HomeMy WebLinkAbout0006 LOVELL'S LANE - Health 6 LOVELIS LANE, a 14�:S : n S o r4 Is
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I TOWN OF BARNSTABLE
LOCATION C oVim!�S SEWAGE #
VILLAGE �141/6 , ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY / 000
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility l Feet
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
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
• DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292-5500
11
TRUDY CORE
secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
- SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM -
PART A
/ / �t�J / CERTIFICATION
Property Address: G �- 0 V e l`�! l 1�1. ! l y �/1-2 Name of er (•t �>°✓1
5 23�Jd Address of owner:
Date of Inspection � "''��''��7777
Name of Inspector:(Please Prim)P,,4 z-✓ a W LC r
1 am a DEP system• rsuarrt to Section 15.340 of Title 5(310 CMR 15.000)
Comparry Name W FA614OC4 L7vii1) ,rd)jnM1P'V1hq1
Mawng Address: (��7/`, 02_6� T
'c Telephone Number:
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 inspection. The inspection was performed based on,my training and experience in the proper function and.
maintenance of on-sites sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
• _ Fails (J C)
ti
Inspectors Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department oftEnvironmental Protectlon.- The original should-be sent to-Vw
system owner and copies sent to the buyer,if applicable, and the approving authority. -
NOTES AND COMMENTS
RECEIVED
MAR 2 7 2000
TOWN OF BARNSTABLE
HEALTH DEPT.
revised 9/2/98 Pagel of11
Printed on Recycled Paper
�l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(contira"
Property Address: L v
Owner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. YSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 16.303 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.
Indicate yes, no,or not determined(Y,N,or NO). 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
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health. -.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
• Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping-more than-%urtimes-a yeardoe to broken or abut mcted pipeW. Thasysten.iWI puss
inspection if(with approval of othe,Board of•Health)-
broken pipe(s)are replaced
obstruction is removed
•
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
• CERTIFICATION(continued)
Property Address:
Owner:
Data of
C. FURTH EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Condit ns-exist which require further evaluation by-the Board of Health in order to determine-if the stem is failing to protect the
public h Ith,safety and the environment.
1) SYSTEM PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 MR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUN ONING IN A MANNER WHICH- O3T:CT-THEPUBLIC_HEALT1iAND.S ANU THE ENVIRONMEN1
Cesspo or privy is within 50 feet of surface water
Cesspool r privy is within 50 feet of a bordering vegetated wetland or a salt m rsh.
2) SYSTEM WILL FAIL UNLESS THE OARD OF HEALTH(AND PUBLIC W/TM SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THA PROTECTS THE PUBLIC HE7and
ND SAFETY AND THE ENVIRONMENT: - -
_ The system has a septic tan and soil absorption syste )and the SAS is within 100 feet of a surface water supply or
tributary to a surface water s ply.
• = The system has a septic tank a d soil absorption systqhe SAS is within a Zone 1 of a public water supply well.
The system has aseptic tank an soil absorption sys em and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and oil absorption sy6tem and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a ell water an ysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that f ility and a presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine ist a (approximation not valid).-.
3) OTHER
1
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revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
_on
D. SYSTEM FAILS
You must indicate either"Yes" or"No" to each of the following:
1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.30 The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be nec ssary to correct the failure.
Yes No \�
e — Backup ofeawags in4o -cesspool: -<�--�-a
Discharge or ponding of effluent to the surface of the ground or surface waters due t an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume 1 ass than 1/2 day flow.
Required pumping more than 4 rCes in the last year NOT due to clog ed 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 ssyfface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is-within a one I of;d-public well. -
• _ — Any portion of a cesspool or privy is within 50 et/of
/f a private water supply well.
Any portion of a cesspool or privy is less-than 10 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well,,has b an analyzed to be acceptable, attach copy of well water analysis for
••coliform bacteria,volatile organiocompounds, ammo is nitrogen and nitrate nitrogen. -
E: LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" to each of the following:
The following criteria apply to large systems in addition to the criteria bove:
The system serves a facility with a design'flow of 10,000 grid or greater( rge System)and the system is a significant threat to public
health and safety and the environment b�cause one or more of the following onditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system-is-within-200 feet of tributarya1eeeur ppltr
t
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Are -AWPA)or a mapped Zone 11 of a public
water supply well•'
I
The owner or operator of any such/system shall upgrade the system in accordance with 310 CMR 15. 04(2). Please consult the local regional
office of the Department for further information.
i
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revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
• Address: L... . U e.f k
Y o
Owner:
Date of hupection:
Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following:
Ye No
Pumping information was provided by the owner,occupant,or Board of Health.
.None of thesystom .flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
D _ The site was inspected for signs of breakout. -
All system components,excluding the Soil 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 orrthe site has been determined based on:--- -
• Existing information. For example, Plan at B.O.H.
N _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)1
Tbe.facifity.owmm.tand nnf-„�nt- f.riufferantfrpQL,ownart,WarP nrnLdna`ilb afar natioQwn_thA prnpnr�nintene�f
SubSurface Disposal Systems.
•
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
• .Nvperty Address: �; L o e
Owner:
Date of hapection:
FLOW CONDITIONS
RESIDENTIAL• �1
Design flow: lJ g.p.d./bedroom.
Number of be-rooms(desi n):` Number of bedrooms(actual):
Total DESIGN flow
Number of current r s�Garbage grinder(yes or no):
:
Laundry(separate system) (yes or no):a-If yes,-separatelaspection.requirad.
Laundry system inspected (yes or no)
Seasonal use(yes or no):&O Water meter readings,if av i ble(last two year's usage(gpd): AM,
Sump Pump(yes or no):Ad
Last date of occupancy: fDrrcj �
COMMERCIAL/INDUSTRIAL-
Type of establishment:
Design flow: 9pd (Based on 15.203)
Basis of design flow
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 INFORMATION
PUMPING RECORDS and source of infor ation:
Ntslo` br even,M De-C4
System pumped as part of inspection:(yes or no)_
If yes,volume pumped: gallons
Reason for pumping:
TY,"F SYSTEM
V/ 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)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installe"f-known)-end sourceofiroferniation:
Sewage odors detected when arriving at the site:(yes or no)�0
•
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION lcontirrred)
roperty Address: 6 o ve, n
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) `
Depth below grade: , /
Material of construction:_cast iron_40 PVC V other(explain)
Distance from►?rivate water supply well or suction line Gn n )/VC�t'�
Diameter
-- Comments: condition of joints,venting;evidence otFoakaye;•etc.) °..- .. -- _ . .. �_.. . .: ...<.__ ._•, -. .-_.-:A=.::....,._.,
SEPTIC TANK: p� d
(locate on site pl nT'
Depth below grade:
Material of construction:VConcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is Enetal,//ll�ist eager_. Js age r nfirmed-by Certificate of Compliance_(Yes/No)
p
Dimensions: I V( �
Sludge depth: \�
Distance from top of Vudge to bottom of outlet teeortsffle
p of scum to top -' —'
Scum thickness: i, \\
Distance from to of outlet tee or baffle: b
Distance from bottom of scum to bott of outlet tee or affle:
How dimensions were determined:
0 ;omments:
(recommendation for pumping,condition of inlet a outlet tees o►baffles,•depth of li uid I vel in relation to outlet-invert;-structureF�irttegri y,
evidence of leakage,etc.) ` 5 L �rl
t +
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.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: O V e,6 ; G n,
F _J
• Owner:
Date of Inspection:
TIGHT OR HOLDING TANK-". y. (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: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX-
(
locate on site plan) I .n '
V
Depth of liquid level above outlet invert:e,N1 '�(r w(i ov� 14 1 " ` 'e r
• Comments:
( e.if veel and.distrib lion is a al,evid of splid carryover;evidence o leakag into or out,of x;etc.)
PUMP CHAMBER:J V O
(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.)
•
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
leoperty Address: ( �, �t✓�l �,
dwrier:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_j/t C7
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type. leaching pits,number:�`� 6 N YJ
leaching chambers,number._
leaching galleries,number:_
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(note con •lion of soil,signs of hydrauli fai re,le el of poryding, da p soil condition of gotatio
f t/ II 1 C� ° '' / J
CESSPOOLS
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
• ipth of solids layer:
epth of scum layer:
DimensioM of cesspool:
r Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil,signs of hydraulic failure,-level of pending,condition of vegetation,etc.) --
PRIVY:40
(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.)
•
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: � �• Ve-4 Ow�:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
41 1
Ak 2-,96
3
Li i
i
62, 2.-�, 5
63
3 ? 5
revised 9/2/95 Page 10of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
•.operty Address:
Owner:
Date of inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked A/0
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope /V/O ,/n
Surface water
Check Cellar ��
Shallow wells A
Estimated Depth to Groundwaterr=Feet
Plea a indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed-Site(Abutting property,observation.hole,basement sump etc.)
Determined from local conditions
Checked with local Board of health
• _Checked FEMA Maps
Checked pumping records
Checked local excavators,installers
Used USGS Data `
Describe how you established the High Groundwater Elevation. (Must be completed)
i e 10 61t 01
revised 9/2/98 Page 11of11
L D A T ION g,, S E VPA G E PE R NI I T NO.
hQ --jet
SrOA/ AMC
INSTA tLER'S NAME ADDRESS I
®soRA S age `=
6 ��
IitiEDEN -OR OWN EA
`. ,0 WeA
D'A-� PERMIT ISSUED
DAT1 COMPLIANCE ISSUED
I�
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ra ,
6
I
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/4................. .
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® RF HEALTH
�.oc J.. ...... oF........ �..----•....................
Applira#iou for Dhipoii al Works Tomunrtiott Frrmit
Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal
Systemat........La.,Ye-L�.. -•-• .......--••.... .I1C1.... .............................................. -•--•---•-----
• Location-Addr ss or Lot No.
_. + �t ........................
...................................JS ........ ...................
Owner Address
W
Installer Address
Q Type of Building Size Lot....74P...5600...Sq. feet
a Dwelling—No. of Bedrooms..............1 ._..._.__...___..____.__Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
PL Other fixtures ------------------------- -----------------------•
W Design Flow................... ---gallons per person per day. Total daily flow.................... 3 Q..........gallon.s.
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............Z.... Depth below inlet.......lt�.._.___. Total leaching area.._ ... ft.
Z Other Distribution box (� Dosip tank ( ) /� ( .
'-' Percolation Test Results Performed by.► =1'�.'F_(�.G.........Y -' WV5.19 Date_..___..�,.-.-.1?:43......
Test Pit No. L.-. •minutes per inch Depth of Test Pit.......I"-Z--Depth to ground water.........................
Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-------•--------------------------------•----------------..........------------.....--•--------.•...........................................................
0 Description of Soil------------------------------------------------------------------- -----------------------------------------------------------._.._..---------
x4....... = ---- o + ------------..............................................................
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 LITI1 5 of the State Sanitary Code—The undersigned fur .er agrees not to place the system in
operation until a Certificate of Compliance has been by t lth.
1gne --- -------•---•-•------ -- ----- ------------------------------------------ ......
ation Approved BY Applic . ..
�at
---
Date
Application Disapproved r th following reasons----------------•----------------------------------------------------------------------------------------------•-
Date
PermitNo......................................................... Issued•.......................................................
Date
- ,
�30. ..... -- Fss...41
_.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-•........1.!'-'L�)1 1--------------O F.........: .{....t_<i-[:7 i '�-f :.C._" - .._.............. ..
F.......... ....
Appliratiun for Disposal Works Tonstratrtiun Prrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
L ��
................__.......1,,, .t i . ................ _ ... ................................•--•----. ...........................................
r Location-Add r s or Lot No.
s ,:L }!LI �e-k� ............... .................................................. -.- ----------
Owner Address
W
Installer Address
Type of Building Size Lot.....�__5ii?�Q..Sq. feet
Dwelling—No. of Bedrooms...............I.........-.:_..........Expansion Attic ( ) Garbage Grinder ( )
a�4 Other—Type of Building No. of persons............................ Showers —
g ---•-----------------•-•---- P ( ) Cafeteria ( )
Otherfixtures .........................................-.............................................................................................................
W Design Flow............... �...-----------gallons per person per day. Total daily flow.._............_.._.`33.�A.........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........60....... Total leaching area..__7 ..sq. ft.
Z Other Distribution box Dosing tank ( ) -
- — cy
$4 Percolation Test Results Performed by.-_ " ! F_ #._ .1 Via_. t=1��`� �
------ ----• Date------. .----
Test Pit No. L___ nutes per inch Depth of Test Pit--------L-:1 Depth to ground water........................
r=, Test Pit No 2....... minutes per inch Depth of Test Pit.................... Depth to ground water........................
p :
Desctilptiffiof Soil............................................................................ -----------------------------••---------------------------------------•-•-------------
VI........................................................... ...... ............ f ...............................
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 of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the.,board he:�lth.
c, ........... ---
Date
- � .... late
Application Approved BY
Application Disapproved fo he f(owing -'
'
reasons--------------------------------------------------------•--------------------•----------------------------....._
------------------------------------------•--•---•-----------------------...------------.....------....••••-•--••--••-•--•-...._..-----------------••-----------------••-•----•-----•-•••-•-------------
Date
PermitNo..........................................:.............. Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..:.......................................OF................... .................................................................
Trrtifiratr of ToutpliFanu
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
bY-.••--- ......... ---•----------••------------------•-----•----....._........-------------------------••••-...---•----
Installer
has been installed in accordance with the provisions of Tl � 5 of The State Sanitary Code as'de gibed in the
application for Disposal Works Construction Permit No.... . .---Aj ..... dated....... � _ .__ .................
THE ISSUJ NC OF THIS CERTIFICATE SHALL NOT>BECONSTRU A GUARANTEE THAT THE
SYSTEIOeI W F CTION SATISFACTORY.
DATE. ...... ..............•-•-----.....-•---•......-•••-•------......-•-• Inspe . ......`..............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-...........................................OF.....................................................................................
No... .. . .- FEE..... ...........
Dispos urk� . unstrudiun rrutit
Permissio -is reby granted_.. -------a� .
to Constru or Repairz an -Ixflividual Se_ r e Disposal System
at No.. __ _. f
•�. x ee .............
Street•\ �''
as shown on the applica 'on for Disposal Works Construction Permit No``— " ed_.` __: :_ ..............
Bo d of Health
DATE-�� Z/..-------- ------------------------•-------•--•--- .+
FORM 1255 HOBBS & WARREN. INC.; PUBLISHERS
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SIsG>r�C-_ Fp,M1LY - :3 BEDRooM I
vA►�Y F-bw _ 110 x 99•r �r�: .
T� .� �'P►JK - 330x15�% A95G.P. o \ r ' (a�;�:
�-.. u5E. •1000
N
015Po5AL P1T v5E Ivoo GAL. 21o,tS(cb 49 -4
t
50TTOM AREA a l 0 5 F•- �� �TM P)T
u
-•roTA1- pE.S1GNz
•"TOTAL. DA►t- ? 33oMew
PW
PE2 -OL.ATION RATE ] 1"IN 2MIN oR.L>✓55
ti OF
I ' MCHAAD o� AKIN
I' BAXTERmow.;
Na 24048Q . 251 _ s ,
ALE
I -r I-C�a�bO TOP FNu=IoI,QP ,
�'�T P 15�3 Y�y �•,�
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