HomeMy WebLinkAbout0015 EVERGREEN DRIVE - Health s �
15 EVERGREEN DR.4 �
A= 103134 JVJOcrSZ�11
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TOWN OF BARNSTABLE
LOCATION �� ��—Cr��3 ��-- SEWAGE #
VILLA E RI� toM_c\ ASSESSOR'S MAP &LOT i!3 13
INSTALLER'S NAME&PHONE NO. 1
SEPTIC TANK CAPACITY (C 00��1
LEACHING FACILITY: (type) _ tom (size) d
NO.OF BEDROOMS
BUILDER OR OWNER rr�C'CAA7k1V�
PATE: ���C` 9_e COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility t i Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Ar Feet
Edge of Wetland and Leaching Facility(If any wetlands exist N I Feet
within 300 feet of leaching facility)
Furnished by lgs�&�
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R'-\-31
COMMONWEALTH OF MASSACHUSETTS �! ° �
EXECUTIVE OFFICE OF ENVIRONMENT / 'F Ry V�®
DEPARTMENT OF ENVIRONMENTAL CATION
ONE WINTER STREET, BOSTON MA 02108 (617) 29 1,,Q
A UG 98
I. TOWN OO�H RIV ABLE
WILLIAM F.WELD TRUDY CORE
Governor e�� Secretary
ARGEO PAUL CELLUCCI 6 �DAVID B. STRUHS
Lt. Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
T PART A
L® 1 — ( CERTIFICATION
Property Address �� �VCvL � .�t(v F�twt�S M11 Address of Owner:
Date of Inspection: (If different)
Name of Inspector:
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name:
Mailing Address: �.s-� . r,x a.��',�y K�,�Dr
Telephone Number:
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 Ev on the al Approving Authority
_ Fai
Inspector's Signature: _ Date: �Ct-s
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: J
A] 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:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
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 exftltration, or tank failure
is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 04/25/97) Page 1 of 10
V__� Pnntrd on Rrc,clyd Paper ._
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) .
Property Address:
Owner:
Date of Inspection:
B] SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health).
Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection
if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
• MANNER WI-DCH 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) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETER1vIINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
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 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 (appro)dmation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in/CM�R03. The basis for
this determination is identified below. The Board of Health should be contacted to determine what to correct the
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 more than 4 times in the last year NOT due to clged or obstructed pipe(s).
Number of times pumped _. y
Any portion of the Soil Absorption System. cesspool or privy i blow the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of ublic well.
Any portion of a cesspool or privy is within 50 fee[ of a private water supply well.
Any portion of a cesspool or privy is less than 100 eet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has een analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria. volatile organic compounds. monia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the foil ing:
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 or operator of any such sys m shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and700. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
_ l CHECKLIST
Property Address: �--
Owner:
Date of Inspection: 7
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
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, naterial 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 Pan C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
L FLOW CONDITIONS
RESIDENTIAL:
Design flow:' . p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):
Laundry connected to system (y s or no):
Seasonal use (yes or no):�
Water meter readings, if ava fable (last two (2) year usage (gpd): 1✓
Sump Pump (yes or no):
Last date of occupancy:�t. SLYJN—
COMMERC IAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present. (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
n
GE`'ERAL INT'ORMATION
PUMPV G RECORDS tso urce gf information:
System pumped as part of inspection: (yes or no) �
If yes, volume pumped: Gallons
Reason for pumping:
TYPE OF SYSTEM
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: �e l
Sewage odors detected when arriving at the site: (yes or no)
(revised 04125/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -�IL a It.1Y\
Owner: (k�-(+--T-<J -
Date of Inspection: -7130
BUILDING SEWER: `
(Locate on site plan) N U
Depth below grade:
Material of construction: _cast iron _40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan
01
Depth below grade: 2,
Material of construction: &oncreLe _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list are _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: (�y TG C-i 4
Sludge depth:_ t
Distant from top of`fudge to bottom of outlet tee or baffle: 9-% t'
Scum thickness:__ It �.
Distance from top of scum to top of outlet tee or baffle: % 43 (I
Distance from bottom of scum to bottom of outlet tee or affle:�
How dimensions were determined:
P
Comments:
(recommendation for pumpin . condition of inlet and outlet teas or baffles, depth of liquid level in relation to outlet invert, structural integrity
evidence f leakage. etc.) 1 e-Cq—
GREASE TRAP: &57
(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 baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert. structural integrity,
evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S
Owner: 0 1-(q,CVq,
Date of Inspection: 7T-7 c(
TIGHT OR HOLDING TANK:(Tank 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:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes. _ No
Date of previous pumping:
Comments:
(condition of inlet tee. condition of alarm and float switches. etc.)
)ISTRIBUTION BOX:_
(locate on site plan) ,• ,�+cd
Depth of liquid level above outlet invert: (d u�T
Comments:
!mif level and distribution i equal, evidence Hof soli(k carryover, evidence offt�akage into or out of box, c.)
IJ k \t a A c.s�Q� - t.ct►--. �� c- �C `�
N G) of E
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.)
(revised 04/25/97) P2ge 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner.�4
Date of Inspection: 7 ( `�co
SOIL ABSORPTION SYSJTE-'M (SAS):
(locate on site plan, if possible. excavation of required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number: lo+�
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note co ition of soil. signs hydraulic f 'lure, level of onding, condition f vegeta ion, etc.)
d
CESSPOOLS:
(locate on site pan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on sae plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) Page 8 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: Ay
Date of Inspection: '�30 6 C.
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)
1�
12
14
(revised 04/25197) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:%*-���VL-
Date of Inspection:
Depth to Groundwater-�20 Feet
t
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
n io s �, • ,'�
`A
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)
t
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4
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(revised 04/25/97) Page 10 o1 10
F,5,SESSOR'S MAP NO. (03 PARCEL I��
L C AYON SEWAGE PERMIT NO.
VILLAGE
Nn�(z VT,:U. Tr\
INSTALLER'S NAME a ADDRE °S
B U I L D E R OR OWNER
DATE PERMIT" ISSUED
DAT E COMPLIANCE ISSUED, �jjJJ
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ASSESSORS MAP NO:
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No................_....... FEB... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
- - .............OF.............. 1 ...
Applirati�an for Diipaial Workii Tanitrn.rtinn rami#
Application is hereby made for a Permit to Construct ('V) or Repair ( ) an Individual Sewage Disposal
y
s stun L� � 7 ��� �'vep����,v D2 /�i � � Af I GAS
....---•-•----- -------- ---------•-------................----...-- ....._----------
Location-Address or Lot No.
v e '6`7 UP�fCs 2� S i uC.L 4
j,, Owner Address
--.
........M� _ .!- �!................................ ...................................................---- ------------•------ --------....------
Installer Address 3 ®�
d Type of Building Size Lot_.__...__.f_____________Sq. feet
U Dwelling—No. of Bedrooms............. .............•__.....__.._...Expansion Attic Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a Other—Type g ---------------------------- P ( ) -- Cafeteria-( )
dOther fixtures -------------------------------•----•-------------------------•--•-•--•-----------._.._...-------•--•--•-•--..-•--• --•---
w Design Flow..............5.5_•--------------------gallons per person per day. Total daily flow............. -J__��' ............gallons.
9 Septic Tank—Liquid capacitN/ gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—l�?o..................... Width. f.------.-.--- Total Length........ ...........Total leaching area---__-_ -----------sq. ft.
Seepage Pit No------------/:______ Diameter........ -------- Depth below inlet... 1....... Total leaching area._.. ...sq. ft.
Z Other Distribution box � Dosing tank ( ) i4; ovQ PF
a Percolation Test Results Performed by..__ C CPo
-12...�.......�. Date.........._�.�....�.
Test Pit No. I..... '..._._minutes per inch Depth of Test Pit-------/ ......__ Depth to ground water.___...`......_--
f14 Test Pit No. 2................minutes per inch Depth of Test Pit...... ?1__._.. Depth to ground water........................
------•---------------------------•---•-------••--•-•-•--•-•-•-••-------•-............_......_...--•... ---------------------------------------------
..
O Description of Soil_______ __________ -
w
---------------------------------5.��.1�-- —._.. 1........................--- -------- r-�-�. -•� :�� ------
VNature 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 i i %L� ; of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of heal
Signed--Z d
to
Application Approved By............. -- ... --•---•-•••-.....---•••-••--------- l ._ �-
Date
Application Disapproved for the following reasons:-•-•----•-•----•...............•---••--••-------•--•--------•----•-------•------•------------------------
------------------------
----------------
..._............................................................................................................................
Date
PermitNo......................................................... Issued......................................
Date
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No.47.�i.. 7t.. Fss............._.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....... ............... .----......OF..........................------.......-- ...-------....---------------..............--
Appliration for Disputiai Works Tonstrnrtiun 1hrmit
Application is hereby made for a Permit to Construct ('t/) or Repair ( ) an Individual Sewage Disposal
System Ca-7 � ��L � '�� �!'"_...._. t1LSY�3 W I L.C.j
..................-........................................................................- •----•-------•--------------------------------............------------
1,I,/L A,,1,� L�cat�.o' d or Lot No.
................................................................................................. -•--.........__.........----•---.....................---.......------...._........................
rer Address
Installer Address
U Type of Building Size Lot___+ ...Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QI Other fixtures .................................
w Design Flow_______________��._......._....•...__gallons per person per day. Total daily flow..................3 _v.............gallons.
04 Septic Tank—Liquid*capacity__�Bllons Length................ Width................ Diameter................ Depth................
w Disposal Trench—NTo. .................... Widt _. ......_..__.._.. Total Length............_._.... Total leaching area.................... ft.
x //
Seepage Pit No-------------1_...... Diameter....... -__-__-____ Depth below inlet._...._(s?..._.. Total leaching area.�_..'�...sq. ft.
Z Other Distribution box ( ) Dosing tr,nk ( ) —7
~' Percolation Test Results Performed by....... K. .9 ./N _ __-�................. Date.._1__.................................
�.
aTest Pit No. 1.._ ..minutes per inch Depth of Test Pit.................l._ Depth to ground water-------_-----------
Test Pit No. 2................minutes per inch Depth of Test Pit.......1-2...... Depth to ground water___.•----.............
-•--•-•----•--------•--•-•--•-------•• •---•----...--•-•-------•----......•-•••----•---•••--•.•-•..............•----............-•-•-•--•-•-------••---...-
0 Description of Soil........................................................................................................................................................................
x
c.,
w
VNature 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 i I p 5 of the State Sanitary Code— The undersigned furti er agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
np
1C� Signed...................................................................................... ...._-----Z�........•_..._
Date �
Application Approved BY ----•••--= ...................................... ........... 84.
Date
Application Disapproved for the following reasons:-•-------------------------------------------------•---•------------------------•------•---•--••--•••-•-••----
Date
PermitNo....................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� ``�� ......:Z + �.1 4.X r..l ..............O F.
%Trrtifiratle of Tomplianrr
i I
L6 T p CERTIFY That the Individual Sewage Disposal System constructed or Repaired ( }
by .. ..... --------------•-------------- ------
Lo— .7 co (11{ Installer
at.-•--•-••---�•-•--------•-------------•----•--••-....... I..f
has been installed in accordance with the provisions of TILT E j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated..._--___.-__._..--___.........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT HE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector......................................................................................
r
3 THE COMMONWEALTH OF MASSACHUSETTS
tV BOARD OF HEALTH
pro :'7v5� �....................OF........ .i[' .1N.A...rs,�� •-----•---....
FEE........................
11ispogal Works Taantrnrtuan amit
1471�2LL --
Permission is hereby granted..-- �`�------A--- �•I��------••--•--------------•---•...........-----................--•-----
to Construct (V or Repair ( ) an Individual Sewage Dis osal System
atNo&P_!_------ ......LJ). 1 �:.-.��._........ 1 -_..►,�1. ................... _ ._ ..................................................
Street
as shown on the application for Disposal Works Construction Pugh . :'70--5••.... Da ed..... _�'��.................
1 ..............•...... =. ------....--------•--------------•---•----
`
DATE.. ...� 3 ..Z<Z------------------••-------
Board of Health
FORM 125b HOBBS & WARREN. INC.. PUBLISHERS