HomeMy WebLinkAbout0068 FRAZIER WAY - Health 68 FRAZIER WAY, MARSTONS MILLS
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL., 367
Main Street, Hyannis, MA 02601 (Town Hall)
DATE:
E � rt m, 't Fill in please:
' APPLICANT'S YOUR NAME/S: s S . C.L L k N W o p Zj
BUSINESS YOUR HOME ADDRESS: a ke
a> � C f, Q
n�.rfn�4x� � J Al a S Jsc) AA
lls A;A 11
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AA A ig CD 4
TELEPHONE # Home Telephone Number Svc Z E3 I c_
NAME OF CORPORATION:
NAME OF NEW BUSINESS N ern. :,r 0 0 16, kn TYPE OF BUSINESS C can s ,V To
IS THIS A HOME OCCUPATION? .YES NO eoi�o 1
ADDRESS OF BUSINESS Co J3lkhqq AA,I —MA PARCEL NUMBER 6t2Co 00C-1 (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING CO SSIO ER'S4CE MUST COMPLY WITH HOME OCCUPATI N
r This individ al h s en p rmit requir mentsc �s' TdSI inF1LURE � Q,u �,P w,Q,�MPLY MAY RESULT IN FINES.Aut orize_d _ f
COMMENTS: �YL tp
2. BOARD OF HEALTH
This individual ha�� lvt e p r it<req ents that pertain to this type of business.
Authorized Si ature** �-
MUST COMPLY WITH ALL
COMMENTS: "AZAQMUSMATERIAI SRECUL44ONS
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:'
TOWN OF BAR:M�
T
{-7Y. LOC:k ? Iv` , �YL iA WAGE #
VILLAGE tAtc)NS kkAl ���tS ASSESSOR'S MAP & LOT 00
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l.00R O C V2�,-
LEACHING FACILITY: (type)_ ��- (size) S k-
NO.OF BEDROOMS
BUILDER OR OWNER
'PER*ffT-9ATE: '1\:SQ I5�ra _COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 f`fet of leaching facility) Feet
Furnished byY� C�C-�
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ti= 1 8
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF �1
%. � r 9�
DEPARTMENT OF ENVIRONMENTAL PROTEC N c9
ONE WINTER STREET,,BOSTON MA 02108 (617) 292-5500
Y COXE
WILLIAM F.WELD Secretary
' Governor
• DAVID B. STRUHS
AR.GEO PAUL CELLUCCI Commissioner
Lt. Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
puQ_ QS� PART A
CERTIFICATION
Property Address: �vct�V80S At�<<j• Address of Owner:
(If different) k OC`c�l +•
Date of Inspection:
Name of Inspector: �ir �� 1 .��- �= n 15� of Title 5 (310 CMR 15.000) �ru tT 1 {'�r4• �Z ]°3�
I am a DEP approved-system inspector pursuant to Sectio Company Name: / TLh� "�Yc Zw��t��;JMQ ►'�T 14
Mailing Address
-Telephone Number.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below true, accurate an
The inspection was performed based on my training and experience in the proper
complete as of the time of inspection. function and maintenance
of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes'
_ Needs Further Evaluation By the Local Approving Authority
_ Fa'Is
Inspectors Signature:
QD Date: 5
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 now 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 SU1 IA6tRY: Check A, B, C, or D:
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 exfiltration. or tank ilur
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.
Paee t or to
r ' '
• INSPECTION FORM
M INSPE
' SUBSURFACE SEWAGE DISPOSAL SYSTEM .
PART A
CERTIFICATION (continued) .
Property Address:
Owner:
Date of inspection:
B)SYSTEM CONDITIONALLY PASSES (continued)
_ high static water level observed in the distribution box is due to broken or obstructed pipe(s) or
Sewage backup or breakout 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
..
_ imes a year due to broken or obstructed pipe(s). The system will pass inspectic
The system required pumping more than four t
( f 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:
Board of Health in order to determine if the system is failing to protect the
Conditions exist which require further evaluation by the
public health. safety and the environment. .
I) SYSTEM WILL PASS UNLESS BOARD O PI[TB CTHHEALTH ANDS�,Y AD SYSTEM
E1�RO�fET7CT10nZ'�G Iti A
MANNER WHICH WILL PROTECT THE
t Cesspool or privy is within 50 feet of a surface water
_ feet.of a bordering vegetated wetland or a salt marsh.
Cesspool.or privy is within 50
2) SYSTEAi WILL FAIL UNLESS TI[E BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE ANDDETEILNIINES THAT THE SYSTEM IS FUNCTIONING IN A MAIYNE THAT PROTECTS THE PUBLIC IiE
SAFETY AND THE ENVIRONNIEYT:
_ 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 i
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 pi
Method used to determine distance (approximation not valid).
3) OTHER
• Pa e2of10 .
C
(rerlsed W125/9'� � 1 .
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
A
Owner: t
Date of Inspection:
DI 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 310 CMR 15.303. The basis for
I this determination is identified below..The Board of Health should be contacted to determine what will be necessary 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.
s
i ution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Static liquid level in the
distribution
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 clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System. cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.'
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet-but greater than 50 feet from a private water supply well with no
quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
acceptable water
coliform bacteria. volatile organic compounds. ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
— the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
— — the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area -IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
r.. ei rin
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 6� (j ►4 2-1 Z(/j.
Owner: 4x4N,14_4 �
Date of Inspection: 4\�;O`qlb
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes N9
Pumping information was provided by the owner, occupant, or Board of Health.
_ �
_ None of the system components have becn pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
"r _ The facility or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
'xC _ All system components. excluding the Suil Absorption System. have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
_ The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
Existing information. Ex.,Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.301(3)(b))
(revised 04/25/47) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property�A�d,dress: �ctRti4>;.i e+L
Owner: 1�-,
Date of Inspection:��P`et
FLOW CONDITIONS
RESIDENTIALI.
Design flow: Q p.d./bedroom for S.A.S.
Number of bedrooms:_
Number of current residents:_
Garbage grinder (yes or no):_LV
Laundry connected to system (yes or no):
Seasonal use (yes or no):_p.)
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no).
Last date of occupancy: 3mh.5 +2�2�a�L.-t-b wca�01�
CON,BlEERCIAL/INDUSTRIAL:
Type of establishment:
Design now: _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:
GENERAL INT'OPUNIATION
PUNEPING RECORDS and source of information:�
System pumped as part of inspection: (yes or no)_tJO
If yes. volume pumped: eallons
- Reason for pumping:
F SYSTEM
L
Septic tic tank/distribution box/soil absorption system li
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:
Sewage odors detected when arriving at the site: (yes or no). b ..,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: fo% AZ-\e�
Owner: MYVAA ,
Date of Inspection:
BUILDING SEWER: Nn
(Locate on site plan)
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:M.S
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal. list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions: 1 C>OO q e,
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
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.)
GREASE TRAP:-
(locate on site plan)
Depth below grade:
Material of construction: concrete metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or 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.)
(rerised 04125/97) Page 6 of 10
SUBSURI:ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:APA\C(L
Date of Inspection:h
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: galldns/day
Alarm level: Alarm in working order _ Yes. _ No
Date of previous pumping:
Comments: _
(condition of inlet tee. condition of alarm an,d float switches. etc.)
)ISTRIBUTION BOX:11��
(locate on site plan)
Depth of liquid level above outlet invert: •+mot DOtZsT
Comments:
(n to tf level and distribution is e,ul. evidence of solids carryover, eviden of leakage into or ou of box, etc.)
k Loti.s� 1<T�t�U lZa r c .y S �"`�l �Gi1�K1�LZl �:.� U (oakCiC.tQ
PUMP CHAMBER:/`6
(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.)
^ , _rin
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION (continued)
Property Address:
Owner: AYiOvt-
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):*-c
u required. but may be approximated by non-intrusive methods)
(locate on site plan, if possible; excavation
If not determined to be present, explain:
Type: .: .
leaching pits, number:Atox�
leaching chambers, number:_
leaching galleries, number:
leaching trenches. number.length:
' leaching fields, number, dimensions: '
overflow cesspool. number:
Alternative system:
Name of Technology:
' Comments:
(no condition of soil. si ns of hydraulic failure, level of ponding. condition of vege on, c.) v 1Zv
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top,of Iiquid 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 pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding condition of vegetation, etc.)
i
PRIVY:_
(locate on site plan)
Dimensions:
Materials of construction:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.)
Page s of to
(rc.isal 01/al97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �.fi fi�P2 K�• f
Owner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM: "
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
f
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33, 3z-
�� b-1 3
(reriscd 0J/23197) Page 9 or to
SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM
PART C '
'-SYSTEM INFORMATION (continued)
Property Address:
Owner:
,
Date of Inspection: 1;0
5� ;
Depth to Groundwater t� Feet
Please indicate all the methods used to determine High Groundwater Elevation:'.,
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
1
Determine it from local conditions
Check with local Board of health
Check FEMA Maps l
1
' Check pumping records
r
Check local excavators. installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
t
Page 10 of 10
(revised 04125/97)
L,o� N SEWAGE PERMIT NO.
VIrLAGE HS: =H 6
I N S T A LL . R'S NAME ADDRESS
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R UILD'E R OR WNEIR
skmi-Q-L,�
f e
DATE PERMIT ISSUED
DATE COMPLIANCE 15SUED ,,�
.�� __ _ __
�_ �P ����
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No._................1 00_ Fss..... ....._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
....TZO- .)................OF......... .�k� .sS.T..F� .C_ .........__.....
Appliratinn for Biopasal Works Tnnstrnr#iun Prrmi#
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
S st at
y............................ ..................................c' oT --------------------------
-_-----.
Locatio s Lot Sto' pit
Y Owner Address
n , I
M Installer Address
^Q1i Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms............... ._................._......Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g •--•--•--------------------- _.....__. .... ( ) — Cafeteria_(_..._).
dOther fixtures .----•-----------------------------•--- -•------------------------------ ---------•-••--•-------•---•••--
W Design Flow...........6 ........................gallons per person per day. Total daily flow......... .. .b.....................gallons.
WSeptic Tank—Liquid capacity.4200.galIons Length---6....... Width......I..`... Diameter................ Depth.....4.'-....
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No.._..�............. Diameter..... ...... Depth below inlet....4............ Total leaching area_'Ygl1t..`...sq,4.6 Pp
Z Other Distribution box (pQ Dosing tank ( )
Percolation Test Results Performed Date-•--•••-••--•-----•-•-..----.......•----
Test Pit No. 12� .._..minutes per inch Depth of Test Pit-.14-4..7... Depth to ground water..! o,^J E.._..
0.4 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...�._.wa���
fx
.....5� ------���O Description of Soil.......... .._..---........---......-------•----------------•-•----•-•-•----•.......-----....--•--•--•----•-••.._..............
x
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
------------------------------------
•----------
--------------------------------------------------------------------
....................................................................
...... .......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i1TLL 5 of the State Sanitary ode— jbyhe
ersigned further agrees not to place the system in
o n until a Certificate of Compliance�Y►Z bee issued oard of
health.
g ---- 1I--_5.....Y5
t ed Date
PPlication Approved By-------•-••......-••----•-- 'u —�
l Date
Application Disapproved for the following asons:----•-•-----•-------••••••....................•------•-•---•-•••--------•-•----.........._......----•----._....
....................••--.........--•-••-•.........•----------.............--•----•---........--------------•----•---•••..._......•••----•-•--------•---------------------•----••----..............._..._
� - 1605
PermitNo......... ..................... ---•-•---•--....----. Issued...........................................Date-----
Date
THE COMMONWEALTH'OF MASSACHUSETTS -
_ BOARD- OF HEALTH
" O. .AJ................oF........ a
Appliration for Disposal Works C oustrurtion permit
Application is hereby made for a Permit to Construct (k) or Repair ( ) an Individual Sewage Disposal.
System at: I
t Locatlo •Address Lo t N o.
-
Owner �--- '
Address
a . FR. K fS_a
Installer Address
Type of Building Size Lot........................:...Sq. feet
.-t Dwelling—No. of Bedrooms..............3..........................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T of Building g ••••-...................... No. of persons............................ Showers ( , ) — Cafeteria ( )
Otherfixtures ----- - ------------------•-------------------- -------•- ----- •- --•-----------
W Design Flow•------_- ��.......... gallons.per person per day. Total daily flow._... �..3......................
� ._...gallons.
WSeptic,Tank—Liquid capacitvl.D00.gallons Length--.A.- •...... Width..... _._ _. Diameter................ Depth....' ......
x Disposal Trench—No. ................. Width._ -:f,._..... Total Length.................... Totah.leaching area....................sq. ft.
3 Seepage Pit No..... Diameter_:::/2 _._. Depth below inlet...". ........... Total leaching area.4*. ---sq�€t:.6 pp
Z Other Distribution box (p4) Dosing tank ( . ) 1
~' Percolation Test Results Performed ....................::....... Date.. 8•.-8Z................
�
Test:Pit No. 1.0 -_._:_.minutes per inch Depth of ,Test Pit../< 4_......._ Depth to ground water..!V .....
(z, Test Tit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....�...C_...v� (L5
a : ---••�---•-----------------------------------------------------------------------••---•-•-•--•-------.........................................................
V0 Description of Soil...._`-.._..._ ......P �_.._
x �±`�^ •...... ----
.....---••---••-•-•-••-----•••••..._..-----•-•-••-•-•••-••----•-------•-•••••--•••-••-----=---••••--•---•--•-•••---•......•--••------•-••-•...-•••••••-••-••---•-•••••-••--•--•--•...-•---•._......
x .....----•-•-------------------------------•------------•-----...........--••---•-•-•--••.......=......................................................................................................
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 TITLE 5 of the State Sanitary ode— T e un ersigned further agrees not to place the system in
Zoerat' tiha Certificate of Compliance, b e issued by. he oard of health.
l PDat�
pApprovedBy............................. --••-•_... --• ............
Date
Application Disapproved for the following ons:-••=---•--------------•-----•-.----••---•---- ....-----....------------------------......................
..............•-----•--.....-•-•--------...........------------•----------•------------....----:::-••- ---------•----•---•-•---•---------------------------------------- -•----•-•---•----••-------
Date
Permit No..._..�s---•-. -•••••------•-. ^ Issued.................................
.•- . .....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.........................:...........................................................
(Irrtifiratr of Toutph ttrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed X) or Repaired
by--........ -------------
11M, •-•----•-- ----•-• -•------•--•-..._._..
Installer g,
at...................La..T.........!-.6-..............f.i?A .t>E<. ---------- ............ --
has been installed in accordance with the provisions of TITIE 1 of The State Sanitary Code as described in the
^Z
application for Disposal Works Construction Permit No:___ ..r-- I r 1 dated_.�./"_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE !
SYSTEM WI FUNCT ON SATISFACTORY
DATE........... --.... Inspector. ...
j1 ....4 ............................
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
Q5' /G'CJ OF..................................................................................•. FE . SG7c
No.. . ...... -
Disposal lVorks Tonntrurtion "Fantit
Permission is hereby granted.............. fZ-!A......... .............................----•...............•-•....................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System `
at No..........................LOT_*..&...... ......v.+� :....
Strcct
JJ
as shown on the application.for Disposal Works Construction "Permit.No._-------�----_ - Dated_. ....__�.!l.. �J
DATE----•-. ,a a .
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