HomeMy WebLinkAbout0011 EMERALD LANE - Health 11 Emerald Lane (Marstons Mills)
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Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
5
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Carmen E. Shay
use the return
key. Name of Inspector
Shay Environmental Services
rab Company Name
P.O. Box 1576
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-294-7498 3080
Telephone Number License Number
B. Certification
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 the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of 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:
x❑ Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4/10/15
Inspector's Signature Date
The system inspector shall submit 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.
****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. IN!,
UY
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage is sal Ss e `'Page 1 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
1 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:
System consists of a 1000 gallon tank a dbox and a 6' deep leach pit with 2 feet of stone.
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.
Check the box for"yes", "no" or"not determined" (Y, N, ND) 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 failure 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.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out 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 pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 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 ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page_ 11 Emerald Lane
E Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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 from 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 fecal
coliform bacteria indicates absent 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:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ❑x Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ❑x Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ x❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ❑x Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ x❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ x❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ❑x 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. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent 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
and chain of custody must be attached to this form.]
❑ ❑x The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ❑x 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.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
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.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑x ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ❑x Were any of the system components pumped out in the previous two weeks?
❑x ❑ Has the system received normal flows in the previous two week period?
❑ 0 Have large volumes of water been introduced to the system recently or as part of
this inspection?
0 ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑x ❑ Was the facility or dwelling inspected for signs of sewage back up?
x❑ ❑ Was the site inspected for signs of break out?
❑x ❑ Were all system components, excluding the SAS, located on site?
❑x ❑ 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?
0 ❑ 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 (SAS) on the site has
been determined based on:
❑x ❑ Existing information. For example, a plan at the Board of Health.
0 ❑ 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(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
CityTTown State Zip Code Date of Inspection
D. System Information
Description:
Tank, Dbox and a 6' deep leach pit present.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 0 No
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes 0 No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
78,000-2013 72,000 2014
Sump pump? ❑ Yes 0 No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Current
Date
Other(describe below):
General Information
Pumping Records:
Source of information: Board of Health
Was system pumped as part of the inspection? 0 Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑x 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)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1977 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes x❑ No
Building Sewer(locate on site plan):
Depth below grade:
3
feet
Material of construction:
❑ cast iron ❑x 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 20
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
No evidence of leaks, plumbing properly vented.
Septic Tank(locate on site plan):
Depth below grade: Tank is 18 inches down.
feet
Material of construction:
❑x concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5' x 5' x 8'
Sludge depth:
3"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
23"
Scum thickness 1/2
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank in good condition. Inlet and Outlet Tee/Baffle in good condition.
Grease Trap (locate on site plan):
Depth below grade:
feet
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:
Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert D-box Present/found
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.):
One outlet to leach pit. Dbox in fair condition. No evidence of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑x leaching pits number: 6' diam x 6' deep
pit 2 stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Pit had 4 feet of effective depth available per stain line. No evidence of backup noted.
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
I
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
Indication of groundwater inflow ❑ Yes ❑ No
D. System Information (cont.)
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.):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
LOCATION SiEWASE PERMIT MO.
VILLAGE
I IN S JA LLERIS NAME IL ADDRESS
,!e;q AC'y�
RU11091t OR OWNER t
DATE PERMIT ISSUED
DAY E COMPLIANCE ISSUED
I
I i
�d�>�,� '+:•ems
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑x Check Slope
❑x Surface water
Check cellar
❑x Shallow wells
Estimated depth to high ground water: No GWI at 13 feet per soil logs
Please indicate all methods used to determine the high ground water elevation:
❑X Obtained from system design plans on record
If checked, date of design plan reviewed:
Date
Observed site (abutting hole within 150 feet of SAS
( 9 )
0 Checked with local Board of Health -explain:
TopoObtained records for the site and surrounding properties.
❑ Checked with local excavators, installers- (attach documentation)
❑X Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
available perc data at BOH
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Owner Title 5 Official Inspection Form
information is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
required for every
page. 11 Emerald Lane
Property Address
Carol Williamson
Owner's Name
Marstons Mills MA 02360 4-10-15
City/Town State Zip Code Date of Inspection
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
❑x Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
System Information—Estimated depth to high groundwater
❑x Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVE®i
V�
JUN 1.3 2001
TOWN OF
DEPT.
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 11 Emerald Lane
Marstons MIlls
Owner's Name: Paul Cannon
Owner's Address: same
Date of Inspection: O l
Name of Inspector: (please print) William E_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5 0 8) 7 7 5—8 7 7.6
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuantt to Sect' n 15.340 of Title 5(310 CMR 15.000). The system:
l/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: ,.�, - �,� Date: "a -o 1
The system inspector shall submit 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
Page 2 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address•11 Emerald Lane
Marstons MIlls
Owner: Cannon
Date of Inspection:d-X—,O
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys Passes:
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.
Co ments:
B. Sy tem Conditionally Passes:
e or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. a system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer y ,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The eptic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,a ibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A metal s pric tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating at the tank is less than 20 years old is available.
ND expl
O servation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval o Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND expla' .
Th s stem required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspectio if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
• Page 3 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
11 Emerald Lane
Property Address.•
P rh'
Marstons Mills
Owner: Cannon
Date of Inspection: --1— 0
C. rther Evaluation is 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 failin to protect public health,safety or the environment.
1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s tem 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 s 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
sur ace 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 from a
rivate 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
ailure criteria are triggered.A copy of the analysis must be attached to this form.
3. Ot er:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 111 Emerald Lane
ars ons Milis
Owner: Cannon
Date of Inspection:4*-J.-o
D. System Failure Criteria applicable to all systems:
You Awst indicate"yes"or"no"to each of the following for all inspections:
Yes o
_ Backup of sewage into facility or system component due to 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 %z 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.
_ 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 than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
(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. rge Systems:
To be onsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You in st indicate either"yes"or"no"to each of the following:
(The fo owing criteria apply to large systems in addition to the criteria above)
yes n
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
_ Y g
Zone II of a public water supply well
If you h e answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in ection D above the large system bas famed.The owner or operator of any Large system considered a
significa it 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: 11 Emerald Lane
Mars tons Mills
Owner: Cannon
Date of Inspection: of 7-- f'
Check if the following have been done You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
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)
1/ Was the facility or dwelling inspected for signs of sewage backup?
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(SAS)on the site has been determined based on:
Yes no
— Existing information.For example,a plan at the Board of Health.
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)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 11 Emerald Lane
Marstons Mills
Owner: Cannon
Date of Inspection: elf";—&
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): J Number of bedrooms(actual): 3
r
DESIGN flow based on 310 CMR 15.203 for example: 110 gpd x#of bedrooms): a
Number of current residents:
Does residence have a garbag grinder(yes or no):—
Is laundry on a separate sewage system(yes or no):.G-D [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no): k O
Water meter readings,if available(last 2 years usage(gpd)): 2000 47, 000 gal.
Sump pump(yes or no):I/ a 1999 76,000 gal.
Last date of occupancy: d-.2-al ,
CO MERCIAL/INDUSTRIAL
Type f establishment:
Desig flow(based on 310 CMR 15.203): gpd
Basis f design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industr al waste holding tank present(yes or no):_
Non-s nary waste discharged to the Title 5 system(yes or no):
Water eter readings,if available:
Last ate of occupancy/use:
OT R(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 SYSTEM
eptic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach 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
talled(if known)9d source of information:
69
Were sewage odors detected when arriving at the site(yes or no):/i e)
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: 11 Emerald Lane
Marstons Mills
Owner: Cannon
Date of Inspection:
B DING SEWER(locate on site plan)
Depth elow grade:
Materi is of construction:_cast iron _40 PVC_other(explain):
Dista a from private water supply well or suction line:
Co ents(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ locate on site fan
—( plan)
1
Depth below grade:---
Material of construction:_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) L� / % 0
Dimensions: Q- t
Sludge depth: 3— J I
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 1-2=
Distance from top of scum to top of outlet tee or baffle: ,
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: G ��` - T K 1-
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREAS RAP:_(locate on site plan)
Depth below ade:_
Material of co struction:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thicknes
Distance from t p of scum to top of outlet tee or baffle:
Distance from ttom of scum to bottom of outlet tee or baffle:
Date of last p ping:
Comments(on umping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to ou et invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Emerald Lane
Marstons Mills
Owner: Cannon
Date of Inspection:
TIG or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth b low grade:
Material of construction: concrete - metal fiberglass_polyethylene other(explain):
Dimensi ns:
Capacity gallons
Design ow: gallons/day
Alarm p esent(yes'or no):
Alarm 1 vel: Alarm in working order(yes or no):
Date of ast pumping:
Comm nts(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (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.):
8
` Page9ofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Emerald Lane
Marstons Mills
Owner: Cannon
Date of Inspection: ge-..-6
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type !
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,sighs of hydraulic failure, level of ponding,damp soil,condition of vegetation, f etc.): 6 )b c z
s 0 e4AI
CESSP OLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number nd configuration:
Depth—t p of liquid to inlet invert:
..Depth of olids layer:
Depth of s um layer:
Dimensio s of cesspool:
Materials f construction:
Indication f 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)
Material of construction:
Dimens' s:
Depth of olids:
Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Emerald Lane
Mars tons Mi Tls
Ca-
Owner: nnon
Date of Inspection:Lf,2-6 1
SKETCH OF SEWAGE DISPOSAL SYSTEM
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.
3 ro
i
J
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 11 Emerald Lane
Marstnns Mi 1 1
Owner: C_annnn
Date of Inspection: � —d 1
SITE EXAM
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:
O med 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:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
v i
You must des ibe h you established the h gh ground water ele t n
6 /-Akr 3Ze�7 t,9e d1�gq
s i
11 ��
T LOC A ION S.EWAG E PERMIT NO.
;,
VILLAGE
INSTA LLER'S NAME & ADDRESS
�+ �J1A✓-V 1'"0A- Ave
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED z/�,�'`'77
'a
a
,, as
}
39
a`a
............. -7� .1 ..
No.... ........ � F��....A9
THE COMMONWEALTH OF MASSACHUSETTS
' BOARD
/.il�.............OF.............................................................. ...........------------. 7�
J
Appliratinn -fur 43WV iial Works T. nstrnrtinn Vrrntit
Application is hereby made fora ermit to Co true ( or Repair ( ) an dividual Sew isposal
System at* ,
/.... --------------------------•-----
L.•' n- ress fr or Lot No.
..... .�.. ... ' L/ ---------------•--.........----
... ..... ......... Y"-......... . ----•---Ad- es- .........................................
Installer Address
e of Building Size Lot...
_ ----Sq. feet
Dwelling—No. of Bedrooms-----------_________________________________Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ---------------------------- No. of persons_.......................... Showers ( ) — Cafeteria ( )
p' Other fixtures --•------------------•-•---•-- -. . .
W Design Flow.............._............__..__........gallons per person per day. Total daily flow....._.._ ......................gallons.
WSeptic Tank—Liquid capaciX� _.gallons Length..... Width.......... Diameter------------.--- Depth----------------
x Disposal Trench—No. ............. ...... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter-------- ......... Depth below rule -_-_.____ __..._.. Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) �' y �v� y. z 2
aPercolation Test Results Performed by.......................................................................... Date----------------------------------
a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water......................
(� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
-----------------------________________________________________________•.• _ w 4 ___
Description of Soil-------: ...�..� . �� �� �y�l t�.. . --•--------- --
W
-----------------------
� _ - - --
UNature.of Repairs or Alterations—Answer when applicable.-.---------------------------------------------------------------------------------------------
---------- ---------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------.
Agreement
The undersigned agrees to install the aforedescribed In ivi al Se age Disposal System in accordance with
the provisions of Article NI of the State Sanitary o —T n e sigt d further agrees not to place the syste m
operation until a Certificate of Compliance has b n sued t b ar of health. 1;
ned
------- ---- ------------------
Date ,s
Application Approved By--- ---- - -- �� . ... . ----------- .... . -et/-" h--_
Date
Application Disapproved for the following reasons:................................................................................................................
----•----------------------•-----........----•-----------•----------•--...----------•--•-••-••------••--•.......--•••---•-----------.....-----------------------•-----------------......-••.------..-----
Date
PermitNo......................................................... Issued........................................................
Date
- - - ---------"-"----------------------------------------------
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
IM ^\c� C
DATA
i�
No. -, Fic$............................_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......... OF................................... _..........................................
Appliratiun -fear ]]Wp a ial Works Tonfitrurtinn Vrruift
Application is hereby*made for a Permit to Construct ( I-)or Repair ( ) an Individual Sewage,,,Disposal
System at:
Location•Address / / or Lot Nof.
• - ,11--- -- -
,/ owner f / Address
/:'f' l l" �t...c� e
•..................... ..•--•--••-•••--------•-.....--•
/ Installer Addres
Ts
feet t....d Type of Building Size Lo
U y g _ _ feet
., Dwelling—No. of Bedrooms---------------__----_-__-•--__.-___---___-Expansion Attic ( ) Garbage Grinder ( )
I Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures -------------------------- -
Design Flow...---------•--•� gallons.
W g gallons per person per day. Total daily flow___________________-_ g�
WSeptic "hank—Liquid capacity---..__'---gallons Length---------------- Width--------.------- Diameter-----........... Depth----------------
x Disposal Trench—No. .................... Width-------------------- TotalLength.................... Total leaching area...............-----sq. ft.
Seepage Pit No..................... Diameter.................... 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...--.--.----------.---.
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_._-.-..-_.----____---.
W ----------------------- -- •-----•-•---••-•--•..............................................................................................................
ODescription of Soil----------------------------------------------------------- = -..... t --`-..-+-r=_-y- '-
U ---------.:.--- ......-----------------------•-------------------------••-......------------------.-----------------------------------
W
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 systemrin
operation until a Certificate of Compliance has been issued by the board of health.
Signed
...It.----17. ------
Date
Application Approved B i " = .::. --------i--•------- / ' _.2 1 - 7
PP PP Y•-------•-------------------------•--••....
Date
Application Disapproved for the following reasons--------------------------------=-----------------------•------------------------..........••-•••--•-•--•---••...
-------------------------------------------------------------------------------------------------------•.•----•---•-------•--------•---••--•------••-•---•---------•-----•••••--------------•-------•---
Date
PermitNo---------------- ..................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS LTC BOARD,�OF HEALTH �'-
..........................................OF......... . ...,..................................................................
Trrtifirate of 01him;iliatirr -
THIS IS TO CERTIFY, That the:Individual Sewage Disposal System constructed ( v)or-Repaired ( )
Installers
-
4/1
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
7_
application for Disposal Works Construction Permit No./ .�...._.. �_��__._ ------ dated---------Z_.____..-t
------------
THE ISSUANCE OF THIS CERTIFICATE SHALL-NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL,)FNCTION SATISFACTORY.
---------•--•-- Inspector...
'
DATE. ��
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ... . of.....JV4 ............ ........ ......--------------..........----......---... ............................No. . . •-----•
FEE-r1-�- --........
�>���trnrtinat ��rrmit
Permission is hereby granted----------------=-------------------- --------- - =-'- --------------------------..
r ------
to Construct ( L)�o,;ll,epair ( )man Individual Sage DisposaljSystem /f9
at No. f Y"t-t '. "� ` /vr
r-----------------------------------------------------------------------•-- ----------------- ...................................................
Street
as shown on the application for Disposal Works Construction Permit NO.-----.................. Dated. f _"2J' 7l
................................... Boa' -rd/,of/s..-r.lth
......................
DATE...............................................................
r Hea
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