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TOWN OF BARNSTABLE
LOi ATION O -TI M�Cr In. SEWAGE #
Vr:LAGE 1'Yl. yVl, �i5 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE/NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) r ► / (size) (O X (o
NO.OF BEDROOMS —3
BUILDER OR OWNER HAn S en
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: 4 ,
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / 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 2 1999
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET, BOSTON MA 02108 (617)292.5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 85 Timber Lane, Marstons Mills, MA Name of Owner: David Hansen
Address of Owner: Same
Date of 1►ispktion: January 19, 1999
Name of Inspector: (Please Print) James M. Ford
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: James M. Ford
Mailing Address: P.O. Box 49, Osterville, MA 026SS-0049 Map: 149
Telephone Number: (S08)862-9400 Parcel: 053
Lot. 28
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:
✓ Passes
Conditionally Passes
Needs Further Evalua on y the Local Approving Authority
Fails
Inspector's Signature: Date- January 25, 1999
The System Inspector shall submit copy of this ins tion 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 V
revised 9/2/98 Page Iof11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Timber Lane, Marston Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM 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. 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 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 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 ' t
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 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 85 Timber Lane, Marston Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
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
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)
THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND
THE ENVIRONMENT:
The system has.a septic tank and soil absorption system.(SAS)and the.SAS is within 100 feet to a surface water supply or
t 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 bui 50 feet or more from a
private water supply well,unless a well water analysis for colifotm bacteria and-volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of an monia 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)
Property Address: 85 Timber Lane, Marston Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
_ I have detemuned 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.
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 '/2 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 1 of a public well.
Any lw cesspool portion of a or privy is within 50 feet ofa private water supply well.
in
- -
f s,v
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 roust indicate either "Yes" or"No" as 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 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 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 85 Timber Lane, Marstons Mills, MA s.
Owner: David Hansen ==
Date of Inspection: January 19, 1999 :` r 1.•>..: .<. ;}'s
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.
n/a 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.
✓ _ 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 conditions 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. _
✓ _� ' `•Detemuned 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)]• - r
✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,INFORMATION
Property Address: 85 Timber Lane, Marston Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999 a
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom.
Number of bedrooms(design): 3 Number of bedrooms(actual): " 3
Total DESIGN flow n/a
Number of current residents: 3
Garbage grinder(yes or no): Yes
Laundry(separate system) (yes or no): No ; If yes, separate inspection required
Laundry system inspected(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available(last two yeargs usage(gpd): private well
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied.
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: mA(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: r. ,
PUMPING RECORDS and source of information:
Puniped last year-per owner.
System pumped as part of inspection(yes or no): No
If yes, volume pumped: _gallons
Reason for pumping:
TYPE OF SYSTEM
✓ 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: Unknown
Sewage odors detected when arriving at the site: (yes or no) No
revised 9/2/98 Page 6ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM•INFORMATION (continued)
Property Address: 85 Timber Lane, Marstons Mills, MA
Owner: David Hansen - "
Date of Inspection: January 19, 1999
BUILDING SEWER: _
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC _other(explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: ✓
(locate on site plan)
Depth below grade: 8"
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: 10'6" x 5'8" x 5'8" (1500gal.)
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle:' 7"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How dimensions were determined:. ..Measuring.stick
Comments:
(recommendation for pumping,condition of inlet and outlet ieesor baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) The tees were present. The liquid level was even with the outlet invert. There were no signs of leakage. The tank
was pumped for maintenance.
GREASE TRAP: None
(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 7of 11
' to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Timber Lane, Marstons Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
TIGHT OR HOLDING TANK: None (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: Yes
(locate on site plan)
Depth of liquid level above outlet invert: 0" <_ r
Comments: t
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) The box was level and there
were no signs of solids carryover. -
PUMP CHAMBER: None
(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 8oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Timber Lane, Marston Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
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: 1 -6'x 6'
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number: ~o
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
There were no signs of failure. Grass and scrub brush cover the pit. The pit was full. The bottom of the nit to Qrade was 9'.
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:-
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.)
PRIVY: None
(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 9oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Timber Lane, Marstons Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
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)
W el j l 50
18
34
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revised 9/2/98 page 10of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 85 Timber Lane, Marstons Mills, MA
Owner: David Hansen
Date of Inspection: January 19, 1999
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
Estimated Depth to Groundwater 33 +/- 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
Check local excavators, installers
✓ Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
Using the Barnstable topographic and water contours maps, the maps were showing approximately 33'to
groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty
or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,
written or implied,relating to the system, the inspection and/or this report.
revised 9/2/98 Page 11 of 11
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEAL
............teA ._.......OF................. :......................._
Apptiratiun for Uiipuual Works Tontitrnrtiun 1hrmit
Application is hereby made for a Permit to Construct ( ) or Repyrt ( } an Individual Sewage Disposal
System at:
..............••••--•---•-------_.... a, �e,r L<<v�.
Address or Lot No.
.�:e1........................................ ..........................................
p Owner Address
a
J�sl�t I t --• l7l �ccrlDi�2 _L �i eta :-...... .
ller Address
U Type of Building/ Size Lot............................Sq. feet
Dwelling No. of Bedrooms___________ _______________________________Expansion Attic (X) Garbage Grinder ( /V"
aOther—Type of Building ............................ No. of persons......................_..._. Showers ( ) — Cafeteria ( )
P4 Other fixtures --------------------------------
W Design Flow.............. ................gallons per person per day. Total daily flow............2..7�-_.O....:t�........gallons.
WSeptic Tank—Liquid"capacity./,WD..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 ( ) N<., 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........................
R+ ------------------•.• . . --
-- ---
O Descripti n o Soi- ------ _ �� "f '..t1w Jl-• z
x ... 3,
--------------
W ---•-----•-••.. ...............................•-------------......••-•-••--•--•-•--------•......-•---- �_
x �: o '.::
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 TIT1Z- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of IvIth.=
igne .....f r.. _ -------------------••---- ................................
`, ®® Date
Application Approved By..... ( � .... f --
�y Date Application Disapproved for the following reasons:.................................................................: - .............
--------------------•----....-•---••-------•---. -----------
-- --- --------------- --
i a� � Date
1
r
PermitNo.......................................... - IssuecL--------------•-------------------• .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH .
......r... :.....O F......... ........ ... ........... .............
(Irr#ifirate of TompliFana
THIS 0"CERTIFY hat the. Individual Sewage Disposal System constructed ( �or Repaired ( )
L ... . ................................
�. J Install �I / 1/
at. J.....- -•-- �------------------------------•-- --------------------------
has been installed in accordance with the provisions of TI r r of Thff State Sanitary Code as described in the
application for Disposal Works Construction Permit NC .. ... 7!.-j�_.._. dated. /A..:SQ._.-�.7..9.............
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM -WILL FUNCTION SATISFACTORY.
.DATE......::........................................................................ Inspector.....----...........---...........................................................
No.............. .... Fps.. ......_.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O �-I EA
.---.....oF..........
: ::
Applira titan for Disposal Works Tonstrur#inn rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
................_........-.................•--•---•---•-----•------•-----•--•--.........•....... .......---...----............-•-•-----------------•---•--------------------------•--------.------
Location-Address or Lot No.
.................................................................................................. ............................................... ---------------------------------•-------.----
Owner Address
W
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling 7No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) ,,
Other—Type of Building No. of persons____________________________ Showers — Cafeteria
a
W
Design the. fixtures ------ g
-Flow per person per day. Total daily flow.............x_.26. _41_....►........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. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................
(s, Teste,Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--.. .'"�,
ti n Soi•- -�w ,. ' Y-_ . . .
V (rQ ( � f �' l• �trv�
x -^� ,,
....... re-....--- ---•----•-� ------....;244 ilf
D Descrip
.....................................................-.................................................
V 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 TITIE 5 of the State Sanitary Code—The Undersigned further agrees not to place the system in
operatiori'until a Certificate of Compliance has bee issued by the board of livlth.
t igne ..!.. •---- - ---- ---------
Date
•`-
Application Approved BY.... ' ,.mo t „ ............. '
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------- -----------------_
....................................................-........................................................................................................................------..=- ...............
Date
PermitNo............................................................ Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. AA1._,., �
A�'te,.+...._OF............. ��.. ,�x�i� ..:..........
Trrtifiratr of Tumplittnrr
THIS 0 CERTIFY, l-Ft the Individual Sewage Disposal System constructed (A<or Repaired ( )
.»e
by .42
Install (�
at.............
/ --------------------------------------•---------------------------
6aMaa- �
has been installed in accordance with the provisions of TI F 5 of Thf State Sanitary Code as described in the
application for Disposal Works Construction Permit No... -.-_--�!_sk-_.. dated_.. =�,,; ."_.7_r�.._.______.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Anseector-••••-••----•-----------------------------------------••----._...--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF........... � 'f'�''Y... ............ ...................
N �� ........ FEE. ............
�i��rn�nl nrk� Cni�n Milan rani#
Permissio i ereby granted.....:.. ---- ............................................................. ---_._..
to Coristr c � )-or a 'a .( ) an ndivid a ge Disp�% stem
atNo. A ? . .- -e...... ._. ! ,-�'I
/4 --•.-----
S
.. ' t
as shown on the application for Disposal Works CZtruction Per t No. .'__ Dated �_d- .11".7. _t........
Board of Health
DATE
w
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