}' the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..............................
........._•--•• ••..._• __ .. ►!'' .. .....-•------•-----------------•---------....----------------------------------------------------------•----_..._
nstaller
at-_------------•-•--_-- 1- 7----•- r � �.,-. rf� --_----------------•------------------------•--------------------------------
has been installed in accordance with'tfie provisions of TI T IE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No._7��_":_.5=3_�__-------- dated........... I ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCT SATISFACTORY.
f
DATE.................... �------••�---•••--•--••-_.. Inspector - :------------•------•-•----....---......--•-•---------•-------___..
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF HEALTH
c - r—-.
No....:............ct`��. FEE.= ....
Disposal Vorkv Tullnutrnrtalan jJamit
Permission is hereby granted. ---------•-----•....j-I.
---.............. ---==•';./1=, L�
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System -
atNo............ •n•-••- Z i _(_ ���=�_:_. f'�_...l =ry- --•------.-----------------------------------------------------------------------------------------------
Street
as shown on the application for Disposal Works Construction Permit No ::"��/.. Dated_.____ . ..�-►_��i................
---
Z�DATE.... -------••-•---•---------f1•�-----........................................ Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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