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HomeMy WebLinkAbout0130 CHUCKLES WAY - Health 130 CHUCKLES WAY, MARSTON MILLS A= 101 057.002 /o l COMMONWEALTH OF MASSACHUSETTS ^ 8 EXECUTIVE OFFICE OF ENVIRONMENTAL AFF� �p DEPARTMENT OF ENVIRONMENTAL PRO T1 �© t ONE WINTER STREET, BOSTON. MA 02108 617-292-550 S ;' N WILLIAM F.WELD OXE Govemor 4, ecretary ` -` ARGEO PAUL CELLUCCI Z B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A- CERTIFICATION ` Norman Sylvester ,O uC-21es: Wayt Property Addre;.;.- Marstons" a 02648 Address of Owner: Date-of Inspection: ? � 7 Mills ,' (If different) i�Vi Name of Inspector: it' ��inson Sr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: Wm E Robinson Septic Service Mailing Address: PO Box 1 089, Centervi 1 1 a* MA 02632 Telephone Numbers 508 j 775_8776 f CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate .. and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes' Needs Further Evaluation By the Local Approving Authority _ Fails V�/C Inspector's Signature: �V i /� Date: 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: -AI 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. COMMENTS: . III SYST M CONDITIONALLY PASSES: _ ne or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon ompletion of the replacement or repair, as approved by the Board of Health, will pass. Indicate es, 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.' (ravis 04/25/97) Papa 1 of 10 } DEP on the World Wide Web: http:Hwww.rnagnet.sMte.ma.us/dep >� Printed on Recycled Paper { SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) A1W�•yi ' J t •, 6 s Property Address: 130 Ch4ckles WA'y, Marstons Mills, MA 02648 Owner: Norman S'iVlvester Date of Inspection: B)S TEM CONDITIONALLY PASSES (continued) A. _ 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 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) FURTH R EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: onditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the ublic 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 50 feet of a bordering vegetated wetland or a salt marsh. 2) YSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT HE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND,THE NVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a-surfacewater supply or tributary to a surface water supply. _ 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 s. 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) THER • (revised 04/25/97) Page 2 of 10 " SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Ad ess: 130 Chuckles Way, Marstons Mills, MA Owner: *orman Sylvester Date of Inspection: 11/17/98 D] SY EM FAI You must indicate ei;!,er "Yes" or "No" as to each of the following: I ave determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis fo this determination is identified.below. The Board of Health should be contacted to determine what will be necessary to correct th failure. Yes No Backup of sewage 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 distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping mdre 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. P Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. Ej LA GE SYSTEM FAILS: You ust 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 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) The owner r 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. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 130 Chuckles Way, Marstons Mills , MA 02648- Owner: Norman Sylvester Date of Inspection: 11/17/98 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 part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of 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 (and 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)] (revised 04/25/97) Page 4 of 10 r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Ad es �30 Chuckles Way, Marstons Mills , MA 02648 Owner: 1`�o man S�lve st er Date of Inspection: 11� ' 7/98 FLOW CONDITIONS RESIDENTIAL: Design flow:.?L 0 p.d./bedroom for S.A.S. Number of bedrooms:3 Number of current residents: Garbage grinder (yes or no):A- o Laundry connected to system (yes or no) Seasonal use (yes or no): IL-O �' Water meter readings, if available (last two (2)year usage (gpd): 1998 (6 mos) 30 , 000 gal. Sump Pump (yes or no):LD 1997 50, 000 gal. 1996 4.6, 000 gal. Last date of occupancy: LZ Q� COM ERCIAUINDUSTRIAL: Type o'establishment: Design ow: gallons/day Grease t ap present: (yes or no)_ Industria Waste Holding Tank present: (yes or no)_ Non-sani ary waste discharged to the Title 5 system: (yes or no)_ Water m ter readings, if available: Last dat of occupancy: OTH : escribe) Last d to of occupancy: GENERAL INFORMATION PUMPING RECORD aid source of information: System pumped as part of inspection: (yes or no),�0 If yes, volume pumped: gallons Reason for pumping: TYPE OF.!1YSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: ,Zl "r —nl' d Sewage odors detected when arriving at the site: (yes or no) /t�(� (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 130 Ch`?ckles Way"; Mar•storis M, lls , MA 92648 Owner: Norman Sylvester bate of Inspection: 11/17/98 BUIL ING SEWER: (Locate n site plan) Depth low grade: Material f construction: _cast iron _40 PVC_other (explain) Distance rom private water supply well or suction line Diamete Comme ts: (condition,of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No) Dimensions: 4 x �� Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle: 1/ Il Scum thickness: J . Distance from top of scum to top of outlet tee or baffle: 3— , Distance from bottom of scum to bottom of outlet tee r baffle: "3 How dimensions were determined: 0 a 1� Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles depth liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) O -6 Al noh 7— GRE E TRAP: (locate on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensi ns: Scum t ickness: Distan from top of scum to top of outlet tee or baffle: Dista a from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Comme ts: (recomm ndation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, vidence of leakage, etc.) (revised 04/25/97) Page 6 of 10 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 130 Chuckles Way, Marstons Mills, MA 02648 Owner: Norman Sylvester Date of Inspection: 11/17/98 TI!GfOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (Iota on site plan) Depth low grade: Material of construction: _concrete _metal _Fiberglass _Polyethylene.—other(explain) Dimensi ns: Capacity gallons Design ow: gallons/day Alarm vel:_Alarm in working order_Yes; _ No Date f previous pumping: Com ents: (condi on of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_L— (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of olids carryover, evidence of leakage into or out of box, etc.) PUMP CH MBER:_ (locate on ite plan) Pumps in orking order: (Yes or No) Alarms in orking order (Yes or No) Comm.) c ition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1.30 Chuckles Way, Marstons Mills , MA 02648 Owner: Norman Sylvester Date of Inspection: 11/17/98 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 hydr ulic failure, level of ponding, condition of vegetatioffq�, etc.) v CESS OOLS: _ (locate on site plan) Number and configuration: Depth-to of liquid to inlet invert: Depth of solids layer: Depth of cum layer: Dimensio s of cesspool: Materials f construction: Indicatio of groundwater: inflow (cesspool must be pumped as part of inspection) Com nts: (not condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate o site plan) Materials of construction: Dimensions: Depth o solids• Comme ts: (note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Add sss: 130. Chuckles Way, Marstans Mills , 1v1A b2648 Owned iV 11 '17�98 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) (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:. 130 Chuckles Way, Marstons Mills , MA�02648 - Owner: Norman Sylvester,.,. Date of Inspection: 11/17/98 36 Depth to Groundwater )o� Feet Please indicate all the methods used to determine High Groundwater Elevation- Obtained from Design Plans on record (/ Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators,.installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) 7- (revised 04/2S/97) Page 10 of 10 TiOW11 OF BARNSTABLE LOCATION La aq, - f��' 1;/ SEWAGE # 90 VILLAGE M A(_S�00_S_ ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACH1140 FACII.ITY:(type) c co NO. OF BEDROOMS_rPRIVATE WELL OR PUBLIC: WATER' BUILDER OR OWNER. SACA�S , DATE PERMIT ISSUED: DATE COUPLIANC'E ISSUED VARIANCE GRANTED: Yes - No 34`5►1 L6+ C uC- k 6s WO No.. Fizz ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........1.0-W.4 ....................OF.... G>_..4,2T.to,aus-M............. ............... Appliration for Dispooul Works Tomitrurtion ramit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: ............... 1A A ....................... ...... . ............... .......m.m.................................`I"-- ...... .................................. A/fy:5/ L i Address or Lot No ...................61 L-......ocg--,' ,,,).6......(-0.......M.............. ........M..................15- V14_Z_A� Address ................................. ......................................... ............................................................................................... Installer Address Type of Building Size Lot................1 6��.Sq. feet U Dwelling—No. of Bedrooms.....................3............ _.Expansion Attic Garbage Grinder (Ali) 04 Other—Type of Building of persons........ ............. Showers Cafeteria 04 Other fixtures ..-........... ---------------_--- ----M...........M..................M----M-------------------------------------------------------- Design Flow........................55.............gallons per person per day. Total daily flow....................m........33®-..gallons. 04 Septic Tank—Liquid capacity.icM.gallons Length................ Width....._._.._..... Diameter__.__........... Depth.....__......... Disposal Trench—No..................... Width.........._____._... Total Length..__................ Total leaching area_.................sq. f t. Seepage Pit No..._.__ Diameter.__........ �._-_- Depth below inlet.._...4........ Total leaching area....Z.P!PL_sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Results Performed by......7b04ff._6R_..-1-..)JY_Q......1JJ ............ Date.... ........ Test Pit No. 1......7;n-n.minutes per inch Depth of Test Pit._J!� .O'_ Depth to ground water...... ......... 44 Test Pit No. 2................minutes per inch Depth of Test Pit..._................ Depth to ground water----___.............___. P4 .......I........M---------M....................M...........;��....---------..........M.............M.......M..................................................... 0 Description of Soil......................... ..................A-V t5t— �4 ­-- ------M.M.................................................................... U ......................................... .................... .............................MM...............................M.......................................................... W .........M----------------------- ....................M.M........................ .............M..........M-M..........M................................. �4 U Nature of Repairs or Alterations—Answer when applicable------------------------------------------M-M..........................M.................... ........................ ..............................M.............M................................................. ....................... ........................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the syste.m in operation until Certificate of Compliance has been issued by the board of health. Signed .... .................................. ......1� ------------11-11,-------- /Da-�V? ----- ------------l, --- ----------------------------------------------------------- - -------- Application Approved By ................1�..... -- Date Application Disapproved for the following reasons: ...................................................................................................................................... ................................................................................................................................................................................................................ ---------------------------------------- PermitNo. ----------/9: )-,-------6.21..............M--- Issued .............................-------------------------- Due j No... Fzcs......��.� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........J.0W174-----------------OF.....�-�.��.f'.. . 1 1:.4 . ................................... Applira tiou for Dispas al Works Toustrurtiun Vernfit Application is hereby made for a Permit to Construct ( ") or Repair ( ) an Individual Sewage Disposal System at: _ ................-....................t- 01j6V_ _S .............. ....... ' " - .......... f> ,,, Location Ad re s -i o Lo - o . Ow , j Address W -•-•---------•-- - =. - ----. . - ,�............................. ............ .:.-•-•-----=-�. Installer Address d Type of Building Size Lot...............1__...J..Sq. feet U Dwelling—No. of Bedrooms..............y__________ ...............Expansion Attic ( ) Garbage Grinder '4 Other—T e of BuildingLUGi f. ` t �No. of persons____________________________ Showers — Cafeteria P4 Other fixtures -------•------------------------ - W Design Flow.............................-5.__..,.._----gallons per person per day. Total daily flow................_________.___ %_..gallons. � Septic Tank—Liquid capacity_ .. allons Length................ Width................ Diameter................ Depth................ Disposal Trench—No_ ____________________ Width...... .__._.__..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------------I---- Diameter.................... Depth below inlet........ _.______ Total leaching area___2-p�__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b .____ . .... � t� ______ Date._.__"_ .� ?______.. Test Pit No. 1........4''-.minutes per inch Depth of Test Pit....1"" ...._'. Depth to ground water______'----"________. 44 Test Pit No. 2................minutes per inch Depth of Test Pit____.____-___r____-_ Depth to ground water........................ --------- .....................•----............................................................................................. O Description of Soil •L = -�-A���._'�'...__ �Ft�V x - - --------------•--------------•.....---....------------------------...__---------•- U -----•-------------••--••-•-----------......•--.......-•----••••----------------•----•-----...--•----•------_- W ......................................................................................................................................................................................................... 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the syst in operation until Certificate of Compliance has been issued _y the board of health. ✓ Z Signed ..................... . ..............----~-----` ---.....------------.................... ......... > e -- ------ Application ApprovedApproved By .................. -.-...............-....... ------ Application Disa roved or the o lob win reasons: ................................... ... ............................ ........... . ................................... PP f f g - - ------------ -- -------------------------------------- - -- --- ------ ----------- --- ------ -- --------------- ........................................................ ...................................-- Date PermitNo. ----------- / .. ...... .. .. . // Issued ................ ..........................---- .-- -------- C! •" �1----.._........ Dace THE COMMONWEALTH OF MASSACHUSETTS ,. BOARD OF HEALTH -------............ -------- -- . . . .........-- CTertifirate of Cgomylinure TH IS�TO.CERTIFY, That the Individual Sewage Disposal System constructed ( ,� ) or Repaired ( ) by ' � - ------------------------ ------ ------------------------------------- -- - ---------------------------------- Installer at Alt . .. , - ------------------------------ -- ---- ---- --- -----------.............-------- -- --................................... --- ----------------- has been installed in accordance with the provisions of TITLE 5 of)�4 e State Environmental Code as described in the application for Disposal Works Construction Permit No. ............/�----�-71--------- dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE . ... .... ............... ............ ............................ .............. Inspector ..---------...---..--............ ...........--..............------.---...................-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 7-0 we•4 ?_ �Into)`7i�I�� No...... �.:.. �/ FEE.__...& ........... i �a I . rk �Maa #r i n rrmi� Permission is hereby granted --------•- --•- ------- to Cons rust (W ) or Re air ) an Individual Sewage Disposal System at --------•----•------------•-------------------------------- Street as shown on the application for Disposal Works Construction Permit No---- ___________________ --------------------------------- ................ 7 �., � Board of Health DATE............... -...................................... 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