HomeMy WebLinkAbout0087 FOXGLOVE ROAD - Health 8 ' Foxglove Road
Marstons Mills
, A= 149- 130-010
I�
i
COMMONWEALTH OF
1VtAssAcxusErrs
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
lop DEPARTMENT OF
ENVIRONMENTAL PROTECTION
OAp q'9
PARCEL )b 010
TITLE s LOB` ;,...�
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address; X�rlG�iG IQc
Owner's Nance: �/i h C a,.� b y
G,��
Owner's Address: o,,e ,,� RECEIVED
GGN ✓y► ni ��.}
=.te of Inspeca
APR 2 12004
Name of Inspector. (please rant) Ve o
Company Name; ,E f/,0 _ EGI4 TOWN OF BARNSTABLE
Mailing Address: N5-
p HEALTH DEPT.
Telephone Number; V— e
CkE'RTIFICATION STATEMENT
i cetOy that I Live persomliy inspected the sewage disposal
below is true,actuate and complete as of tlnr time of the at this addr 1 and that the inormation reported
traini�g p W"function and mspectron.The inspection was based experience in the mai�rtenanoe of on site sews di �� on mry►
approved system inspector pursuant to ;ec�,,�5.340 0l Tltle S 310 spy ems.I am a DEP
���Sr---• ( CMR 1�.000I. The system. .
passes
Conditionally passes
Needs
Fails Further Evaluation by the Local Approving Authority
Inspector's Signature:
Date:
The system inspector shall subaut cepv of this inspection
DEP)vWhin 30 days of completing this inspection.If the system is a Approvingrt to the "' '(Board of�tb or
gpd or&oar,the inspector and the system owner shall submit the report to the or hia a design flow a IQ000
DEP.The original shouid be sent to the system owner and copies sent to the buyer rL•gional office of the
authority. applicibte,and the approving
Notes and Comments
'*"This report only describes conditions at the time of'
time'This spection and under the inspection does not address how the system will perform,rm in the future ditiOns of use at that
ender thesame or different
conditions of use.
f
- . Page 2 of I1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL
L SYSTEM. INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address 6:-A W
Owner:
� �
Date of Inspection: 3 _ o
Inspection Summary: Check AAC,D or E/ALWAyy Complete aQofSecHoa D
A. S
I have not found any information which indicAes that any of the failure t bcda dtnbed in 310 CUR
15.303 or in 310 CMR 13.304 exist Any failurecriteria not evahWed are indicated below
Comments
B. System Condidonally Passes;
Zone or more system components as described in the"Conditional
wP�d.'the system,upon completion of the replacement Passe by section need to be d or
repair,as approved the Board of Health,will PmAnswer .
yes,no Of not detcrmined(Y,iN,I M)in the for the followiexplain , ng statements:If"not deteanrine�ply
IU septic
is Metal and am
CA&'hs�sabstaWd mfiltration20 years Old*or or exfiltration o �sepil tank(whether metal m not)is sEnrcduany
g tank is replaced with a complying septic tank or tank System will Pass inspection if the
'`��l�c tank will P�inspection if it is strucpually sound,�l he Boats aI'Health.
indig that the tank is less than 20 years old is awaftim �°°g and a Certificate of Compliance
ND explain.
Observation of sewage backup or break out or high static water level in the distribution bolt due to h or
obstnrcted pipes)or due to a broken,settled or uneven dstn'bution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distnbation box is leveled or replaced
ND explain:
The
P� System Mpov of tPuMWghe Board doof H�a year due to broken or obstructed IuPe(s) The system will
broken pipe(s)are replaced
obstruction is removed
ND explain:
h
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
TCERTIFICATION(continued)
Property Address: t"O�COvt; fZ�l
Owner. a
Date of Inspection:_ 7-- .,p 11
y
Rvaleation is Required by tht Board of Health:
Candk
is failingg to PO ns p blw�require�eval � Boats of Hearth is order to determine if the system
1. System will pass unless Board of Heahth determines in accordance with 310 G71Ht 1 system is not fu tMning in a manner which w01 protect public health,safety and�e�ro moment the
— Cesspool or Privy is within 50 fed of a surface water
_ C.empool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Z System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is fmwdoning in a manner that protects the public health,safety,and environment:
— The System surface water has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
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 mpply 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 wager supply wells'*.Method used to determine distance
**This system passes if the well water
bacteria and volatile organic ''performed at i�EP certified laborataryr,for coliform
the presence Ofa mumnia nitro indicndes that the well is use from pollution fT0m
chat hdk and
failum criteria are triggered,A copy of nitrogen be equal att�to less of�provided the no other
3. Other:
r
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM S
PART A
CERTIMCATION(continued)
Property Address; �d� /OG.e.
Owner, w ��- 3�
Date et Inspection: _ 3
A System Faiiare Criteria applicable to all systems:
You must indicate W or` e to each of the following for&juspectionx
Yes No
-- i/"• Imp of into facility or system component cite to overloaded
Or Clogged,SAS or cesspool
�1oSged SAS tO surface of the ground Of SutFace watersan overiaad€ or
i/ Static liquid level in the lion box above outlet invert
z"Cesspooldue to as overloaded or clogged SAS or
=qiddeTth in cesspool isPoulpin IEss tnes
6"belowinvert&ro"Twlable volume is Iessday now
ZoftimesPumpedg more than4 in the last year due to clogged or obstructed
ld per()Number
_ �portion of the SAS,cesspool or privy is below hi
gh v �P01don°t l or Privy is within 100 �d elevation.
a,�may feet of a surface water sue,or tabutaiy to a surface
— /��°Y portiam of a cesspool Portion of a or prh7 is within a Zone 1 of a public well.
Z AM Portion of a of p is within 50 feet of a private water SW*well.
supply well with� less than 100 feet but greatm than 50 feet from a private water
Performed at a DEP certified laboratory,for rm acteria a M*Systemnd o as"It the well waxer analysis,
indkafea that the well Is tree t3mm pollution from that f rg�compounds
nitrogen and nitrate nitrogen is equal or less than 3 and the presence of ammonia
are triggered A copy of the analysis must be PpD1'Provided that no other failure criteria
�' attached to this form.]
(Yes/No)The system la-4 I have determined that one or more
described in 310 CUR 15.303,therefore the of above failure criteria exist as
Health to determine what will bem .The owner should contact the Board of
necessary to correct the fair
E. Large Systems:
To be considered a large system the stem must serve a f
gpd. �' aciliity with a design flow at 10,000
You must indicate either`eyes"or"no"to each of the following: gpd to 15,000
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface&inking water supply
the system is within 200 feet of a tributary to a surface&*king water supply
the system is located in a��S tive area(Intenin
Zone H of a public water Wellhead Protection Area—IWPA)or a mapped
If You have answered"yes"to as�squestion in ystem has Simon E the t>ur�or
"yes"in Section D above the far &fed �' is considered a Significant �,�
si owner or opezatorof ally large115p cant t Under Section E or failed under Section D shall upgrade the �m Considered a
System owner slrould contact the appropriate system m accordance with 310 CIMR
regional office of the Departma,
Page s of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
Q �-- CHECKLIST
Property Address:.
owner.1 r`i' SOIL
'�
Wade of lnspretion: —a.1_o
Check if the fiftwMIX have been dom You mast indicate es"or"no"as to each of the followin
Yes o
— _ plunnins
b&1rm3d0a was provided by the owner,oaf,or Board of Heafth
eneany of the systm c0Uqoae2ts pumped out in the p+evious two weeps
Wskm received normal flows in the pevw"two week perm#
Have WF voinnres of water been introduced to the system recently or as part of this inspection
Were as built pig of the system obtained and c a abed?(If they were not available we as N/A)
Was the facility or dwelling inspected far sign of sewage,bad up
Was the site inspected for signs of break out
' Wim all system componem%=10ding the located
/_ Were the �' on site
of took �°°° o and the n>teria�of the tank inspected for the condition
teed material of construction,dimensions,depth of liquid;depth of sJudge and depth of scum
mice of sewage disp(=uPauftif&ftvM from owner)provided with information on the proper
The she and locative of the SoR Absorpd w System(SAS)on the site has been determined lased on;
Yes no
information For ewe,a plan at the Board of Haft
Determined in the field(if any of the failure criteria related to Part C is at issue approximation���
rs u ptable)(310 C MR 13.302(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
-:5z p�G 3�--
Owner.
Date of lnspecdM.
RFMZNTIAL FLOW CONDITIONS
Number otbedrooms(design). Number of bodmoms
SIGN sow based on 310 t� (for
for ( )�
DE
Number otaureot residents: "am0w 110 gpcl x#of bedroonwp
Does residence have a garbage girder(yes or no): /16"o
L-Undlysysteln (yes at no):sy (yes or no) [dyesSeP=ft hqnction mquireQ
Seasonal use:(yes of no).
Water metes readinA if&8&de(at 2 years usage(a*).
SumPPump(yea orno}
Last date atoccnp mcy: �er•,c,�-
COMMERCLUANDUSTRIAL
Type of establishment:
Design flow(basedon 310 Clv R 15.203} _ .Wd
Basis of design sow(seaWpers0nWsg0,etc,):
Grease tMP present(yes osno)r_
IndosbW waste holding tank present(yes or noy —
Non-sanitary waste discharged to the Title 5 system(yes or no):—
Water meterread a ifavailable: .
Last date of occapancy/oser
OTHER(describe):
-------------
PumPmg Records GENERAL RMATIO
Source ofiwarm�; Jed-000 Po/� Qo he
Was system Pumped as p the inspection(yes no):
H yes,volume pumped: gallons—How was quantity Pumped
Reason for pumping:
TYPE OF SYSTEM
—Septic twk won box,soil absorption system
ovefflow cesspool
—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if my)
Immalive/AobtarnedW wner)technology Attach a cogry of the cmient operation and maintenance WMW(to be
--Try tank _Attach a COPY of the DEP app maj
—Other(describe):
� = of aH components,date (if oun of informatio
pa 0
Were sewage odors detected when arriving at the site(yes or no): /t4
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM FORMATION(contj=4
Property Address; o OZ �lov� aj
Owner:
Daft of Inspection: 1- O
BUXDING SEWER(locale on
site plan)
D%M below grade: 3011
Materials ironc/
Distance private r a* well or .other( )•
Comments(on condition of join Vcnt*g evidence of
SEPTIC TANTZ_(lie site plan)
Depth below grade:�v2 fMataial of constutwtion: W.
�
other( —' --°��--SO4,0thylene
If tank is meta `i 1 ae age:_ Ts conimud by a Ce<tidc
certificate), ate of compli�0e(yes Of no):—(attach a copy of
ShwpdlepdL
Distance from
S toP to bottom of metlet tee or baffle- 30
13lsfauoe front top of scum to top of outlet tee or baffle-
Distance from bottom of scarce to bottom of oft�eC or bade: 1l
How were moons determined: o/r FFCC //
co -4 ve c
(Q° 6 moms,inlet and aetlet tee or
as mlated 1Iet imveet,evidence of ledge,��J b�condition, ,,limd levels
GREASE TgAp.—J 1oc a on site plan)
Depth below grade:o —
Material f wnstructiom
( ): —concrete metal—fi _polyethylene_.ote,
Dimeosior�s:
scam ems:
Distance from top scrim to tc�of outlet tee or befits:
l�staace�m bottom of scum to bottom of outlet tee os baffle:
Date of last pumping
Conanab(on outlet tee or p
as ig recommendations;inlet and baffle condition,
�evidence of leakage etc.): iWeg ',liquid levels
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(condor ed)
Property Address: pp( �,`o
4✓yr '!` c2
Owner. c
Date of Iaspeqam. /--
TIGHT or HOLDING TANK; f'l/(lark mnst be pumped at time of kVwfi.Xlft on site
Pam)
Dpth below grade
Material of coon;—concrewmetal fiberg>a"._P* ,lene
lAmienstow
.Pity: ..++,�
Design Flow:
l.AhmpmFut�ar nor
A1a®leve
Date of last pumping Alarm in wmjti,og order(yes or no):
Commeata(condition alarm aad Sant switches,etc); .
DISTRIBUTION BOM
`..(if peasant must be opened)ftae on site plea)
ncp*0f lfmud kvel abo re outlet mvftt ✓t tpikl.%�j
Comte(note if box is level and Amon outtft evidence of solids lealmp into or out of box,etar can7'over,any evidence of
PuW L'HAMBER: (locate on site plan)
Pumps in working cWw(yes or no):
Alarms in wwoddng order(yes of no):
Commeft(,ft ocean of pump chamber,condition of pumps and app rteaanc,etc.):
f
Page 9 of 11
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DI
SPOSAL SYST
EM INSPECTION FORM
PART C
SYSTEM INFORMATION(cond=4
Property Address:
Owner.
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS nut located explain why.
� pit%number:kw mimbw.
l (,✓ . /
s Puy►mmnber:
leaching tnmd* ,lath:
8 fields,nunber,dinmeasions:
overflow cesspool,mmmbw.
system Typelhame of technoloi r:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,
� // 5� ' / etatio
: itatioyC n
CESSPOOLS:,�cwwWol must be pumped as part of mspKtcQ)locate on sift Plan)
Number and c:on6guratioc
Depth-top of NpU to inlet invert:
Depth of solids layer:
Depth of scam layer:
Dimensions of cesspool
Materials of comtrocd=
won of groundwater ktftw(yes or no):
Comte(note condition of soil,signs of hydraulic faihue,level of pon&g,condition of ve
getation,etc.):
PAY: on
pocate she per)
Materials of comtrnctiom
Dimensions:
Depth of solids:
Comments( condition of soil,signs of hy*anlic failure,level of
londmg,condebion of vegetation,etc.);
PaW 10 of 11
. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Aaaress� g12 / (0C /0pc
owner. Da CS.L
Diteofm
SKETCS OF SEWAGE DISPOSAL SYSTEM
Prow&a dortch of the sewage disposal system inc uftg ties to at least two pemn mw*reference Imubadcs or
benchmadm.Locate an wells wid&100 fWL Locate where public water supply eaters the buWm&
21 - �s
�- 31 /
Page 11of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Q� SYSTEM INFORMATION(contimuxl)
Pmperty Address: U l fioa
�• r v► � /h U a.6 J�
Owner:�G
Date of Inspedlon;
SM EXAM
Slope
Surface water
C *cellar
Shallow wells � CJ. Y
Estimated depth to pound water 7{ed
Please in&8tc(check)all methods used to deteome the high E;mund water devatiun:
Obtained from'system dedi p phum on mold-If cheeped,data of deli
site(fig PAY/observation hole w"ISO feet of )
P 'viewed:
with kcal Board of Health oplain; V"j
TV Chocked with kcal excavators,installers-(attach docnmeotauon)
Accessed USES database-explak;
You mast ow You established the hip, d wager dev
aa5
1 0 0 0 �
U
( L
13- 1,
� J1
COMMONWEALTH OF MASSACHUSETTS
i EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
j DEPARTMENT OF ENVIRONMENTAL PROTECTION ,
4+
Ala`t. r .r
r
{ jjj
TITLE 5 p. {
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM }Igw,w
PART A � '
z <<i, CERTIFICATION � �
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632rL14
Owner's Name: JOHANNA JOHNSON/ROBERTA JOHNSON
Owner's Address: 7 LINCOLN FARM RD.FALMOUTH MAINE 04105
Date of Inspection: 11/6/00
Name of Inspector:(please print) JOHN GRACI A IV O(/ 29
Company Name: SEPTIC INSPECTIONS �000
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 ,, In r 4E
Telephone Number: 508-564-6813 FAX 508-564-7270 'W i
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 pursuant to Section 11�,340 of Title 5(310 CMR 15.000). The system:
t��e
' �*
�s;Y 4 ' $
X Passest 7 i` ,� .
_ Conditionally Passes A
Needs Furt Evaluation by the Local Approving Authority z '
_ Fails i.
Inspector's Signature: ,a Date: 11/6/00
The system inspector shall submi 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,
and the, authority.
sent to the system owner and copies sent to the buyer,if applicable, i �`_,
{ t:
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO TWO r
YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. }1:
j ****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
it h
Tlth 5 lncnPrtinn Fnrm (,/15/,)nn l'W 1
IPage2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM �
4 `
I PART A
CERTIFICATION(continued) r.
Property Address: 87 FOXGLOVERD CENTERVILLE,MA 02632 L14
( Owner: JOHANNA JOHNSON/ROBERTA JOHNSON
Date of Inspection: 11/6/00 3 ' }
inspection Summary: Check A B C D or E/ALWAYS complete all of Section D
zr ta:
A. System Passes: 1 N�
§ 4 y4M
X 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. :'
j Comments:
t
' THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM EVERY ONE TO TWO
i YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. f. r
B. System Conditionally Passes: Rn
One or more system componentskas described in the Conditional Pass section need to be replaced or repaired.The system,
upon completion of the replacementior ,repair,as approved by the Board of Health will pass.
Answer yes,no or not determined(Y,N;ND)in the for the following statements.If"not determined"please explain.
n/a 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 Lank failure is imminent. System will ass inspection if the existing .1.
Y p p sting tank is replaced� �r
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. }rr} '
ND explain: n/a r9Fi ;t;
w
n/a 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
_ obstruction is.removed f=4
_ distribution box is leveled or replaced
:f
ND explain: n/a
n/a The system required um in j,more than 4 times a year due to broken or obstructedpipe(s).The s stem will pass
r�,r
Y 9 P P gt,c Y Y P
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removedUt
ND explain: n/a
a A r?�
X'
7
f
Page 3 of 11 , {.. •,..
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` `
PART A `
CERTIFICATION(continued)
j Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14 r , ;
Owner: JOHANNA JOHNSON/ROBERTA JOHNSON
Date of Inspection: 11/6/00
i j y. xY
C. Further Evaluation is Required,by the Board of Health: 4##`,,•� ,�
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 thelenvironment. .
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 t��t"
i A
;i. is yi�E
2. System will fail unless the Board of Health and Public Water Supplier,if an determines that the :" '.
system is functioning in a manner that protects the public health,safety and environment: �K �.'
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water 4'r e
supply or tributary to a surface water supply. '
PP Y �'Y �rim
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
g
_ 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 a :
supply well".Method use&io determine distance n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and i t
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. 'Sf
a 3. Other:
n/a
i
� �
i z
Page 4 of 11
1, 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS41
SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM in" .fit
PART A T
CERTIFICATION(continued)
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14
Owner: JOHANNA JOHNSON_/ROBERTA JOHNSON
Date of Inspection: 11/6/00
D. System Failure Criteria applicable to all systems: 1;
You must indicate"yes"or"no"to each of the following for all-inspections: 'M
S _ �t
Yes No
X Backup of sewage into facility or system component due to.overloaded or clogged SAS or cesspool
_ X Discharge or ponding of etlluent to the surface of the ground or surface waters due to an overloaded or clogged 4 j y{' �
SAS or cesspool r s z a
_ 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''/z day flowr".q
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times a `iEt s
pumped WITHIN THE.LAST 5 MONTHS. r
f X Any portion of the SAS,cesspool or privy is below high ground water elevation. t
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply ; .r
X 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 privateAwater supply well.
f _ 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,00
} no acceptable water quality analysis. [This system passes if,the well water analysis,performed at a DEP x1
1 certified laboratory,for coliform bacteria and volatileorganic compounds indicates that the well is freed r
from pollution from,thaf facility and the presence of;ammonia nitrogen and nitrate nitrogen is equal to or ^,N
less than 5 ppm,provided that no other failure criteria"are triggered.A copy of the analysis must be g .
!Y ,a
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 . t{
CMR 15.303,therefore the system falls.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure. gill
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. .k
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above) 1. ,.
yes no
X the system is within 400 feet of a surface drinking water supply
- Yx . K
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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
1
I �
If you have answered'yes"to any question in Section E the system is considered a significant threat,or answered r , ,
"yes" in Section D above the larg®system has failed.The owner or operator of any large system considered a significant threat 1a�
under Section E or failed under Section D shall upgrade the system in.accordance with 310 CMR 15.304.The system owner,
lar.i ,
should contact the appropriate regional office of the Department. ' . 4� ,
• }r
' 6Pv.l
I� , d `b�2
tt :4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS '
F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B °
i si�r
�a
CHECKLIST °i x
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14 $A ;
Owner: JOHANNA JOHNSON/ROBERTA JOHNSON
Date of Inspection: 11/6/00 ` `l
A
4 Check if the following have been done.You must indicate"yes"or"no",as to each of the following:
0-
Yes No ' `M` �+
X _ Pumping information was provided by the owner,occupant,or Board of Health s° w
_ 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? €"
X Have large volumes of water been introduced to the system recently or as part of this inspection? b l :
t t s+ t
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) rG� �
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out? �' k
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 1, s. L'r
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance I;
d;.
of subsurface sewage disposal systems?
.4
The size and location of the+Soil Absorption System(SAS)on the site has been determined based on:
i Yes no F
, 14.
X _ Existing information.For;,example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is 'tr ; f .4
! unacceptable)[310 CMR 15.302(3)(6)] '=+fii,t
F. +i7 YF
.� %°'
I l�
5
Page 6 of 11
f.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r."y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '` +f �
PART C
SYSTEM INFORMATION .
.ik..
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14 ��.; <;�
Owner: JOHANNA JOHNSONhROBERTA JOHNSON i {
Date of Inspection: 11/6/00
iFLOW CONDITIONS
RESIDENTIAL t'`
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents:0 , ^{t
Does residence have a garbage grinder(yes or no):NO »c
Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required]
Laundry system inspected(yes or no):NO`
Seasonal use:(yes or no):NO
�i i 4
Water meter readings,if available(last 2 years usage(gpd)): n/a {f ,
Sump pump(yes or no):NO tits�;. '
Last date of occupancy:6/5/00
COMMERCIALANDUSTRIAL S
Type of establishment: n/a �
Design flow based on 310 CMR,15.203 : n/a gpd
Basis of design flow(seats/persons/sqft,etc.): n/a «.1 �
Grease trapes or no :NO
resent(yes )
Industrial waste holding tank present es or no):NO
Non-sanitary waste discharged to the'Title 5 system(yes or no):NO . .
Water meter readings,if available n%a
Last date of occupancy/use: n/a
OTHER(describe): n/a , ]
GENERAL INFORMATION : i 1—C-4
Pumping Records
Source of information:WITHIN THE LAST 5 MONTHS t° Y�
Was system pumped as part of the inspection(yes or no):NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a "' f
. 1.
yt. `Fer
€'s J
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system ;
Single cesspool ,
_Overflow cesspool
_Privy
ar ete
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): n/a
Approximate age of all components;`;date installed(if known)and source of information: r�ir
1984
Were sewage odors detected when arriving at the site(yes or no):NO 1
ti,f
e� J
t, P
a ;
"i
Page 7 of 11
,t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMh
PART C
SYSTEM INFORMATION(continued) ,'
s r�
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14 ri. '� c;
Owner: JOHANNA JOHNSON/ROBERTA JOHNSON
C,'AZf A� Z
Date of Inspection: 11/6/00
BUILDING SEWER(locate on site plan)
Depth below grade:30"
Materials of construction:_cast iron _40 PVC Xother(explain):20 PVC
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.): u4
E TOWN WATER
SEPTIC TANK:X(locate on site plan) f``{
Depth below grade:24 :i n
Material of construction:Xconcrete_metal fiberglass_polyethylene,other(explain)n/a }
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8'6"H 5'7"Wl4' 10"" E u
Sludge depth: n/a
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a s
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of,ouilet tee or baffle: n/a
How were dimensions determined:MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related ' r� s
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING
EVERY YEAR TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a Nt
Date of last pumping: n/a vr ;
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related, (,�"w'
to outlet invert,evidence of leakage,etc.):
n/a
t .- I �7t�( c•
R�
k
y e
b
c 5
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4E '
N,
PART C J� `
SYSTEM INFORMATION(continued)
Property Address: 87 FOXGLOVE RD CENTERVILLE MA 02632 L14
P Y "t i'
Owner: JOHANNA JOHNSON/ROBERTA JOHNSON
Date of Inspection: 1,1/6/00
4;t}F
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) `.
�+ t•,
Depth belowgrade: n/a
Material of construction:_concrete_metal_fiberglass polyethylene_other(explain): n/a !
Dimensions:n/a j,
Capacity: n/a gallons ••V ;
DesignFlow: n/a gallons/day
g Y
Alarm present(yes or no): N/A '+
Alarm level:N/A Alarm in working order(yes or no):NO ,� ,
Date of last pumping: n/a .�
Comments(condition cf alarm and float switches,etc.): t'
DISTRIBUTION BOX:_(if present must be.opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.): k '
n/a
PUMP CHAMBER:_{locate on site plan) tr
Pumps in working order(yes or no): NO s `t
Alarms in working order(yes or no):NO :
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a48,
fly t�
44r,{�
P. ,�,'
E �k
• r;fit�;
r �S x 3vx.3
t '42
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 1.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) + t
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14
Owner: JOHANNA JOHNSON/ROBERTA JOHNSON
f" r
Date of Inspection: 11/6/00 ,.
cz
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why: :r
n/a k ;
Type ;l
1000 GAL 6'X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a '
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a F` `
n/a t innovative/alternative system
Type/name of technology: n/aY ;Fl
Comments(note condition of soil,signs�of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): Ut
THE LEACH PIT APPEARS TO BVFUNCTIONING PROPERLY.THE PIT SHOWS NO SIGNS OF FAILURE. ,THE PIT WAS EMTPY AT THE TIME OF INSPECTION.THE"PIT SHOWS SIGNS OF THE LIQUID LEVEL
BEING 16"TO PIPE.RECOMMEND RAISING COVER TO PIT. 3 f:
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) `. 4
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a k '
Depth of solids layer: n/a
•TA IM4_1�:.
Depth of scum layer: n/a 4, �"
Dimensions of cesspool: n/a ,?r0
Materials of construction: n/a
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): ;
n/a t^'
PRIVY: (locate on site plan) l
Materials of construction: n/a ?�::'..
Dimensions: n/a
Depth of solids:n/a
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): z
n/a ,;, , Rif
Tk�p4�y•.��'t
e�'€
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART C 4
SYSTEM INFORMATION(continued)
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14
Owner: JOHANNA JOHNSON/ROBERTA JOHNSON `'=K:
Date of Inspection: 11/6/0041
SKETCH OF SEWAGE DISPOSAL SYSTEM 3
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.
4
d °
r i
t
1.5N
Dilk; AA
Atli
ac
At
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a
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,
SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM r �
PART C
SYSTEM INFORMATION(continued)
Property Address: 87 FOXGLOVE RD CENTERVILLE,MA 02632 L14t; r,
Owner: JOHANNA JOHNSON/ROBERTA JOHNSONk.
Date of Inspection: 11/6/00
SITE EXAM
_Slope
_Surface water
_Check cellars
Shallow wells
W
Estimated depth to ground water 10+feet `(«,
Please indicate(check)all methods used to determine the high ground water elevation: Nl!
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS
NO Checked with local Board of Health-explain: n/a
i1:..:t
NO Checked with local excavators,installers-(attach documentation)
YES Accessed USGS database-,explain: n/a
You must describe how you established the high ground water elevation: i•
USGS MAPS AND CHARTS-10+FEET
{F, w
fk
4�k .A.�-
N.
1
4
` -4�k1
f r.n
s�<< f} r=
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1. ij.A;t"J!f.
E.
�
,42... ;
-
r;
l % / 36-0/0
LOCATION �I SEWAGE PERMIT No.
Ina+ E-®k Oft E Y
VILLAGE
1 �S
INSTALLER'S NAME A ADDRESS
or 40
e U 1 L D E R OR OWNER
1!!�tomfnUf?f Fads.
r
4(.j
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED � �
l�6 roa-
�� ,�
3�
i�.
��k � J
6,r IoC � fb
No.........RY._-I.f CJ Fims.............................
THE^COMMONWEALTH OF MASSACHUSETTS
d BOAR® OF HEALTH !-.
. ............ .....d... --...._.'/..1. _ ...............................
Appliration for Disposal Works (fnnstrnrtinn Prrmit
Application is hereby made for a Permit to Construct (C--<or Repair ( ) an Individual Sewage Disposal
System at:
........•-- ��------cj .()v:�...- •-------•---•------ •- -----... .. - - .............. •....
Locatio ddress ----
or
------------------------------- --- ---- s . ..............................................
•Q / Owner �1da�ss
------------------------------- ----------/��� .tor_.c f�:.f � ......
Installer Address
d Type of Building Size feet
U Dwelling moo. of Bedrooms---- .............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fix res ...........................
Design Flow...... ..... ...........gallons per person per day. Total daily flow._ ........................gallons.
WSeptic Tank quid capacityk-W40gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area.;_.._......._......sq. ft.
Seepage Pit No.---.,�----------- Diameten-A _...... Depth below inlet.................... Total leaching ar; ......sq. ft.
Other Distribution box Dosing tank ( )
Percolation Test Results Performed by...
-•--•----•----------- Date-7"z�42��-------------
,aa Test Pit No. 1.... -------minutes per inch Depth of Test Pit.................... Depth to ground water./ �-5m,__..
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 --•-••••--•-•••--------•-----•-•-•-•------•--•••-----•-•-•--•----------•--------•---......-••-•••--•.........................................................
O Description of Soil..... _- .....
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 TITi% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operat' n until a Certificate of Compliance has been iss b the board of health.
' ...._
G.e^.�. Signed - �l Dat�
Applecation Approved By........................... = . .......................
Date
Application Disapproved for the following reasons:------•-----------------------------•---------------------------------------------------------------......--•••-
..............•------------......--•--------•----------------------------------------........----..........--•----------=--------•---------------••-------------•------------------------------------•...
Date
PermitNo....... °�n --••--•-•--•-•--------. Issued.......................................................
Date
--- -- --- ---- - _ _.��._-- ---------- �_,�__---- ------------------------ --Ji _ ---
No .�I .Y Fm$............._............
THE,COMMONWEALTH OF MASSACHUSETTS
BOARD OF H EALTI- --
13 U
f ram'i!a' -------------OF..:.:�r'.'`"c ` �. . ................................
ApplirFatiun for Disposal Works Tonstrurtiun Prrmit
Application is hereby made for a Permit to Construct (L,<or Repair ( ) an Individual Sewage Disposal
System at:
•..............._--------_......................------....--'-............•.........-----•----.. ..._....-•------•---•---••---------•-••-•--'-'-•--•-••----•-----•-•-'-----.._.........----•-••-•-•
/ Locatio - ddress� or Lot o.
owner w r Ad ss
Installer Address
d Type of Building Size Lot. /..0_//..Sq. feet
V Dwellings lo. of Bedrooms.._................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other res ............... --
-_ _
• - ------------------------------------------------------ ---------------------------- ------------
W Design Flow...... ............................gallons per person per day. Total daily flow ,:.? '- _........................gallons. f
W Disposal Trench q i capacit/w, 4: .gallons Length................ Width................ Diameter................ Depth................
Di tic Tank i u> o..................... Width......._............ Total Length.................... Total leaching area ...............sq. ft.
T -
Seepage Pit No...../�------------ Diameter../ _.I_...__ Depth below inlet.................... Total leaching area`'-_-�°`._-.___...sq. ft.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed by...�~�•�'. -....._-�. ...................... Date. �!`- __<-Y- __._..___..
,tea Test Pit No. I..._'�.......minutes per inch Depth of Test Pit.................... Depth to ground water-A �'=.._.._.
(s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___-____-_-___---_..___
a •---•-••-•-•.-••••-••••...::............••••••............•••••••-•...._..............--•••-...............................................................
0 Description of Soil..... �' �`' - _ .+ "T="
W .....•••--------------------••--••-•-•-------------.._......_..........-•--•...............•--•-•-•------•-•---••-------•--•••-.....••••----•••-----•••----•••••....-----•--•-•-............---•--_••••.
U Nature of Repairs or Alterations—Answer when applicable._..............................................................................................
-------------------------------------------------------------•----------------------...............-----......--------------------------------------•--------------------------••--•••••••--•-•••--•-••-
Agreement: a
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 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 health.
1�p
*'-t;
Signed' ....................
Ap y . .................cation Approved B --•--•---•......••• at .. �.,-Wit'-••-•--•-••••.... Date---•-•••--....
•�+' <
Application Disapproved for the4 following reasons::...................•------•---------------S-.....
..........................................
------•-----•------- �
n . Date
PermitNo.. S - -d ....................--- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................................................................................... )
(9rdifirFatr of Tuntplianrr t 7 ►no Yo�'f
THI,� IS�7'O CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by-------.�_!:.....`...M-0!2- /V---------------------------•---•----- -- --------------------------------•------•--------..-....-----.---•------•------------•-----.--.--------••--
..................4...._..• •• --..........-•-•---•-••••--••••-••--•--••--•-•--......•.........---•-_....-•-----•-•--........
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code s d cribed in the
application for Disposal Works Construction Permit No.___. 5'-"_ _7.__.__.._.. dated------------ __� _�_................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST E® AS A GU AN EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. Inspector.............. _..f.c ••-••----•-•--••---•-•-••----•-•--..._...
THE '
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....OF......................
y 9 '7 ..................................No.........i............. FEE....S'..L........--•---
Dispus�tt#l.,, arks �unstr ion rruti#
Permission is hereby granted......1-... In UgL &)........................................................................................................
to Construct ( ) or Repair ( an Individual �ewage Disposal System
at No....,�i .l_ __' �L.lt_t!_€_. �%.........filn �n!S,MIYLg .................................................................................
Street
as shown on the application for Disposal Works Construction Permit No..................... Dated....................................
...............:.........
Board of Health
DATE..............---------•--------•-•--------•---•--------•-••......•-•••.._...•.
FORM 1255 A. M. SULK.N, INC., BOSTON
L 1
�W(P% b FAWL-Y • :5 BCOROOM _
px, ti. 4. pro-GAa�w� Ga,�lo6a. ' � .
t)AALy Rt,OW a IIOx 3 = 330G•p�
A9�G.l�
'� ♦ 3301ri/O% = 0i / r
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x ` Al.. mkt, ;s "+
V 0 0 •,G
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.3?liv• rr� �� \ Go•
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I ?'OT�►4• DESIGN . = `F c.{ l G.�?> ��� � .,�.
Tvr L- LILY Flu! 33�G•I? i�. . \ €t i
PC5,614 MP.G4L4Tpq I?Ai1r: l" N 4 ON.GQ
O�A Of
PETER ti `'► \ t, ,-
o SULLWAN v`r� 4fi RICHARU
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No. 29i33 BAXTER
Ndu 24048 J
�GF PCISTF
�ONAI
�'e
9 _
TIG�.�' ,�:L�.l'' f� :GO•-r � .• -Top FNty•
of-PA-V pIST. IN S64,
1000 INV.
17
d , plr INV. INV. >
71
b II
cE SLITS SLIGO PuDer P1.ASJ
I Lo�
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REF62614CAL
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i A1J fir?OAGK R.G Q V Q E AND TS ►�o T'NpO4/.E/4.
10 WN opt g&2�31_C.. A I�sty Fes.G / y�
1.00�►Tfs�•WITN 6 F%.000 PL&IN
pATb -t '8 �l gaxT6rtt My& IWC•` {
REGIS'Tf&V.&'D moSvtcv6�bC'3
'Ttll�j i>K.0►N is NC�T (3A�jFsD old /!►W OST6eiZVIL.Lrr aAk"�i.
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