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HomeMy WebLinkAbout0070 BRACKEN FERN ROAD - Health 70 Bracken Fern Road, Marstons Mills A:043--r-0070022 i i F i V `,21 2 COMMONWEALTH OF NIASSAC14USETTS EXECUTIVE OFFICE OF EwIRONMENTAL A -P IRS RECEIVED DEPARTNIEN*T OF EN-N'IRO'.NNIE\TAL PR CTI� 1997 13 �' TOM OFBARNST ONE 11'INTER STREET. BOSTON. At.A 02105 617-29:•':0t AB 6s HEALTH DEPT. W'ILLIAV F 1A•ELD AW- 07,) Par. J 00 jl, V L 2- 8 TRL•DY CO?a Governs • Sc;retan ARGEO PAUL CELLL•CCI DAVID B STRIJE Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A CERTIFICATION Property Address: � r ic:�v� �`e,Y�,, , �'�}E5©1.IS Address of Owner: Date of Inspection: `iZ2l�l {� j (If different) Name of Inspector. E� �o M I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) �1-��. Company Name:A t-g En P-I,P" 42.—/ Mailing Address: ]2 Q Telephone Number: f-15,a J 1:;- /4& CERTIFICATION STATEMENT I seai� than I have personal]\ inspected the sewage disposal syster.:at this address and that the information reported belov% is true. accurate and comolete as o;the time of tnspec,o-. The inspection was performed based on my training and exoenence to the proper function and maintenance of on•sne sev.age disposa systems. The system: Passes _ Conc-t.onai;% Passes Neec= Furthe• Eya!u n e Local Approving Authont\ _ F Inspector's Signature: Date: � 7 The Svs:e-n Insoecto, sha" submit a cope of this inspection report to the Approving Authority within them (30, days or completing this inspec-o-. If the system is a shared sN•stem o• has a design flow of 10,000 god or greater, the inspector and the system owner sna!i submit the repo^ to the a )propnate regional orrice of the Deparment o; Environmental Protection. The orig:na! should be sent to the system owner and copes sent to the buve% if applicable, and the approving authont) INSPECTION SUMMARY: Check A, B, C, Or D: Al SYSTEM PASSES: I have not found any 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. COMME-NTS: 61 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. 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. (r•.:••d 0�/.35/97) Page 1 of 10 DEO on the wona wine wen hrx uwww maomt state ma usroec _ r , 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM PART A + CERTIFICATION (continued) Property Address: Owner. Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continu-d _ Sewage backup or breakout or high static water lev observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven•distri tion box. The system wilt pass inspection if(with approval of the Board of Health;. Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled r replaced _ The system required pumping more than fo times a year due to broken or obstructed pipe(s). The system will pass tnspeaion if(with approval of the Board of ealth): broken pipets; are repla ec obstruction is*removed C) FURTHER EVALUATION IS REQUIRED BY THE BO RD OF HEALTH: Conditions exist which recuire further evaluat n by the Board of Health in order to determine if the system is failing to protect the public health, safery and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF EALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING Ih A MANNER WHICH WILL PROTECT THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prn\ is within 50 ° t of a surface water Cesspoo! or prn, rs +ithin 50 eet of a bordering vegetated wetland or a salt trsarsh. 2) SYSTEM WILL FAIL UNLESS THE BO RD OF HEALTH (AND PUBLIC WATER SUPPLIER, K APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The s•stem has a septic t nk.and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tnbutan• to a surface wa• r supply. The system has a septic ank and soil absorption system and the SAS is within a Zone I of a public water supniv well. The system has a septi tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a Sept tank and soil absorption system and the SAS is less char 100.fee.( but 50 feet or more from a private water supply elf, 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. thod used to determine distance (approximation not valid). 3) OTHER (revised 04,25/97) Yaq• 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address; Owner: Date of Inspection: DI SYSTEM FAILS: You must indicate either "1'es" or -No' as to each of the following• I have determined that the system violates one or more of the following failur criteria as defined in 310 CMR 15.303 The bans for this determination is identified below. The Board of Health should be co taxed to determine what will be necessar• to.correa the failure. Yes No Backup of sewage into facility or system component due to an verloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground r surface waters due to an overloaded or clogged SAS or cesspool. 5ta:ic hauid level in the distribution box above outlet rove due to in overloaded or clogged 54S or cesspool Licuid depth in cesspoo! is less than 6" below invert or ailable volume is less than 1/2 day fiov. Recurred pumping more than 4 times in the last year T due to clogged or obstructea pipe's . I'%urnDer o`times pumped _ An, port,on o-'the So!! Absorption Svsterr,, cesspool r privy is below the high groundwater eievatior, Any portion o'a cesspool or privy is within. 100 f t of a surface water supply or tributar to a surace Ovate, supply. r And portion of a cesspoo' or pri\,� is \-\&iir a Zo e I of a public we!l. An-, pc-tic- e a cesspoo! or pri,.N is within. 50 feet of a private water supply weU Any pon-on o-a cesspool or pri\,y is less tha 100 feet but greater than 50 feet from a private water supoiv well with no acceotabie Ovate, qualm analvsis. If the we has been analyzed to be acceptable. anach cope of well water analysis for colaorm bacteria volatile organic coinpou ds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate ether "Yes' or "No" as to each of the f Ilowing. The io!iow;r.g criteria app;\, to large systems in ddition to the criteria above: The syste^n serves a facility with a design flo et 10,000 gpd or greater (Large System; and the system is a significant threat to public heath and safety and the environmen because one or more of the foliowing conditions exist 'Yes No the system is within 400 feet o a surface drinking water supply the system is within 200 fee of a tributary to a surface drinking water supply the system is located in a itrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a public water supply well) The owner or operator of any such syste 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. (revised 041/:5/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Propert% Address:'.�U Owner: tkicaX9 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. 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 pan of this inspection _ As built plans have been ob;a:ned and examined. Note if they are not available with N/A. The fac:li-. or d%%elimg \%as inspected for signs o-sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. The site .%as inspected for signs of breakout. _ All s\sterr components, excludme the Soil Adsorption 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 bafiies or tees. materta� o• construction, dimensions, deptn of liquid, depth of sludge, depth of scum. The size and location of the So i' Absorption System on the site has been determined based on The facdi" ovine' ;ano occupants. if difteren: from ov.nen were provided with information on the proper maintenance of Sub-Surface Disposal System. _ Existing information. Ex. Plan at B.O.H. _ Determined to the field :r an% of the failure criteria reiated to Part C is at issue, approximation of distance is unaccea:able (15.302.31:b`? (revised 04/25/57i Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-St PART C SYSTEM INFORMATION Propem Address: 16 Pcw-t.to ^u—;, Owner:WnarQ - Date of Inspection: ` FLOW CONDITIONS RESIDENTIAL: Design fio),% ¢.p.d..rbedroo_rr, for S.A�S Number of bedrooms Number o:current residents Garbage g•. der (yes or no., 1J h Laundry co-•^ected to system (yes or no! Seasonal use Ives or no,.±�p Water meter readings. if available (last two i2 year usage tgpdf: _tZxz) Sump Pump (yes or not l L%Q� Las dare o;occupanc-, COMMERChkL'INDL'STRIAL• Type of establishmen: Design fio\% _gahonscia,. Grease trap present Ives or no_ Indusna' \%aste Holding Tani; Dresent -ves or no Non.sanita,� Haste d�scnargec to the T,t!e 5 system ,vet or no_ \%ater meter reading: if a%ailabie Las Fare o: o --;:a-C. OTHER: .De:cube Last ca:e or occu:;a-ic. GENERAL INFORMATION PUMPING RECORDS and source of tnformanor. . � fJ�-ec� � R�� t�3T' � •�- Systern pumped as par, of inspection: we5 or no If yes, vo,ume pumped ¢allons Reason for pumping TYPE OF SYSTEM Sepik tank'dis:nbution box:'soil absorption system Singe cesspool Overflow cesspool Prn). Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 'r Sewage odors detected when arriving at the site. (yes or not (revixed 04/25/91; D�9• S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAT10% (continued) Propert,t Address:o-64.p A�• Owner: �t'Cfa� Date of Inspection: `� BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other texplain! Distance from private water supply well or suction Ir-e Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK:-4ts (locate on site plan Depth beloN grade :11�41 material of construmo. Ilconcre;e me-,a _Fiberglass _Polyethylene _othertexplain If tank is metal, Its: age _ Is age cor.firmec b% Cel:fica:e of Compuance _(1'e&'No _ Dimensions ( UQ Sludge depth Disiance from top o: sludge to bosom of outie: tee or ba-";e -3LA Scum thickness b , 11 Distance from top of scum to top of outle: tee or bz�a �2 x Distance from bottom of scurn to bo-o^- ci outie: tee e- bane How dimensions Here determined Comments trecommendation for pumping. rondrtion o� inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structu integrity, evidence of leakage, e:c.t k)O t t � `RR i�..t e.` --� , � r-,.._ .,,ram � ' ' :� 1 ,`�•.: ":A/".�. GREASE TRAP: (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 baffle. Distance from bottom of scum to bottom of outlet tee or baffler 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.; (raviiad 0�/25.'9%) Page 6 of 10 ^ i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address:'�lf u �� Owner.Q-16- Date of Inspection:a TIGHT OR HOLDING TANK: 'lank must be pumped prior to, or at time, of inspection: (locate on site plan, Depth below grade Material of construction _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions. Capacm• gallons Desig^ floes galions-da. Alarm level Alarm in working order _ Yes. _ No Date of pre:sous pumping Comments (condition of inlet tee. condition o- a'a,m. and float switches. etc.) DISTRIBUTION BOX: (iocz;e on size p a- Deah of Iicu:d lee' aoo•.e rune: .me': qci. Comments tnote :f level and d:st•ib-,t-on Is e 'j evidence o1 solids cam ver, evide�rice of leakage int ,-or o of ox, etc.) �� A ®ice` : C :clQ�VNLI 91y t .t � `���1N C3Y �iC tCi��il�'c.�'.v� t�l� ;c,,� PUMP CHAMBER:_ (locate on site plan Pumps in working order: (Yes or No, Alarms in working order (lees or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properh Address: Owner: Date of Inspection: ?� SOIL ABSORPTION SYSTEM (SAS): ' (locate on site.plan, if possible, exca - � A not required, but may be approximated by non-intrusive methodst If not determined to be present, explain: Type: leaching pits, number._,,, leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, di^iensiors over;low cesspool, number Alternative system Name or Tecmr,oiog\ Comments. in a condition of soil. s!grs of hydraulic failure, leve' of pond,ng. condition f wegeta n, W.t CESSPOOLS: (locate on site plar Number and configura:.or• Depth-top of liquid to inlet rnver, Depth of solids laver Depth of scum laver. Dimensions of cesspool Materials of constructior Indication of groundwate- inflow (cesspool must oe pumpeC as par, of rnspecion 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.) (ravaged 04/25/97) Page a of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 7 �11Zti21� i' Property Adcress: Owner: . �\- Date of nspection:,n ,G� 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) li � U i , il (revise! 01125'S-) Page 9 o: 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertm Address: 70&ki kit3*Z—, Owner:*42T CA VF Date of Inspection: l I Depth to Groundwaterv5 Fee; Please indicate all the methods used to determine High Groundwater Elevation: Obtained irom Design Plans on record Observation of Site (Abutting property, obsenatjon hole, basement sump etc.) Determine it from local conditions Cnec:. %+dh Iota' Board o• ❑ea'1r Cheri FE.NAA Mam Check pumping records Check local eacavato,s irs;allers use LcCS Da--a r Desc%ibe in %ox o++". %%or05 \a- e::ab!-Shec the 6�ig� Groundwater Elevation. (Must be completed G cc` - U;S � ZO�C%�► CG�l c��:'�,: ( �dCG� A�C .�..t:�.•.,`z,�l�rj��,Gt'v~�i 1�.'rl-•EIS 1•.4 . (i. �o�Z (rev_sed 01;2519 Tags 10 of 10 1 ,440,vWN OF BARNSTABLE elNl 40/ LOCATION��� Aec%e., Afir/ SEWAGE # R-6>q7 VILLAGE fiy-A. H111 f ASSESSOR'S MAP & LOT® -O INSTALLER'S NAME & PHONE NO. `t-lZ G 77 L( SEPTIC TANK CAPACITY LEACHING FACILITY:(type) P 4 size NO. OF BEDROOMS ✓ PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER� I-z In,. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED."' ` VARIANCE GRANTED: Yes No r - 2� � �- Idea ---. � Lj �- 5-7 No....... Fxs..... THE COMMONWEALTH OF MASSACHUSETTS _� BOAR® Off' HEALTH ------......Lclwn..................OF.....7 arY.5+0.1s....................................................... Appliratiun for Uhipoii al Vorks Tomitrnrtiun Errant Application is hereby made for a Permit to Construct ()r, ) or Repair ( ) an Individual Sewage Disposal System at: . irlC°�t�it/ i✓ 79 M.: 4-:--.------- Location-Address or Lot No. �4sx1 4._._tam..c.J'XY!!............................. C1C�C7..... rz?...Rc .......__.......•.............._..._. ............................ ••-- Owner Address Q.Rq_� ............•------- .............. y,^ �s ��??.il/. .. Installer Address Type of Building Size Lot,.... ..--..Sq. feet Dwelling—No. of Bedrooms.........T7I_ --c.....................Expansion Attic (R/o) Garbage Grinder ((j/o) 04 Other—Type of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures ---------------------------••••. . W Design Flow................................... per person per day. Total daily flow-_____--..__._._....._.........- O..gallons. WSeptic Tank—Liquid*capacity.tMn.gallons Length_?:7�.(...... Width.4`:I `.�.... Diameter-_.__-__.-_.... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..._- ......... Diameter......ro._-...... Depth below inlet......A._-....... Total leaching area..... .0.?....sq. ft. Z Other Distribution box ()Q Dosing tank ( ) ''1, • '~ Percolation Test Results Performed .................................................. Date.... IV................. aTest Pit No. 1.....Z--------minutes per inch Depth of Test Pit.....4S._......... Depth to ground water________ ____________ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wat ----ISIF'-- 0 Description of Soil.....01.--Z.'.70-0P-_-dam---,S<L��Qi/..j.._Z'-E �_.yYllcc�uuxx!�.. ► .............. SffW+Ei�1 x W • -WILSON...... •---------------------------------•• . . • -•-••-•------- •--••---••--•••••-•-----•-•-•-------••---------------......••------•-----•-------•---••••----•--- o.30216 U e------------------------------------------------------------- N Nature of Repairs or Alterations—Answer when applicable ........ Agreement: A The undersigned agrees to install the aforedescribed Individual Sewage Disposal System ' c� with C-",W4- the provisions of TITLE 5 of the State Environmental 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. Signed // Z -------------------- ---------................ Dare Application Approved By .......... ... .................. -------lt-------- ------ .Dare Application Disapproved for the following reasons:,--------------------------- ------ --------- ------------------------ -------- --------------------------------- -- ---- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- Dare Permit No. .....gt-..6---V_7 Issued ------------------------------ ------- Dace r1 No....... Fim$...... ��......� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Appliration for Diipnsal Works Tomitrttr#inn Prrutit Application is hereby made for a Permit to Construct (K.) 'or Repair ( } an Individual Sewage Disposal System at: ............... .................... . - ---..•...... - . . ............... Location-Address or Lot No. ......................... sa1i:?............................ ............... tZ... <rr_..R-4......................................... Owner Address a ......... g?.s!� .d+^y�S'�. 6 ". a9,:1:::.�'---. .... ......... .....•-•------•----••-- ...e - _ .,ems: --•...............••--•-=r•'--._.. ter' ----._.............. ...._.....__.��-�fln'Tf.T�l !...�1_�. �....... . !A Installer � Address Type of Building Size Lot....--.___o._._23......Sq. feet Dwelling—No. of Bedrooms.........1&^x�-.r....................Expansion Attic (41o) Garbage Grinder (41o) Other—T e of Building ... No. of persons............................ Showers — Cafeteria QI Other fixtures -----•......-•••---•--------•---- - ---- W Design Flow....................................5= ..gallons per person per day. Total daily flow..............................._ --gallons. WSeptic Tank—Liquid capacity.l.�?d _..gallons Length .'-4...... Width.At-_�O.'... Diameter____-__._-..._. Depths�:�� x Disposal Trench—No. .................... Width.................... Total Length...............00,..... Total leaching area....................sq. ft. Seepage Pit No....gn4;�i-------- Diameter......I®........ Depth below inlet...... .... Total leaching area..... .2...sq. ft. Z Other Distribution box ()Q Dosing tank ( ) Percolation Test Results Performed by._-�.:_Imc-ob!.....................:...r._____......-__........ Date....5/Z` � ---------- Test. Test Pit No. I.....Z...__._minutes per inch Depth of Test Pit.... ?_._..__.__. Depth to ground wate .. .�_. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground w OF 04 ................................................1..`._............_......_..............__.._.........._.._._._....._ _ ......__ Description of Soil-•-•--0.na•� ! ' an? 5`,z�s� a 6�I�rt 9.�;cv!__SZrA Q ...STEPHEN x ACM -----•-----------------•-•-•......--------•--........._...•--•-••..........-•----•----••---•------•--------••--•-------------•---------••---••------•------- �q We-3Q21&�Q U Nature of Repairs or Alterations—Answer when applicable.............................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in cordance with �o•s/•P� the provisions of TITLE 5 of the State Environmental 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. Signed - - =" ` - ;�_------------------- --------------------------------------- �.�„�}�(k Date Application Approved By -- .,.' '"� t�-' -7 --------------------. ........//-=g?------ - Application Disapproved for the following reasons: ................................................................................................................................................................"----........................................... ----------------Date----------------- PermitNo. ------- -_-----_---_-------------- Issued ..------------- ---------------------..--.-.-.------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '' - OF -... ' .. r% , . ------------------------------------------- Certifirate of Q-11-Ompliance G�. THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by .. -C'----- 4e�- .T ' -------------- -------------------- ..... -------------------------. ....--- _ Installer - .. ... ......... .......................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....fj.j-(..rY'.%................ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......77 .... - --- -- L....-96.....................-------- - Inspectorc ............. ---y............ THE COMMONWEALTH-OF—MASSACHUSETTS BOARD OF "HEALTH No....F?- 6y7- FEE.��........ �nn� ilan fermi# � Permission is reby granted . :-...!�'??... :.__::? _'`:........ ...•- Q ?�%b'• ' -----•---------•--•..................•-•--. to Construct ( or Repair ( ) an Individual Sewage DisposaP"System at No.,.ar. 4 ......................................... ........................: ' ...... �r --- •--- Street as shown on the appli tion fo Disposal Works Construe ' n ermit No. i _�_ Dated..____... ..'.......................... L..'--- .� _... DATE_ .... - Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS _h. -S/G/l/ DA 7",Q /3737z'� SIpE de�4 /78. s.F Al Wra1L F3o77"n^- 4e---A s 79 x /.o 7a7 l�Esic•�/ = 5zy a.P. D. � oSEr> ,`. I err - ini Z iii.✓.'U� � a : 7 ,� . � OFF STEPHEN NICK ALLYN A. i`ter•y t __ 3 I 4 1 WILSON .�No.30216� N0.24048 -. t�/�;�� e?y. Tbwiryi�i Z"F� d ' i *G� GPM �st t/Ea yl�� /WO A/k Map. ' ' 1c�4'G[.c�✓ /,yy. 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