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0088 JOE THOMPSON ROAD - Health
88 Joe Thompson Road Marstons Mills P _ - A = 151 087 -� i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL. PROTECTION RECEIVED NOV 6 2003 TITLE 5 1 TOWN OF•BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY DEPT. SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: lJ O-e R ova �/l &.XC 4g 'ld8a H1ld8H Owner's Name: Gi r y n D18t/IMAVB-�0 NMOl Owner's Address: o, G✓� .-s °h fd 6q-9 COOZ S 0 AON Date of Inspection: /o Q 03 ' Name of Inspector: (please print) Gt r yr- /e ///' 03 AI 3 0�i N Company Name• Maili Address• Q as- ® 2 S MAP Telephone Number: D !f PARCEL ' CERTIFICATION STATEMENT LOT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000 The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fail Inspector's Signature:ibmi, Date: /O The system inspector shall copy of this mvection 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 ins pection and under the time.This inspection does not address how the system will perform in the future under t conditions of orat ereat conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �� ✓ 0-e T76 vy to n I-ej rS o✓il /1�fi/ Qa��.r� Owner. er 44 Date of In on: O Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 7otfound : have 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. Syste 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 pipes)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 ptpe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A o CERTIFICATION(continued) Property Address: �4 0-e Owner. v� Date of Ins 'on• C. Punt er Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to Protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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 prpm,provided that no other failure criteria are triggered A copy of the analysis must be attached to this form 3. Other: ilk Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A - CERTIFICATION(continued) Property Address* d©� /ho•�r� Owner S.-'GH �rs s" Date of Ins •on: p> D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for aIl inspections. Yes No ,>3aclmp 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 gged SAS or cesspool — Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or ,oesspoo1 Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow ,zf�ired limping snore than 4 times in the last year NOT due to clogged �tunes pumped or pipe(s).Number y portion of the SAS,cesspool or privy is below high ground water elevation. —_ V Any portion of cesspool or Privy is within 100 feet of a surface water supply or tributaryto a surface /water supply. f f,.-Any portion of a cesspool or privy is within a Zone 1 of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria Oare triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system LML&I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either`yes"or"no"to each of the following: following criteria apply to large systems in addition to tier criteria above) 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 — _ e system is located in a nitrogen sensitive area(Interim Wellhead Ptotection Area—IWPA)or a mapped 11 of a public water supply well If you have "yes"to any question in Section E the system is considered a significant "yes"in Section above the large system has failed The owner orb or answer significant threat under Section E or failed under Section b shall u operator of any large system considered a 15.304.The system owner should contact the P the system in accordance with 310 CMR appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B �Q CHECIMST Property Address a tJ ©Q oP' * o oC.1 Owner. Date of Check if the following have been dom You must a"yes"or"no"as to each of the following: Y No --�Wac g information was F� by the oar, or Board of Health _. any of the system components pumped out in the previous two weeks V Has the systm received normal flows m the previous two week period; — v large volumes of water been wed to the system recently or as part of this'mspwuon Were as built plans of the system obtained and exammeo(1f they were not available note,as NIA) Was the facility or dwelling.inspected for signs of sewage bast up. _ Was the site inspected for signs of break out Were all system eomponenK exchuling the SAS,located on site Were the septic tank manholes unco emd,open4 and the intaior of the tank inspected for the conditi of the bate or tees,serial of on c// �tr�ion,d�nsions,depth.of licpid,depth.of serge�depth of seam _ Was the facility owner(and occupants if different from owm)provided with infomation on the proper moe of subsurface sewage disposal systems The size a"watm of the Sail Absorption System(SAS}on the site has been determined based on: Yes information.For exampie,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is mmxeptable)P10 CMR 15.302(3)(b)j Page 6 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION Property Address: J QG I o V7 RG1 Owner. a�. •f/ �/9 ®a 1G �� Date of&Veition; ! FLOW CONDITIONS _ ��f 4e ve r RESIDENTIAL Lju ��- q+- Number of bedrooms(draig m). 3 of (ma).- 3 . DIJSIGN flow based on 3I0 CUR 15.203 for 3 t•+ s'�a<!a�i o y • Number of tint residenM D ( : 110 gpa x#of Does residence have a garbage gtiadea(yes or no).- Is.laundry on a separate,sewage system(yam or n0;Ev [if yes separate inspection �� Laundry systeffi inspected(Ices or no}:, (LV Ga/ �� Seasonal use:6=or no} Water meter rea dlaM if 0=2 years usage(gpe: lol O o 0 // 3 00c, lS4v- i G N� Sump pump(yes or no ___ Last date of off: COMMERCIAIJlNDUSTRIAL. Type ofeshMishment: Design flow(based on 3I0 CUR I5.203}.. Basis of design flow(�tslpersonstsgft„ete.y Grease trap present(yes or no).— Industlrial waste holding,tank present(yes or no):— Noa-sanitary wee to t Title 5 system(yes or Water meter reading$,if available: — Last date of oc cupangy/use. OTHER(describe): Pumping Records GENERAL INFORMATION Source of information: Was system pumped as part of the inspection es,or n0}r0 If yes,volume pumped ,—How was quantity pumped Reason for pumping: OF SYSTEM _Septic tank,distnbut ion box,soil absorption system —Single cesspooi _Overflow 0mv0d —ivy —Shared system(yes 0f no)(if yes,attach prm ious inspection records,if any) Im ative/ative/Attemative technology.Attach a copy of the current operafton and awe contract(to be obtamed firm system owner) —Tim tank —Attach a copy of the DIP appcaval —Other(desmbe): Approxhnate age of all components,date installed ifkrand smgp of inforntaticm; Were sewage ours detected when arriving at the site(yes or no):IL4 Page 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: / f/►/G�h Date of I&S '09: 07 WELDING SEWER(locate on Site.Pjanj Depth below grade: lt3 Materials of construction:— iron —`.�'r C— ("Plain). Distance from private water supply well or suction line: Comments(on condition of join venting,evidence of leakage,etc.): SEPTIC TANK.-"on site per) Depth below grade: 3 _ �// Material of eon on l.�ncrete metal fiberglass_Polyethylene other(explain) If tank is metal list age:— is age confirmed by a Certificate of Compliance mP (yes �):_ (attach a copy of Dimensions: tQ x Sludge deprh: Distance from of ! top shidge to bottom of outlet or bail: �? scum fttn ss: / r Distance from top'Of scum to top of outlet tee cur baffle: 7�� / Distance from bottom of scum to outlet tee oba8le How were dimensions d o 4C. / Comments(on pumping.recommendations,,inlet and o tee or baffie condition,structural rote as;#�-?Z,05ou tlet my ,evidence of}�ge etc.): testy,hQ d levels ,/10 t !?QeeCd I GREASE TRAP: on site plan) Depth below grade:_ Material of construction:—concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scam to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: e: Date of last pumping Comma(on leg commendations,inlet and outlet tee or bate condition,struGpual integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ) r Pa�8of11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION( ) Property Address: ✓0 e_ %�'f or►, o I'�GJ Owner. Date of 'on- p TIGHT or HOLDING TM;-tank must be pumped at time of inspw ion)(loc ate on site plan) Depth below grade:. Material of constructiom comrete metal Mxrglass.__polyethylene. other(explai:q; Dimension Capacity- Design Flow: VflonVday Alarm pment(Yes or no): Alarm level: Alan:in wading order(yes or no) Date of last puffing Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOXY/ (ifpresent must be openedy(locate on site plan). Depth of liquid level above outlet invert_,4eZ ta..j Comments(note if box is level and motion to outlets equal,any evidence of solids carryover,any evidence of leakag 'o or out of Pm etp.k PUMP CHAMBER-.."(I on site per) Pumps in working older(yes or no): Alarms in working.order(yes or no):. Comments.(note condition of pump chamber,condition of pumps and apputenances,etc.).. r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(couunuW) Property Address: O O J 4e— T(�!p✓r! 8viACJ Owner: S Date of 3 SOEL ABSORPTION SYSTEM(SAS): (notate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: � lehing chamb ,munber. f q ✓ 'S Ieaching gAfferies,.number: leaching trenches,number,length: leaching fields,number,dimensions: Overflow cesspool number: in�daiternative system Typrdname of technology: Comments(note ccoondition of soil,signs of hydraulic failure level of ponding,damp soil;condition ofvegetation, o� 'It CESSPOOLS:_c (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 con on: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): � PRIVY• (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): f Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM POORMATION(roatimx* Property Address: U� p e �o t o RJ Date of SKETCH OF SEWAGE DrAWAL SYSTEM Provide a soh of the sewage chsposd system mwhx mg ties to at kag two pamnuft referenceL vxbmftor benchmarks.Locate all wells within 100 feet Locate where pubhc water supply eaters the budding. a a A/ 3P �a -------------- Goo 0 j, �� 0 C^ ci _, P E Page 11 of 11 r. ' OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART C SYSTEM INFORMATION(continued) Property Address:. ©e / %o"1.1.0 N R_/ Owner. Date of Inspection: elol_ SWE EXAM Slope Surface water Check cellar �.� ©�� Shallow wells Ct� i Estimated depth tog water So Ed X l 39/ Z-0 Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-Xcheck4 date of design plan reviewed: ssavedsite(Auttingremyl�hole within 150 feet of SAS) ked with local Board ofxealth-explain: 70 w✓% Checked with local excavatcus,installes�(attach docume ioaj Accessed USGScatabase-explain You mug descn'6e y established:the hkh ground water elevation: rh •S 'J Gi.�vr /lr TO F 4a o ^ a D Ile/ow 10-G r ` •e P� C' 0� • 1 S0 (-moo �w�4t✓ l TOWN OF BARNSTABLE LOCATION 11 e �r,c�c , a,,, SEWAGE # 'P.17 - S VILLAGE ` ASSESSOR'S MAP & LOT d 7 !k INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY C )0 V LEACHING FACILITYAtype Q` S (size) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATE BUILDER OR OWNER L e_,�o DATE PERMIT ISSUED: 0- - t `6 b 7 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes t:x-� No �1�q� 3 it w a a No..4..1_ .. 1 .................. THE COMM�WEALTH OlF MAI Al ITTS BOAR® OF HEALTH ApplirFa#ion for Disposal Works Tonstrnrtinn ramit Application is hereby made for Permit to Constr� ( or Repair ( ) an Individual Sewage Disposal System at: nf1 Z�_ _ �3 J Ffe 7h�. for, rYq(VT t � 1-.L , // _ C4 ............. .......... .......................... ................................... .............. Location-Address or Lot No. a�� %Z Lam► ' v�s 7' f�3 ! G) I JZ�E. 2 ----- . ---••---•-•---------•--. --.-- .................................. O n=r Address --- - M Installer Address d Type of Building Size Lot...2`¢4.7.`�---Sq. feet Dwelling—No. of Bedrooms............... ........................... Attic '- Garbage Grinder(---)--'- '4 Other—Type T e of Building ��.-� No. of persons ............. Showers a YP g -----•---------•-------'=--- P _�_ }= Cafeteria a' Other fixtures ------------------------•_-___----. W Design Flow......................-�........__gallons per person per day. Total daily flow-__..._....._3.3._... ...................gallons. WSeptic Tank—Liquid capacity.40°•gallons Length l°.... .... Width... .�..... Diameter................ Depth.s....'�,L x Disposal Trench—No. ...... ............ Width....L .____... Total Length...... Total leaching area.... 3. _sq. ft. Seepage Pit No__________ ________ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( < Dosing tank-(--7— " R e-s 0-"e Percolation Test Results Performed by..... e___ ............... Date....... ..__�`� •-,.... � as Test Pit No. 1...._--_ ..minutes per inch Depth of. Test Pit..... Depth to ground water____./..' ...___. �-, c 2Pit .� �A fs, Test Pit No. 2________________minutes per inch Depth of Test ..__�_.�_..____ Depth to ground water..____......_}._..___. o ----------------•-- ---------------------------------....- .--------------- --------•------------------- . ................ Description of Soil-----.....l..r_1c_. .....r:...'^.�-s....... ....... %. "' �...-- `e '" -------------------------•--------------- x w 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 provisions of.A 'PT- the 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a rtificate of Compliance has been issued by t boa of l ea h. � Signed-<i _.. e Q Application Approved BY------- Z ........ ... o ----•---••---------.........••••.-•-•-- �1. ...Da Application Disapproved for the folloreasons:--- -•------------------•-----------•-------------------------....--------------•-------------------......_..••- ----------------------------------•---------•------•---------------------•-••-------------•--•----------•..--------------------------------------•---------------------------------------------....._..-- �y ^ 5 5^ Date Permit No. -----------------•-•---------•_ Issued_ ----- Date 7-9 No--• / FEB:. :.._.............. THE COMMJNWEALTH [OF MA ACHUSETTS BOARD OF HEALTH J 4 l�b M` �m�' ................... . ................OF.....f.- . ` .. G...... Appliration for Disposal Works Tonstrnr#inn Prrmit Application is hereby made for a Permit to Construct (ie)o Repair ( ) an Individual Sewage Disposal System at: --•------ .....__ _.......... .. ................................ . ...........•••-----......... .. Location-Address or Lot No. __ _ Ovrher Address n t r d ...... � l _ Installer Address Type of Building Size Lot---2 ....Sq. feet �-, Dwelling—No. of Bedrooms............... .........................Expansion Attic Garbage Grinder,�,.(�), Other—Type of Building I....!....�.�`:... .... No. of persons.........2;in.............. Showers_(.,4— Cafeterias-- Pa Other fixtures ------------------------------•. . W Design Flow......................�.... _..........gallons per person per day. Total daily flow............. . ................gallons. R: Septic Tank—Liquid capacity,*_.,"4�t.gallons Lengtheu.'..�:__.. Width-';....._.. Diameter................ Depth.S'...`?_-." Disposal Trench—No. -----1............. Width....�..'-'?_.._._._.. Total Length----- `.__._ Total leaching area___ r......I....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( -1� Dosing tank..(•—)'"' "�` ;� 0 ,r? - ," � 11 , { c �- " ` ~' Percolation Test Results Performed by.....�'' ..... ...... `...................... Date......(.... � ,.a Test Pit No. 1.__ _ ...minutes per inch Depth of Test Pit......_< Depth to ground water....:. .: ..... ri, Test Pit No. 2....!�t -�;:_..minutes per inch Depth of Test Pit__- _:9'L'.. Depth to ground water----1.4-.9.`.`..�?" of- x .......................---•••---•-•-••-•..........--•••----•--....--------------...••----••----------•............_... ODescription of Soil---......A1--=--.`�- ------�` '". ::: t--------:' "� .:5 .-a ...�s ��.,................................... x ------------------------------------------- U ----••-••--••••-•••-•-...-•------------------------••••---•---•-----•-----••-•......---------•-•---------•-----------------•-•-------•••--.---- W -----------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------•----•---- U Nature of Repairs or Alterations—Answer when applicable_-•............................................................................................ --------------------------------------------------------------------•--•------------•---•------•-----------------------------------------...-----------•------------------------------....---•-••---••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions oq"TtLAE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until i(ate of Compliance has been issued by the board of hea th. ��. C.!"' Signed `�'.• _: ✓a"' " - !� Application A roved B �� PP PP Y .... / aR D e Application Disapproved for the f ollo i g reasons----------------•----•----•-•------------•----------------------------------------------------------------••---•- -•........................•-•-------•-----------......••--•-----••---•---•----•-----.......-•-------...•.------•--------------•---•--••--------....---•-••------------•-••----•-----•--•--••-----•---••- Date PermitNo........................................................ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ......... ....................................................... Trrfifirab of Tontplianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (1,1 or Repaired ( ) p Installer at..... ........�..._2..e ~� ��`? a7'�._ . .....t1 t_.... .................... has been installed in accordance with the provisions of T F 5 of The State Sanitary ��ode as described in the application for Disposal Works Construction Permit No. .....) _ dated........'5--...... ________ ____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................... �_.�- ... ..�----------....------. Inspector...------------------V-�D.X.................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r I !F Lad rte'' .............. " ?^l.......,OF.......:._s?........:!:... ....r.................................................. No�--------•-...�-.L FEE�.Z........... Disposal Works Tonstrnr#ion Uprrutit Permission isereby granted_... . . _ A ('� P ( ) ' .. P� ... ...................................................................... to Construct or Repair an Individual Sewa e Dis osal stem at .....,s .: ' I_ "' ._ '..._ '...........................................................' Street 7 as shown on the application for Disposal Works Construction Permit No.• �--r.�.Uzated....?..'/.Slv --.-.�.-?......... DATE_.............................................................................. l Board of�Health FORM 1255 A. M. SULKIN, INC., BOSTON I __ __�___ , ____ " , ___ - __ -_ ---- - ,--,--,-----------_T____ --I------------__ I ,- � � -, �, I 11 � I- - I __ I I I I - ________________ - . -11 I__ ___r__- , -_7____ - - - _'..- , -"",""', �� ____ . � I I .I I --I- ,. _______,_________ ,, . ____-_ . I I . 1, � , , - . "I� _ ". � I �. �, . I-. . , . I ,� � . I I I I � I I . � . I � I . 1, . �,- . I I� I I 11 � % �� 'T",I I , � - -� � � '� - � �" I � I I � I � . � I - . . , , � . I I � I I � I I I� I - - ," ".: - �, , . . I . 11 � - I I I . 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