HomeMy WebLinkAbout0016 LAKESIDE DRIVE - Health 16 Lakeside Drive
Marstons Mills
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 16 Lakeside Drive
Marstons Mills
Owner's Name: Sally (Hutchinson) Burke
Owner's A ddress: 1 Appaloosa Drive-
111 -(',Y•Sft1Lr±Y MA
Date of inspection: - �----- i$
Name of Inspector:(please print) W i 11 i am F._ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (5081 775-8776
CERTIFICATION STATEMENT
s
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.liam a DEP :Y
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: f
t Passes ' c� Z,z;
Conditionally Passes q t Y,
Needs Further Evaluation by the Local Approving Authonty
Fails
Inspector's Signature: i �, ,.,,., Date: —D
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth*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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: Sall (Hutchinson) Burke
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy em Passes:
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.
Comments: —
B. System Conditio ally Passes:
One or more sys rn components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,up n completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not de ermined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The septic tank is netal and over 20 years old' or the septic tank(whether metal or not)is structurally
unsound,exhibits bst�f ial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced ith a complying septic tank as approved by the Board of Health.
•A metal septic tank wil pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank i less than 20 years old is available.
ND explain:
Observation of ewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipes)or a to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board of ealth):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system req ired pumping more than 4 times a year due to broken or obstsiscted pipe(s).The system will
pass inspection if(with pproval of the Board of Health):
broken pipe(s)are replaced
obstruction is rtmovw
ND explain:
Page 3 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 16 Lakeside Drive
Marstons Mil s
Owner: Sall (Hutchinson) Burke
Date of Inspection:
C. Further E luation is Required by the Board of Health:
Condition exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protec public health,safety or the environment.
1. System will ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is no functioning in a manner which will protect public health,safety and the environment:
Cesspoo or privy is within 50 feet of a surface water
_ Cesspoo or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will f it unless the Board of Health and Y ( Public Water Suppler,if any)determines that the
system is functio ing in a manner that protects the public health,safety and environment:
_ The sys in has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface wate supply or tributary to a surface water supply.
— The sy tem has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
— The stern:has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
Th system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a
private ater supply well" Method used to determine distance
"This s stem passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria d volatile organic compounds indicates that the well is free from pollution from that facility and
the presen a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crit ria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: Sally (Hutchinson) Burke
Date of Inspection: R�✓�-�6 S
D. System Failure Cr' ria applicable to all systems:
You must indicate'yes" r"no"to each of the following for all inspections:
Yes No .
_ Backup of sewa a into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or po ding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or esspool
_ Static liquid lev 1 in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in c sspool is less than 6"below invert or.available volume is less than%day flow
Required pumpin more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of th SAS,cesspool or privy is below high ground water elevation.
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 esspool or privy is within a Zone 1 of a public well.
Any portion of a esspool or privy is within 50 feet of a private water supply well.
Any portion of a esspool or privy is less than 100 feet but greater than 50 Let from a private water
supply well wit 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 to well is free.from pollution from (fiat facility and (lie presence of ammonia
nitrogen and itrate 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.[
(Yes/No)The sys cm fails.I have determined that one or more of the above failure criteria exist as
described in 10 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to de ermine what will be necessary to correct the failure.
E. Large Systems:
To be considered a I rge system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000
gpd•
You must indicate ther"yes"or"no"to each of the following:
(The following crit is apply to large systems in addition to the criteria above)
Yes no
— _ the system is ithin 400 feet of a surface drinking water supply
the system is w hin 200 feet of a tributary to a surface drinking water supply
the system is loca cd in a nitrogen sensitive area(Interim Wellhead Protection Area-1WPA)or a mapped
Zone ll of a publi water supply well
If you have answered"yes"to any question in Section E the system is c—sidered a significant threat,or answered
"yes"in Section D above the l ge system has faikd.The wAmcr or operator of ttrry 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 shou d contact the appropriate regional office of the Department.
4
Page 5 of]]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: Sally (H ,t hin on) Burke
Date of Inspection:
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
I
Yes No/
r/ P mping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks
/— Y P P P P ?
✓ _ Has the system received normal flows in the previous two week period?
V Have large volumes of water been introduced to the system recently or as part of this inspection?.
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
I
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 baffles or tees,material of construction,dimensioor s, epth 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.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)(310 CMR 15.302(3)(b)J
5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: sally (Hutchinson) Burke
Date of Inspection: —!S�
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):. Number of bedrooms(actual):
DESIGN flow based on 310 C 15.203(for example: 110 gpd x#of bedrooms): .3 L b
Number of current residents:
Does residence have a garbage grinder(yes or no): /—V
Is laundry on a separate sewage system(yes or no):h� [if yes separate inspection required)
Laundry system inspected(yes or no)4 v
Seasonal use:(yes or no): .�
Water meter readings,if av ilable(last 2 years usage(gpd)): 2.004 — 46, 000
Sump pump(yes or no):.__Lti u 2003 — , 0 0
Last date of occupancy:
COMMERCIAL/INDUS RIAL
Type of establishment:
Design flow(based on 0 CTvIR 15.203): gpd
Basis of design flow( ats/persons/sgft,etc.):
Grease trap present( s or no):_
Industrial waste hol mg tank present(yes or no):—
Non-sanitary wast discharged to the Title 5 system(yes or no):
Water meter read' gs,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: 4
Was system pumped as part of the inspection(yes or no):,Lv3
If yes,volume pumped: /G a u gallons--How was quantity pumped determined? S, 6 �ti
Reason for pumping: A
TYPE OF SYSTEM `
_w
tic tank,distribution box,soil absorption system
gle 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
ob_tained from system owner)
_Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
9 F --
Were sewage odors detected when arriving at the site(yes or no):26
6
I,agc 7 of I I
OFFICIAL INSPECTION FORAZ-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F0101
PAItT C
SYSTEM INFORMATION(continued)
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: Sa1_ly (HUtehinson) Burke
Date of Inspection:
DUILUING EWER(locate on site plan)
Dcpdn belo grade:
Materials o construction:_cast iron _40 PVC_other(explain):
Distance om private water supply well or suction line:
Commcn (on condition of joints,venting,evidence of Icakagc,cic.):
SEPTIC TANK:`(locate on site plan)
Depth below gr e:
Material of cons ruction:_concrete metal fiberglass�ol)•cdiylene
_othcr(expla' ) _
If tank is metal I st agc:_ Is age confi nned•by a Certificate of Compliance (yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge deptll:
Distance from 1 p of sludge to bu►tom of outlet tee or battle:
Scum thickness
Distance from p of scum to lop of outlet tee or baffle:
Distance from Otto",of scum to bottom of outlet tee or baffle:
I low were dit cnsions determined:
Cum",ents(o pumping recommendations,inlet and outlet ice or baflle condition, siructwal integrity, liquid levels
as related to ullet invert,evidence of leakage,etc.):
GREASE TRAP:_(Io ate on site plan)
Dcpdi below grade:_
Material of eonswetioi:_concrete_inetal_fiberglass polyethylene`other
(explain):
Dimensions:
Scuin thickness:
Distance front top of scum to top of outlet nee or baffle:
Distance from bolto n of scum to bottom of outlet ice or baffle:
Dale of last purnpi g:
Conunents(on pu tping reeon«uendatiuns, inlet and outlet ice or baffle conditiunn, structural integrity,liquid levels
as related to oullc invert,cs•idcncc of leakage,ctc.):
7
'age 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
I'AItT C
SYSTEM INFORMATION(continued)
Property Address: 16 Lakeside Drive
Mars tons Mil-Is
Owner: Sall (Hutchinson) Burke
Date or lospcalon: ~�—o
TIGHT or HOLD G TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grad ;
Material of eonst ction: concrete_metal fiberglass_pulyethylcne othct(cxplaut):
Dimensions:
Capacity: gallons
Design Flow: gallonstday
Alarm prescn (yes or no):
Alarm level: Alann in working order O•cs or no):_
Date of last umping:
Comments condition of alann and float switclies,etc.):
DISTRIBUTION/box,
_(if present must be opertcd)(locate on site plan)
Depth of liquid leoutlet invert:
Conunents(note ivel and distribution to outlets equal,all),evidence of solids carryover,any evidence of
leakage into or outc.):
7%vork-i
R: (locate on site plan)
rdcr(ycs or no):—
order(yes or no):
ndition 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
SYSTEM INFORMATION(continued)
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: Sally (Hutchinson) Burke
Date of Inspection: $L --GSA /
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation
'not required)
If SAS not located explain why:
T�✓ leaching pits,number: I
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number: /
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: j" ',, $
Depth—top-of_liquid to inlet invert:
Depth of solids layer: —
3 1
Depth of scum layer: 4/—
Dimensions of cesspool.
Materials of construction:
Indication of groundwater inflow(yes or no):A—v
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (loca/onAen)
Materials of constru
Dimensions:
Depth of solids:
Comments(not)ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 Lakeside Drive
Marstons Mills
Owner: Sally (Hutchinson) Burke
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 building.
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 Lakeside Drive
Mars tons Mills
Owner. Sally (Hutchinson) Burke
Date of Inspection: r?r d
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water L feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting propertylobservation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how yo established the high ground water elevation:
iL�s F .Sr�lc S� a V 6
Il
1
A
_4
....5..pp..........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF I-IEALTI-I
(���V Town Barnstable
ApplirFation for Uhipoii ai Workii Cnnnulrnrfiun Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
,16 Lakeside .....Ua=t. .111l1a,..MA.....0264E..............•-----...--•---........---•-----.-..---
Location-Address or Lot No.
-William T. HutcYl X1bgn.--•.......................................... 3-6..Lakeside..�riye,..Marst.ons.Md].1s,..�tA....CL2648
-
Owner Address
A & B CsSvice esrace....H3aan�s* iA . 26C7lr.......................................... 12 ..�ishaBs.T .....
Installer Address
Q Type of Building Size Lot............................Sq. feet
U g— _Expansion Attic ( ) Garbage Grinder ( )
Dwelling No. of Bedrooms ................................
p., Other—Type of Building ............................ No. of persons...3....................... Showers ( ) — Cafeteria ( )
a Other fixtures -----•----------••--•-••---------•---••-------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__._____.__-_- Depth................
x Disposal Trench- No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation
Pit
Results mierformedr by--•---...-••-•.....................•---------------....... ---------- Date........................................
ap ch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+x ....................................................................................................
Sanc3 ------
O Description of Soil-•--------------------------------------------•----............-•-------.....------.----------------•----------------....-..----------------••--•-••......------.--•--
W
UNature of Repairs or Alterations—Answer when applicable.._in5tallation---of.-.a..l,.00Q..gallon,.__pra-cast,
stone packed leach Pit..(overflow),...(overflow),......................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of HT E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has�beeen� issued by the bo rd iealth. `
Date
Application Approved By.................. C�r/��....,..�,� 6-15.-�2-•-----•-----
Date
Application Disapproved for the following reasons----------------•-----------•--------•-----------------••-----------------------•-------------••-------....•-•---
............................................•------------._....--------•---------........------........--------------------------•-•------ ...................................-........................
Date
PermitNo.................82.................................. Issued................. ......................
Date
{
No..R2-.........._ Fss. .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............T-awn..............O F.....Barns:table..........----.......................---•...............---
Jklip iration for Uiipnsal Workii Tunstrnrtion "anti#
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
..16..I.akesi ci,a..I .sr�, sons N? ...A....02648.............................................................................................
Location-Address or Lot No.
..his.11iam..T—Rutchf.neon.............................................. 1.6... #on%s ;-tile_.-k...•426► 8
Owner Address
__A.&---P ............................................ 128-..B3shopa• � a� u3�a xiisY..Y? ( 641
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.........3.................................Expansion Attic ( ) Garbage Grinder
Other—T e of Building No. of persons..._ Showers — Cafeteria
W Other fixtures ------------------------------•--------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid-capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--___.--_--.-._--.---..-
�, Test Pit No. 2................minutes per inch Depth of Test Pit............--...... Depth to ground water........................
a ------. -•---- -----....-•--•--------------------------------------•---•---------................------........................._...........--
Descriptionof Soil Sand----.......---.....--•---•-------------•-------•----•--•--...------------------------------------.------------------------------------------------•-
x
W •-•--------••-------------- ............................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable...inatallati on.-Af..a•.1,.0A0-..gall,--pre-cast,
stone_.pack
(.saY�rAow)----•---------------•--------.---------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of I l l S 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 bgard,of)health.-
S- � :kjl✓� ............x.. �C`J... ..6-i5-82.............
i Date
Application Approved BY ------•---------------------------- ---------. -1 z
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------•-------------------------------
-------------------------------••--------------------•--•---......•••---......-••---...---------••.....--•-----•----•••------------•--------•------•-•---•--••-------••----•...t:--•---••---------------
Date
PermitNo.................. 2...--...------------------------.. Issued.-------------- -1 -fi2......---•------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........................Town.....OF.....Barn t.Ahlp.....................................................
Trrfif iratve of Tamptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (X)
bY--------- •-&---B_Gessp".I Senai�oe-,----128-- i-shGps JT-V -•-•-------------
6keidrNarstonsr�11 �at................................................s__ ._ -... IA.....02648_.....Wra .M.-.Hutchinan...................................
has installed in accordance wi_li the provisions of TIT Lam, ���The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....5. .............................. dated--_.._--------6- 582...--.......__...
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM.WILL FUNCTION SATISFACTORY.
DATE...........................................ez ............ Inspector... 7,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
31 Town F............Mm table
... ..........................................................
No�.�-=................. FEE. ...-r3II•D-4......
�i��n��t� n�k� �nn��rnt#Uan rrntt�
A & B Cesspool Service
Permission is hereby
� granted -- -- • . ----....
to Con s�irhuc�(ke4i°c�e Dpra1; �1a��onsd��i3��sSt�Age02��SG�m•T. Hutchinson
atNo...............................................................................................................................................................................................
Street 8-2— 6_15082
as shown on the application for Disposal Works Constructio fm N .. .......... .... tp ..._...-_--._-.._.____.__......_._.......
., --------------------------------•----------.--
B and of Health
DATE.................... ............................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS