HomeMy WebLinkAbout0185 PRINCE AVENUE - Health 185 PRINCEd
A=076.030
— J TOWN OF BARNSTABLE
,LON �� `�-� �� SEWAGE #_
V"L..LAGE JA.VVSIb i IC-% ASSESSOR'S MAP& LOT ®�I
DISTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) �k (size) X
NO..OF BEDROOMS ;
BUILDER OR OWNER ! kCC agQ 1,,1--A
ttl`DATE: COMPLIANCE DATE:
Separation Distance Between die:
Maximum Adjusted Groundwater Table to the - \Z Fee
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of teaching facility) "_Fee'
Edge of Wetland and Leaching Facility C'lf any wetlands exist ,
within 300 fe flea hing facility) ' F'
J Furnished by e
-
P�Z,3y` 3S'
3`(oil
3
TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
NAME ZATi . MAZQ 121 t 900
ADDRESS 16", M0615 A 1400 VILLAGE WOM& M I WO
LOCATION OF TANK': CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
U�1d l�UWD lt�l�' �IDU ?000 GAL l9IL eµo
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. �18 2. 3. 4.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED: I� 1, �� �1� b'( I•fi� ( C I
PASSED DID NOT PASS
COMMONWE.kLTH OF T�L-%,sSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AF
_
DEPARTMENT OF ENVIRONMENTAL PRO `ION
554(
ONE X\INTER STREE7. BOSTON 02108 (617) 292-,55,)(
DEC
V TOWNOFSARAfST 9qR -y CO\
S'ecre-a
h&4L7hDFPTAAE
DAVI'E�B/STR.'�-
ARGEO PALL CELLUCCI '..,F
conuniss::.-,
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
� (_
Property Address: �os Name of Owner bLtt)c z —
tAvYLSTbj%j t t\S Address of Owner: ISr-n 16A%J"�, I cc)I
Date of Inspection:. ok%t ,`
Name of Inspector:(Pie a Print) a C)
I am a DEP approved system Inspector pursuant to Section 15.340 of Tide 5(310 CIVIR 15.000)
Company Name: A i Ek 1'...ice—,1. Ak's le L,% - I
Mailing Address:_Za A,= 4 2 4c7
Telephone Number: 4,E7-F=.
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 sewage disposal systems. The system:
Posses
Conditionally Posses
Needs Further Evaluatiop-4y Ike Local Approving Authority
Fails
Inspector's 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 of Environmental Protection. The original should be sent to thre
system owner and copies sent to the buyer.if applicable.and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 of 11
Fronted on Racv%W Pjfw
n y,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (conpnou-d)
'roperty,Address
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, o/ D:
A. SYSTEM PASSES:
A— 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. SYSTEM CONDITIONALLY PASSES:
/z� 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(sl
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 four times a year due to broken or obstructed pipe(s). The system will pass
Inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 age Iof 11
?'' aF i �.,.;
iJ
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C.r�FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
'y Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WTfH 310 CMR 15.303(1)(b)THAT.THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of Jurface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
I
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 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 1 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 eoliform bacteria and volatile organic compounds indicates that tht
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).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM +
PART A
CERTIFICATION (continued)
Pr Address:
Owner:
o Y
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
f surface of the round or surface waters due to an overloaded or clogged SAS or
_ Discharge or onding of effluent to tie su 9
_ 9 P
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 pipelsl.
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. 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 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 publi
health and safety and the environment because one or more of the following conditions exist:
Yes Na '
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 II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 esge4olll
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: ,ue,
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ygs 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 volume of water have not been introduced into the system recently or as part of this
inspection.
A4-b4 at 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.
X _ 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 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)
115.302(3)(b)I
The facility owner(and occupants,if different from owner) were provided with information on the propermaintenaa".of
Subsurface Disposal Systems.
revised 9/2/98 PagcSof11
v
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA.
PART C
a t SYSTEM INFORMATION
Iroperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: qlD g.p.d./bedroom.
Number of bedrooms (deessign):04 Number of bedrooms (actual):_O�
Total DESIGN flow 44
Number of current residents: 01
Garbage grinder(yes or no):
Laundry(separate System) or no):Q; If yes, separate inspection required
Laundry system inspected (yes r no)
Seasonal use (yes or no):
Water meter readings, if a ilable (last two year's usage (gpd): NL
Sump Pump (yes or no):t0 i
Last date of occupancy:R, Soli 1
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on i 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 ource of information:
Z,AA J-Zd
System pumped as part of inspection: (yes or no) Lt
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/eftffibudun boxftoil 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: { o ��S Ek.L:h%C
Sewage odors detected when arriving at the site: (yes or no) �
revised 9/2/.98 Page 6(of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
16�1
Depth below grade:—7
Material of construction:_cast iron 40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter M
Comments: (condition of joints, venting, evidence of leakag etc.
c.L,T
SEPTIC TANK:-S
(locate on site plan)
Depth below grade. XLi( +��
Material of construction: concrete_metal_Fiberglass _Polyethylene_other explain)
•
If tank is metal,list age_ Is age confirmed by Certificate of Compliance_ (Yes/No)
Dimensions Mc Sp'`
Sludge depth: �(
Distance from top of sludge to bottom of outlet tee or baffle:
Scum`thickness: it
Distance from top of scum to top of outlet tee or baffle: \J-t `I
Distance from bottom of scum to bottom of outlet tee or baffle.�_
How dimensions were determined:
:omments:
(recommendation for pumping, condition of inlet and outlet tees or baffle;, depth of liquid level in relation o outlet inv rt, s ructur tegnty,
evide ce of leakage,etc.) l , `\
Qvt ZsC"
GREASE TRAP• L
(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
Q �
SYSTEM INFORMATION (continued)
'roperty Address: v65
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: P^ (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.)
a
DISTRIBUTION BOX:L�
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER: (!
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or Not
Comments:
(note condition of pump chamber,•condition of pumps and appurtenances, etc.)
revised 9/2/98 rage 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued,)
4operty Address: ( 5�d,»uq�
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): -S
(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:—Aw fo
leaching chambers, number:_
leaching galleries, number:_ I
leaching trenches. number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of pondin , damp s •I, c dition of vegetation eSc.)
OF A r Skk���
CESSPOOLS:
(locate on site plan)
Number and configuration.
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
Inflow(cesspool must be pumped as pan of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:-60
(locate an 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 P,ge9ofII
w
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
'roperty Address: I Q�S-t Q%Kx-A—,
)wner:
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)
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tCQAN� .
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S ��` ;lrol4a �1_ aft
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revised 9/2/98 Page 10of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
•
roperty Address: i�S �I�Itti+c�
Owner:
Date of Inspection:
NRCS Report name 1'ro — —'—
Soil Type_
Typical depth to groundwater_ __ _ ___
USGS Date website visited (wo
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slopes I
Surface water 'f' %Coal
• Check Cellar tA-\A
Shallow wells
� I
Estimated Depth to Groundwater VL 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 9/2/98 Pae11ofIt
e
LO q CT:ION S,E VE PERMIT NO.
VILLAGE
1NSTA LL- R'S N E & ADDRESS
2a"
BUIlDEWFOR OWNER
DATE PERMIT ISSUED � '�_
i
DATE CO,*PLIANCE. ISSUED 'mil`
r
��
i� P �
i
� i
��
�- ,
� :
._
L 0� A0Y SEWAGE PERMIT NO.
ag
ViILA �� �/f
"l
I N S T A LLER'S NA i ADDRESS
BUILDER -0 OW
DATE PERMIT ISS ED
DATE COMPLIANCE ISSUED
�K
n�v
No. >�.o
• FI��........N...®.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
>>
l. OF.. � .....................
Appliration -fur Bi-quiittl Workii Tonfi#rurtion Vamit
Application is hereby'made for a Permit to Construct (4 ) or Repair ( ) an Individual Sewage Disposal
System at:
3..... --------
--------------------------------------
Location-Address or Lot No.
Owner Address
�1
Installer Address
Q Type of Building Size Lot...d4_.�..................Sq. feet
Dwelling—No. of Bedrooms--.-__��------------------------------Expansion Attic (A10) Garbage Grinder (a�
per, Other—Type of Building t9M�: a ___ No. of persons.................I......... Showers ( ) — Cafeteria ( )
dOther fixtures -------- K` `',-----------------------------------------------------------•---...---•-------------•-----......__.._..------......----
w Design Flow---------- e_____________________ ____gallons per person per day. Total lily flow-_____________-__---.�d-------------gallons.
W Septic Tank—Liquid capacity_. d._gallons Length....
Width_._ _.....__.- Diameter----6._....... 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 ( )
aPercolation Test Results Performed byA -fit_. ° _ .�_'_-- � __��-__--_ _ .........................2 '..�'__. Date
a Test Pit No. 1.... .-.'�.._---minutes per inch Depth of "lest Pit.....tZ----------- Depth to ground water.....PO .....
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----------------------
--------------------------------------------------------------------------------------------- -•----------•------------------------------- .......!.......tr----- ----•-----------------.-----
Description of Soil_- C�� ®e�" � ) SUA �� t
x
----------- ------t 7.:
i�
VNature 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 Article XI of the State Sanitary Code_---The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be t f health.Signe !... _ _ f 7
...........
Date
Application Approved BY b ---�-�---------
Date
Application Disapproved for the following reasons:.......................... --------•-------..__........-----------------------••-----------..........-•-•-------
............................................... -•------•--------•--......--••---•------------------
------------------
Date
PermitNo..---................................................... Issued........................................................
` Date
9,
:.. ` Finc........ .....................
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD O HEA
Y. .: ..... ...OF...':......
ApplilrFation -for Mixivooal Morko Tottwurtion Vamit
Application is hereby made for a Permit to Construct pair ( ) an Individual Sewage Disposal
System at:,
r = ..... ......................................... ...............•-•---------- +.........••--•.---..--•.•-•------........................
Lo+caattioonn.Address or Lot No.
07
f1 Owner Address
Gil
Installer Address
Q Type of Building Size Lot-.-= -�-�_-_-_----Sq. feet
U Dwelling—No. of Bedrooms.____ .................................Expansion Attic (WO) Garbage Grinder
aOther—Type of BuildingMi ►."�O-.. No. of persons-----------------t--------- Showers ( ) — Cafeteria ( )
Otherfixtures "11'r! ----------------------- -----------------------------------------------------------------------------------------------
Design Flow.......... d.-_---•_____________ gallons per pet-son per day. Total lily flow------------------ .� ,yd gjlon_.-
Septic "Dank—Liquid capacity. t0.gallons Length:-_ O-__ Width__..----._.. Diameter_-- ....----_ Depth. ...........
xDisposal Trench—No-____________________ Width..-._-_-__--_----_-- Total Length-,------------------ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area.-.-..-_-.-_-__-_sq. ft.
z Percolation Test Results ) pe Dosing tank )
Other Distribution box
'-' rformed by� V-w+...-- ,�__ .. � _-- Date__? JS+�'7
a
Test Pit No. 1_..!' ___mmutes,per Inch .Depth of "lest'Pit. . ........... Depth to ground water..... - ...
Ct Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--_-.--.-_-----.-----_-
'v l
Hr11A �» �O Description of Sotj f _ 1(
. � ------ Now
- -- ----- -- -- -
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 Article \I of the_State Sanitary Code , he undersigned further agrees not to place the system in
operation until a Certificate of. Compliance has b s f ealth m
Signe -- ----------
fir.�/•
i
_ i f
77
Date
Application Approved By.:
� - 15 f .1.1 1 . ?
{ Date
Application Disapproved f or fhe following reasons------------------------------------------------•----------------------------------------------------------------
•---------------------------•------------•------------------------------------------•-------------•-•-----------------------------••-•--•--•---•---•---------------------------------- -----------------
Date
Y
Permit No.••--•••---•=-----==-----------.:..----•--'----------_.. Issued--------------------------------------------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEA H
IF'W�Z OF. j
(ffrrtif ir4itr of wompliatur
I IS 0 TIFY, T t t Individual Sewage Disposal System constructed ( ) •or Repaired �( )
Insta /���
y
at... Y-la ' L" --,--•- .fix G+r 4------ I` `...... !r'O
has been installed in accordance with the provisions of Ar ' Iof The State Sanitary Code as describe in the
application for Disposal Works Construction Permit No--=-- --------- )/hr._....._..... dated..."':---+�� _"'_----______.__........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE .CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNC IqN SATISFACTORY.
/-
DATE .................------•----•-Z ----•--•................. Inspeetor- G �� J.........
t
1 .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTM
.............. :..�t ►....... :.
No............. f' FEE._.� ".ww+.....
Cro +tt rrinit
Permission is he by granted..�" -- ----------- ............................................
Constr t �r kr ( ), an ndividual Se s
at No.... t• ... .... ------ --
- ,g4R reef �
as shown on the application for Disposal Works'Construction Pe St'it No.__._ -_._.._ ..._. Dated-_--T-' /'-77 ------
`
------------
Board o
r' DATE_—,-----•-•-•----------- ----------------.............--............
;Kt
,
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS.'.- ��� ' -