HomeMy WebLinkAbout0134 GREAT HILL DRIVE - Health 29 Stallion Way
Marstons Mills
A = 174 036
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C/ COMMONWEALTH OF NMASSAcHusETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFATIZS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
O,9M Ygv
C= q
TITLE 5
OFFICIAL INSPECTION FOAM—NOT FOR VOLUNTARY ASSESSMENTS
jowner's
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
4CERTIFICATION
roperty Address: 1tirs Name: ev'/wner's Address: oL o vt q
in u i`f Od64��
Date of Inspection:
Name of Inspector:(please print)���/i Y'/t-
Company Name:
Mailing Address: Way
Telephone Number 6 — - ,
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Se ' 15340 of Title 5(310 CMR 15-000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 77I)a' Q Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or `
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
K
Title 5 Inspection Form 6/15/2000 page 1
R
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PAIN A
CERTIFICATION(continued)
Property Address: c2 !Q S4A//,,g-, G✓�f
cis S s, Oa ��d
Owner: dV1
Date of Inspection: ! 0�
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A.�ysPasses:
ve not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the_for the following statements.If"not determined"please
explain.
The septic tank.is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
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
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
lip
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSWNTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
Q CERTIFICATION(continued)
Property Address: / /�Io✓I G
Owner: /Gt
Date of Inspection: ay
IF
C. .Further Evaluation is Required by the Board of Health:
/1/ Conditions exist which require further evaluation by the Board of health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIVI
PART A
CERTIFICATION(continued)
Property Address: sTa mo (.✓��_
Gy n s � , 0.,7-6q-g
Owner /a --
Date of Inspection: W116107
D. System Failure Criteria applicable to all systems:
You must indicate`yes"or"no"to each of the following for all inspections:
Yes No/
_ ✓ ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
� ,,,,'clogged SAS or cesspool
v Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
'cesspool
t/ hiquid depth in cesspool is less than 6"below invert or available vohsaxe is less than'/Z day flow
_ 61 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
,,"of times pumped .
any portion of the SAS,cesspool or privy is below high ground water elevation_
t_/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone i of a public well.
�lny portion of a cesspool or privy is within 50 feet of a private water supply well.
_ �4/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.[This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic Compounds
indicates that the well is free from pollution from that facility and the presence of amnmuia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
n are triggered.A copy of the analysis must be attached to this form.]
/f/U (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to connect the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
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)
Xyes o
the system is within 400 feet of a surface drinldng water supply
the system is within 200 feet of a tributary to a surface drinldng water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of I i
OFFICL4,L INSPECTION)FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:_t29
Owner• �1 q 2—
Date of Inspection: !� O
Check if the following have been done.You must:indicate`yes"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant,or Board of Health
f/ Were any of the system components pumped out in the previous two weeks?
!/ Ha the system received normal flows in the previous two week period?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_'7—Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_V/Z—Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the b_affles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_�_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
t/
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
_ _
is unacceptable)[310 CMR 15302(3)(b))
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Q / SYSTEM INFORMATION
Property Address: 7 Y-G//io� 6VA q
®- `/ ®o�
Owner: I
Date of Inspection: VOT
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 7
DESIGN flow based on 310 CM R 15.203(for example: 110 gpd x#of bedrooms): J�O
Number of current residents:_/
Does residence have a garbage grinder(yes or no):/07
Is laundry on a separate sewage system(yes or no);o j/ [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no): /"
Last date of occupancy: Z tR ri'G yr
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no);,L"
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping: _SYSTEMTTYP✓�
Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
_—Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if o )and source of information:
IM - 07
Were sewage odors detected when arriving at the site(yes or no)v_ft
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address �/G���o�'► �Gti
Ot✓5 ✓!S i S/ G /f 61a16 4
Owner: Z
Date of Inspection: 9 0
BUILDING SEWER(locate on site plan)
Depth below grade: sb
Materials of construction:_cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:v(locate on site plan)
Depth below grade:
Material of construction:_ oncrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) �X �o
Dimensions:
Sludge depth: cZ- �9 9
Distance from top ppf_sludge to bottom of outlet tee or baffle:
Scum thickness: 1.
Distance from top of scum to top of outlet tee or baffle: Ic
Distance from bottom of scum to bottom
of outlet t or baffll:
How were dimensions determined: o /��S —0611 ol_p
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
asrJp� ted to outlet inv evidence ofJ1yeakage)etc.): / _
N Wl „ .CIO /� ` ca 7- �/ 4-,✓`!� G•'ly Q„i
LZ
GREASE TRAP-4/ (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8of11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Q SYSTEM INFORMATION(continued)
Property Address: / G��r'0/h we,-
GirS .7 S
Owner: _/di y
Date of Inspection: /S
TIGHT or HOLDING TANK: /t/ (tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction: concrete metal_fiberglass_polyethylene other(expiam):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: if present must be opened)(locate on site plan)
(
Depth of liquid level above outlet invert:l00/"""?4 6--
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leaks into or out fbox,eye.): /10 so/�
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in worldng order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Q SYSTEM INFORMATION(continued)
Property Address:��-/— SXG/� � tt"-ei z 6
/''L� o�+
Owner: Ob/A
Date of Inspection: 1!!4LO
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leac ' chambers,number:
ching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology.
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): yo Ga r7 So. a /�{eu v 6-�e�r, //� f.o•,.
Nl ✓ls c .. + i It,
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,coition of vegetation,etc.}:
PRIVY: locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation;etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �a Mold �i✓lit Vj_�7,Q
Owner: Sla Z
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the budding.
Fro,
v
/f 5 38
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: OC Ia //t G✓ ��
Owner: !u Z
Date of Inspection:
SITE EXAM 6 r
Slope
Surface water p�10 3 7
Check cellar
Shallow wells 49 wt r Lf
Estimated depth to ground water feet t
Pleas�inte(check)all methods used to detemrine the high ground water elevation.
ed om system design plans on record-If checked,date of design plan reviewed:
O rued site(abutting property/observation hole w5 �of SAS)
Checked with local Board of Health-explain: � - )
_Checked with local excavators,installers-(attach documentation / c
Accessed USGS database-explain: i4Q le
You must scribe h w you established a hi h ground water elevation- `��/avl
� ww �
oFtME r Town of Barnstable
Regulatory Services
anxMABLE. : Thomas F. Geiler,Director
�b �0�
ArF16 9. . Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Faz: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health
a th Division
automatically approve the number of bedrooms list does not
listed within this report. The actual number of
bedrooms approved at a, particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC
TOWN OF BARNSTABLE
LOCATION 1 S22tnwossi SEWAGE # 96-- 33 t
VILLAGE �SSESSOR'S MAP&LOT 12y-0346
INSTALLER'S NAME&PHONE NO. tkC,3c ftym%"V- V I ZC-
SEPTIC TANK CAPACITY
LEACHING FACII.TTY: (type) T12-WCk-t (size) 2 6-ZXZ$"'
NO.OF BEDROOMS ,3
UII.D R OWNER �O
PERMTTDATE:k?T COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
V7-
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
r
17 ° 3y
0
y' 3�
9
3 �
No. ,7 33 j FEE --6 fLe-->
THE COMMONWEALTH OF MASSACHUSETTS
�� g$ Ha tri s tabl e , MASSACHUSETTS
�.jjyfirativvt for Biepasat *stem (ganstrurttutt ]Jrrmit
Application is hereby made for a Permit to Construct (X) or Repair( )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Lot #130 Stallion Way The Irene Trust
House #29 (508599, M0023ee, MA 02649
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Ferreira Associates
131 Spring Bars Road, Falmouth—MA
Type of Building:
Dwelling No. of Bedrooms 3 Garbage Grinder(n
Other Type of Building No. per Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 55 gallons per day. Calculated daily flow 330 gallons.
Plan Date 7—5—9 6 Number of sheets 1 Revision Date
Title Sewage Disposal System Plan prepared for The Irene Trust
Description of Soil 0"-24 " topsoil/subsoil , 24 "-180 " medium sand. No ground—
water encountered.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has bee issued by this Board of Health.
Signed �.-���, o e Date 1� I• 6
IP
Application Approved by Date
f
Application Disapproved for the following reasons
Permit No. �����3 Date Issued
L/
No. �l is 3I FEE
i THE COMMONWEALTH OF MASSACHUSETTS
g g Balmehhhl a MASSACHUSETTS
c kppliration for Disposal *V0tem Construction 1hr-utit
Application is hereby made for a Permit to Construct (X) or Repair( ) an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
Lot #1+30 Stallion Way The Irene Trust
House' #29 Box .599, Mash pee, MA 02649
`(508),. 477-0023
Installer's Name,Address,and Tel.No. n Designer's Name,Address and Tel.No.
Ferreira Associates
131 Spring Bars Road, Falmouth—MA
8 540-3699
Type,of_Building:
Dwelling No. of Bedrooms -Garbs"ge1Grinder(nC'
Other Type of Building Persons Showers Cafeteria
YP g No. per ( ) is( )
Other Fixtures
Design Flow 55 gallons per day. Calculated daily flow 330 gallons.
Plan Date 7—5—9 6 Number of sheets 1 Revision Date
Title Sewage Disposal System Plan prepared for The Irene Trust
Description of Soil 011-2411 topsoil/subsoil, 24n-180" medium land. No ground-
water encountered.
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal
system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a
Certificate of Compliance has been issued by this Board of Health.
Signed \,n„ ^ Date
Application Approved by ! !4� Date' 7` — 162 " 9�
Application Disapproved for the following reasons
Permit No. 7 �a ' 33 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS r?
�6_61 � C MASSACHUSETTS
C�ertifirate of (fompliance I
THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced( ) on
by for
at + C? has been constructed in
accordance with the provisions of Title 5 and the for Dispo 1 System Construction Permit No. ' ', `3 7, dated
. Use of this system is conditioned on compliance with the provisions set forth below:
The issuance-of this:certificate shall not be.construed as a guarantee that the s'rys em will function as designed. This
Certificate expires on
GATE Inspector
THE COMMONWEALTH OF MASSACHUSETTS
No. /i ea &� , MASSACHUSETTS FEE ID
Visposal Sgs#em 01-Tonstructiou 1ermit
Permission is hereby granted to
to construct or repair( ) an On- " e Sewage System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her
duty to comply with Title 5 and the following local provisions or special conditions.
I
All construction must be completed within three years of the date below.
DATE Approved by �
FORM 1255 Rev.3/95 A.M.SULKI CO.-BOSTON,MA '
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