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CO.MMONIVEALTH OF MASSACHL;SETTS
_ EXECUTIVE OFFICE OF E:N'VIRONMENTAL AFF.AJRS
_ F DEPARTMENT OF ENVIRONMENTAL PROTECTION
Qt� ` ONE R'INTER STREET. BOSTON hLA,0210c (617) 292-550t,
TRL DY CO\_-
Secre:a_-1
ARGEO PAi;L CELLLCCI DAVID B STR'-*HS
Governor Coniraissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Prop"Address: 34 Lovells Lane Name of Owner Michael `%Kim Glennon
Marstons Mills Address of Owner:
Date of Inspection:
Name of Inspector:( ease Print)Wm. E . Robinson Sr .
I am a DEP approved systerq inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
company Name: Wm. E . Robinson Septic Service
Mailing Address: PO Box 10d9, Centerville , 1VlA
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-site sZs"
disposal systems. The system:
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: ��/`,1 Date: C
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 of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
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revised 9/2/98 PaRclof11
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Vv• -. ied on Rewcled Pane,
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'lop"Address: 34 Lovells Lane , Marstons Mills
Jwrter: G lennon
Date of Inspecbon:,�/—
INSPECTION SUMMARY: Check 6) B, C, or D:
A. SY PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. S STEM 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 s, no, or not determined(Y, N, or ND).' Describe basis of determination in all instances. If "not determined',explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
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 pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipets) are replaced
obstruction is removed
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Prop"Add►ess: 34 Lovells Lane , Marstons Mills
Owner: G lennon
Date of Inspection:
C. FURTHER 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 the
ublic health, safety and the environment.
1) YSTEIM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
1 OTHER
revise.^,. Page 3of11
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress34 Lovells Lane , Marstons Mills
Owner: Glennon
Date of Inspection:
D. S TE1M FAILS:
You mu s indicate either "Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
termination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes N
Backup of sewage into facility or system component due to an overloaded or-clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. RGE SYSTEM FAILS:
You ust indicate either"Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area•IWPA)or a mapped Zone 11 of a public
water supply well)
The o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
offic of the Department for further information.
revised 9/2/98 Page 4orIl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
Prop"Address: 34 Lovells Lane , Marstons Mills
Owner: Qlennon
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
/ inspection.
v _ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
signs The site was inspected for si f r— _ P g o breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_L/ _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
)7/ (1.5.302(3)(b))
v _ The facility owner land occupants,if different from owner) were provided with information on the proper maintenaarA4f
SubSurface Disposal Systems.
I
rev1sec 9/2/98
Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Irop"Address: 34 Lovells Lane , Marstons Mills
owner: Glennon
Date of Inspection: c1-C-6-O
FLOW CONDITIONS
RESIDENTIAL:
Design flow:2,7-0 g.p.d./bedroom.
Number of bedrooms(design►: Number of bedrooms (actual;:
Total DESIGN flow
Number of current residents: d�lA
Garbage grinder(yes or no):_�!' t)
Laundry(separate system) (yes or no):1„ 0; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): --- v
Water meter readings, if available (last two year's usage Igpd): 1 Q R1 , onn gal .
Sump Pump (yes or no):iL 0 1998 76, QQQ gal.
Lest date of occupancy:
CO ERCIALflNDUSTRIAL:
Type f establishment:
Design flow: Qpd ( Based on 15.203)
Basis o design flow
Grease ap present: (yes or no)_
Industria Waste Holding Tank present: lyes or no)_
Non-seni ary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last to of occupancy:
OTHER (Describe)
Last d of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
&ZA
System pu ped as part of inspection: (yes or no)' d
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF YSTEM
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 installed(if known)and source of information: 612
f•p t'
Sewage odors detected when arriving at the site: (yes or no)AI U
revised G/2/9. Page 6ofII
J • '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contimod)
+ropertyAddress: 34 Lovells Lane , Marstons Mills
owner: Glennon
Date of Inspection:
BullING SEWER:
(Loca on site plan)
Depth elow grade:_
Materi of construction:_cast iron_40 PVC_other(explain)
Distan a from private water supply well or suction line
Dia ter
Com ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
) I
Depth below grade:
Material of construction: LCo�crete_metal_Fiberglass _Polyethylene_otherlexplainl
If tank is metal,list age_ ls.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 4 4z'
Sludge depth: E/--
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: )—a `
Distance from top of scum to top of outlet tee or baffle:_ )
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
;omments:
Irecommendation for pumping, condition of inlet and outlet ees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) Ai A C'1'
GR TRAP:
(locate o site plan)
Depth bel w grade:_
Material o construction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain)
Dimension
Scum thic Hess:
Distance f om top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of I st pumping:
Comm nts:
(reco mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
eviden a of leakage, etc.)
revised Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
�ropertyAddress: 34 Lovells Lane , Marstons Mills
Owner: G lennon
Date of Inspection: 6—D
TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(local on site plan)
Depth b low grade:_
Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensio s:
Capacity: gallons
Design fl w: gallons/day
Alarm pr sent
Alarm le el: Alarm in working order: Yes_ No_
Date of revious pumping:
Comm ts:
(condi on of inlet tee, condition of alarm and float switches, etc.)
I
DIST BUTION BOX:
(locate on site plan)
Depth o liquid level above outlet invert:
Comme s:
(note if I vel and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) -
PUMP HAMBER:_
(locate n site plan)
Pumps i working order: (Yes or No)
Alarms in working order(Yes or No)
Commen s:
(note co ition of pump chamber, condition of pumps and appurtenances,etc.)
revises 9/2/98 Page 8of11
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 34 Lovells Lane , Marstons Mills
Owner: Glennon
Date of Inspection: L �
� G_ o-
SOIL ABSORPTION SYSTEM(SAS):_
(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:-2--
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs f�hydraulic�failu1e, level of pondin�, damp soil, condition of vegetation, etc. "
" 6 (�r C y/
Lt art 1 �' T 7/C/b S ]I v+7 L^
CESS OLS:_
(locate or
site plan)
i
Number an 'configuration:
Depth-top o liquid to inlet invert:
')epth of soli s layer:
)epth of scu layer:
Dimensions o cesspool:
Materials of onstruction:
Indication of roundwater:
infl w (cesspool must be pumped as part of inspection)
Comment
(note cond ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:_
(locate on to plan)
Materials f construction: Dimensions:
Depth of olids:
Comme s:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revises 5/2/ Pagc9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Noperty Address: 34 LOvells Lane , Marstons Mills
'caner: I Glennon
Jate 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)
c
39
' fey„w rs i 1
revised Page 10of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
rop"Address: 34- Lovells Lane , Marstons Mills
Owner. G lennon
Date of Inspection:
NRCS Report name (,
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells V
Estimated Depth to Groundwater 21 Feet
Please 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)
revised 9/2/96
Page 11 of I1
LOCATION SEWAGE PERMIT NO.
VILLAGE
. ,
INSTALLER'S NAME & ADDRESS '
9• cow bt c2 �.
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED • f/r
Y
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C ovz s L�,
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THE oomMomvvsxLr* or MASsACnussrrs |
|
BOARD OF HEALTH
...............).0Z,11.n..........OF-' '
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�.�� �� ��x�x�m���
���/�����«����o» ��`� w� Works Tonstr44rtioXK Prrutit
Application is hereby made for u Permit to Construct / \ or Repair an Individual Sewage Disposal
System
----'s.�4-12�8 ....AMC................................... ---------------------------___-_-________________
--------___-__'_--'----_----'_---...................... ---'- '_ ----------------'----
���
Installer Address
� Type c6Building Size l.oL-------------'3q. feet
� Dwelling--No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) -- Cafeteria ( )
Other fixtures
............................ .........................................................................................................................
Design Flow.............................................gallons per person per day. Total daily flow............................................gallons.
� 04 Septic Tank—Liquid coyucity-.-_'.gulnoa Length--------------- Width................ Diameter---............ Depth................
Disposal Trench--No. .................... Width.................... Total .................... Total.leaching area....................sq. ft.
Seepage Pit No--------------------- Diaoetor------.- Depth below inlet.................... Total leaching area..................sq. f t.
� Z Other Distribution box ( ) Dosing tank ( )
'- Percolation Test Results Performed bv.......................................................................... Date........................................
Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to 'ground water........................
� P� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
P4 '
0 of '
'
-__--'_'--__.
U Nature of Repairs or Alterations--Answer when ........... .....................................
.......................................................................................................................................................................................................
Agreement:
� The u��s � ��1d� u��d�c�� �d��u D�n� S�� � u�o�u�e ��
� __�__"--- -_ ~-..-�- '
d����sioua ofIZTL IZ 5nf the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance
. Signe/bDe
----- -��'��~���'�_
u= --
� DateApplicationApproved By----.--------_-. ----------_---------_-______^' ........................................
um^ �
Application Disapproved for the following reasons:................................................................................................................
---------------_-'--------_---------_--'--'_-----------'--.--'_---------'-----------.--------------Dau
�
Date
`
�
——`--`---------- -
�
F�s?�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD .OF HEALTH
-Appliratiun for Disposal Works Tun#rur#inn Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( L�-an Individual Sewage Disposal
System,At: ;
Location Address
....... ------------------ 7 ............................. . F .. ?...{._<�,f�ct• '� — ft),. --•--•--•--..................--..........
W '/`/^p Address
••-
_.... ''a"-�•___C1' ! . [r .`.fcd✓!.... ......._ JF'- ._ .j�i!Y...c.. ........�4.�J- �J.$-f�'� ..................................................
Installer Address
PQ
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
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........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.:......................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f4 •----- -:-**-----------;••-•-
.•-•--
Descriptionof Soil r . .. :.... VI.X-1...............................................................................................
U ••----••-•••-•••----••••-•--••--------•-•---•-----•••-•-----•-•-•-•----•-••-•..................••---._._.....-••-•------•--••-•......--•---••-•-----•.....••-•-••--•-...•----•----...._.._......•------
W
x =-------• ----------------------------------
U Nature of Repairs or Alterations—Answer when applicable........... _ F f - y - -...................................
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 of health.
-41
ram.
SI ned
� f o !y�J
Jate
ApplicationApproved By............................... ••. •...•-••••••••-•--•-•••..............................•--•- ---•-•-•-••-----•••-----------
Date
Application Disapproved for the following reasons------------------------------------•----------------------------•---------------.............--------.........
........--•--------------•-•-------------.....--•--•--------.........----.........------........----•----'---••--••-••-•-------=-------•---------•------•---•---------•---•----•-•••-------•-••-••-•---•-
1 Date
PermitNo............................................. _ _ Issued_.......................................................
Date
THE COMMONWEALTH OF'MASSACHUSETTS 1
BOARD OF HEALTH
............. %mot{„t ' ..........OF... �'. ;t.. lei as ',��!! ...................................
Trrfifiratr of Tuutpliattrr
THIS_.IS,TO CERTI: 'Y, That the Individual Sewage Disposal System constructed ( ) or Repaired )
-
by............
---------------
.f
Installer E Y )
. 3 f 3/,(i 'J d j 1°rgr. ° /d - k 1 A j ..... - ...
at.. Ls9f ! _s �� 4 -__f�vv�. ( .._ nr tv°� t
.___....__._ ...f ................. ............................
has been installed in accordance with the provisions of T�T FF 5 of The State Sanitary Co c)e as dscribed in the
application for Disposal Works Construction Permit No.U_L..__k7..................... d ted_.y/ .Z,� /_ --..__--------------.--
THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTR AS A GUARANTEE THAT THE
SYSTEM , 1 FUNCTION SATISFACTORY.
DATE... . .. .. .. Inspector------ .... -•---•---------------•------••-•----..._....-••-•--•-----•---•......-
THE COMMONWEALTH OF MASSACHUSETTS
— BOARD OF HEALT
............. FEE..,
...... .......Y.
Disposal Piurks (9un rildi rr, t#
Permission is hereby granted....E..,�!.. ����'__�� - �- ------•............ ......................
_,�'to nst' ct ( � o Rep i ) �a}a� ldu y Sy /�b�' �
at No... �trf � r°� f� / /
...................................................... ................................................
Street _
as shown on th appli tion for Disposal Works Construction Permit No...... ...... .:: Dated.......................................... t
DATE,.-- . . .
Board of Health
FORM 1255 A. M. SULKIN. INC.. Br'��T
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