HomeMy WebLinkAbout0056 WHITE MOSS DRIVE - Health 56 White Moss Drive
Marstons Mills P
A = 031 006005
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LF
ED
COMMONWEALTH OF MASSACHUSETTS003
EXECUTIVE OFFICE OF ENVIRONMENTALSTABLE
PT.lop DEPARTMENT OF ENVIRONMENTAL PR
MAP �� 1
PARCEL
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
r/ CERTIFICATION
Property Address: J p �•/�,�� /�/O.Sf a e-
�' ►9 �a � /�� Oat 6 tf�'
Owner's Name: v-% or ,
Owner's Address:
r
Date of Inspection:
Name of Inspector: ease print)
Company Name: — C—
Mailing Address: c� OX /d
a Drl 6
Telephone Number., -ovl
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000} The system:
(/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 157 k' Date:
The system inspector shall submit 4mv of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
*"*"This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: A i s
�3 0 0 f 111f /�,4
Owner: t C G
Date of Inspection:
Inspection Summary: Check A,B,CM or E 1 ALWAYS complete all of Section D
A.
, Syst�asses:
I v not found an information which indicates that of the failure criteria in 310 CMR
ha e y a� . described
15303 or in 310 CMR 15.304 exist,My failure Criwn rWt evai t a ind te4i 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.
Answer yes,no or not determined(Y,N,ND)in the , for the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old' or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution bqa, System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 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
ND explain:
I
Page 3 pf 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address- �,/ /�imSl �,
Owner:
I G
Date of Inspection:
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 public health,safety or 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 public health,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,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within ]00 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory. 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,provided that no other
failure criteria are triggered A copy of the analysis must be attached to this form.
3. Other:
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address; L11, le ' &-- /5/'
Owner: c G
Date of Inspection:. p
D. System Failure Criteria.applicable to all systems:
You must indicate`des"or"no"to each of the following for all inspectigns;
Yes No
ckup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
scharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
lagged SAS or cesspool
S tic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
spool
_ quid depth in cesspool is less than b"below invert or available volume is less than'V day flow
_ Requird pumping more than 4 times in the last year NOT due tq clogged or obstructed pipe(s),Number
of times pumped
v any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
�ater supply.
v�y portion of a cesspool or privy is within a Zone I of a public well.
_ _ y 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. [This system paswv if the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The follgwin$criteria apply to large systems in addition to the criteria above)
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
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
/
Property Address: p �/ TQ
Owner. W
Date of Inspection: / O
Check if the following have been done.You most indicate"yes"or"no"as to each of the following:
Yes o
-Pumnin
iIIf rmation the owner, f Health
g o was provided by ,occupant,or Board o eal
L�
— Were any of the system components pumped out in the previous two weeks
Has the system received normal flows in the previous two week period
— _d Have large volumes of water been introduced to the system recently or as part of this inspection
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out
Z— Were all system components,excluding the SAS,located on site
Were the septic tank manholes uncovered opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes nVE)xdsting
information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
—
is unacceptable)[310 CMR 15:302(3)(b)j
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: ` �✓''`�*BOSS r✓✓
Owner.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 15.203(for example: 110 gpd x#of bedrooms): �O
Number of current residents:
Does residence have a garbage gender Ores or no): �✓�
Is laundry on a separate sewage system(yes or no):-3*yes separate inspection required]
Laundry system inspected(yes or no):,
Seasonal use:(yes or no):&/
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):4 O
Last date of occupancy: "-,
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): apd
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records �0
Source of information: 7 el v/
Was system pumped as part of the inspection(yes or no): "
If yes,volume pumped:__gallons—How was quantity pumped determined?
Reason for g:
TYP 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)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed d source ofjnformauon:
16re l
Were sewage odors detected when arriving at the site(yes or no): ASV
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contimred)
Property Address:
Owner: C or
Date or Inspection:
BUILDING SEWER(locate on plan)
Depth below grade:
Materials of construction: cast iron i.PVC_other(explain):
Distance from private water_supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: �(locateon site plan)
Depth below grade:
Material of construction:_concrete metal fiberglass_polyethylene
_other(explain)
ff tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludgjo bottom of outlet tee or bale: c
Scum thickness: z—
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto�g, outlet tee or b
How were dimensions determined A .r
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as fated to outlet invert, widence of le2kave,etc.):
off
GREASE TRAP:4 (rocate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(expo):
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 bale:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
t Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 6 4e o u
Owner. i C
Date of Inspection:
TIGHT or HOLDING TANK: (tank must be pumped at time of mspection)(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(yes or nu):
Alarm level: Alarm in worlting order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:l�j7QZO 1--t t
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage to or out of box,etc.): � �JL
et�C lPve l /r/O So�r cfs
PUMP CHAMBE (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.):
r
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: rb �•✓ �065 �/
Owner. t 6 V1
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
fw� gg
p chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comore (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc. : i6
all
CESSPOOLS:/ (cesspool must be pumped as part of inspection)(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(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (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.):
i
L .
c Page 1d of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION f contimed)
Property Addeo:
Daftd
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two perroanent reference landmarks or
benchmarks.Locate all wells within 100 f=L L.ocAtc where public water supply execs the bmkktg.
ly
i
I
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE MMSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of inspection:
SITE EXAM
SION
SurfAce water
Check cellar
Shallow wells /
Estimated depth to ground water O feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,time of design plan reviewed:
�. ,fed site(abutting Property/observation hole wit 150 feet of SAS)
Q j% hecked with tnc�!Rcrar�j�xplain: Gr
Checked with local excavators,installers-(attach docume on)
Accessed USGS database-explain:
You must descO)e h you established the hi g nd waA,er elevatiop:
A o II
704
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2Q o-e 1 o � o '® et
0 0 0
PrG 7 -7 0 -i,
1
d 0
TOWN OF BARNSTABLE
LOCATION ��Ih l+e OSS ,SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. -7
SEPTIC TANK CAPACIT bO S
LEACHING FACILITY:(type) (.tP� � r �iT (size) b w-Low
NO. OF BEDROOMS__a, _ _PRIVATE WELL OR UBLIC WATE
BUILDER OR OWNER GP-CeIV 3R,1e -Co(2-10,,
DATE PERMIT ISSUED: `- 7
DATE .COUPLIANCE ISSUED: - t 3. Q1`7
VARIANCE GRANTED: Yes No
I _
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K ASSP%ORS MAP N .06
PARCEL NO.:
Fiz$.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF H ELAN /LTH
----..-OF...-.- n. ! C��............................
ApplirFatioaa for Uiipooal ivorhg Tonstrairtion Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
_.... .................... ...... --
fir' Locat n-Address or Lo No.
Owne Address
-------•-•.............•--••------------__.
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms____.__.___,��____________________________Expansion Attic (Ll/D) Garbage Grinder (Ag)
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fix ures .................................. .. . ...
W Design Flow..........6__ ____________________________gallons per person per day. Total daily flow............._~'_-_3Q....................gallons.
1:4 Septic Tank—Liquid capacity...1W_gallons Length................ Width................ Diameter................ Depth................
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.... vq.___if..fl-4 !90% ililneAr! Date........................................
`.a Test Pit No. 1_...__.2.___.minutes per inch Depth of Test Pit.......I_4.______ Depth to ground water_____� -------
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....... ...............
---••---`-- ----------------------•-------••------------____......_..-•-----------.....----------._...______----•-.....---•----•-•••-••••-•---•--•-----•--
0 Description of Soil.....b 'Z �n`✓d�L.....t...,54nP.561 e•----•••-•---___••••-••••-•--.__-•••••-•-----••••--••----•-•--------•--•••••--•-•---------•-
U
i
W •----•------------------•-------•-•--J� _� .... V •------•-•--•••-----...•---•--•.__..--------•--------------------------------------------•---
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
-•-••-----------------------•--•------••----••----------•--•-•-•-•-•--------------------------------______------•-•--•--••••-----•-•--•-••••••-•••-------------•-•-----------••---••-•-•--••-•.....••---
Agreement:
The undersigned agrees to install the afor edescribed Individual Sewage Disposal System in accordance with
the provisions of i?T iE ;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 bo d of health.
Si ned_.__ W•------------------- ------ '7 A -f
Application Approved BY ...... .Q'-
Date
Application Disapproved for the following reasons:••••---•----------••...._____--•-------•••••----••-•-•---•---•-•-•-------•-•--•----•.•-••••----•-•._.....-•----
................-•••---•-----------------•--•-••••--•-•----•...-••-•••••----•--___.........._---_.........••---•--:..•-_____-•---•-----•-__-_--•--•---•-•••-••_______•-•-•---•=•-=--•-•••••--•---•----•-
+ Date
Permit No. .... - Issued_
Date
Fes$...........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c
ApplirFa#iun for Uiupuual Workii Cnunutrurtiun Prratit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: -33
1 l�1r ,��a
.. .. ..... .? -1 ........ ..... ......._...--•••- ._..._..__...............
Location-Address or Lot No.
--•-_. ........................................ t 1_.. 1 ..
Ownerr/ Address
Installer Address
dType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms__________................................ Attic Garbage Grinder (:)v )
;14 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures --------------- ------------- ----• -
W Design Flow.........6_.6_...........................gallons per person per day. Total daily flow.............
_____._._____________gallons.
9 Septic Tank—Liquid ca.pacity._.,N+ �..gallons Length................ Width................ Diameter----------------
Depth................
Disposal Trench—N?o_ ____________________ Width_____.._..._.__._._. Total Length..__________._...___ Total leaching area....................sq. ft.
Seepage Pit No--___-_- _---__ Diameter.................... Depth below imlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by... '1 i s.--- %-'- . Date........................-...........
-
a --•--------
Test Pit No. 1_._._____�_L_____minutes per inch Depth of Test Pit____-1�____.____. Depth to ground water---
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....... ..............
-- --------------•••--------•----------•------------
ODescription of Soil--------- 1C, g &:�6--------------------------------------------------------------------------------
V i �_---I-�---C
----------�! -14 -•--•- A10----------- -
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 ii'_'%.^ ;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.
Signed __• ,f ' r 'r?sr`". ---------------------- --
ApplicationApproved By-••---------------i= ...................................................... ...........---�.-- ......
Date
Application Disapproved for the following reasons______________________________
------------------------------------------------------------------------------------------•------------_.__....-------------------------------------------------------------------------------••-••-•••-
_ ' Date
PermitNo.... ._.. -S----••--•----------- Issued..................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..t. 0 F .` 1 ; -, Ord
Tatifirati of Tuntpfittnre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed i ) or Repaired ( }
b --r -•------ ........................•----•---
Installer
at �� �' =' Win , - t.lf ..:....�31Y _ tt ..._.e` j_ % 1 f)�'�_-----•----•---.................................
has been instilled in accordance with the provisions of f T L,� /7 f The State Samtary/ ode /a/ 41ribed in the
application for Disposal Works Construction Permit No. �___^____________________________ dated_.. ------!-______
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.._._....___ _" 1 ......4 ? ............................ Inspector--•----I .-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T b r`I_/ . ............t (°C ), ............OF.... .. ? .t, _ . _ .t_:_,�"...........................
-�•"'•'•-'•--•............ - FEE........................
Disposal Workv Tomitrttrtun ramit
Permission i� hereby granted-•• 2 1Ayi*.•--••--•- _ ..C011_4_-------•--••••---- -----------------•-----•----••-•----_____-------
to Construct
�i( ✓per) or Repair ( ) an Individual Sewage Disposal SystemyB 1 fnyrp3 j
at No..---t,v `e-x--- ". �......L.X-re-- +`f=f i�''x"`, •.«;y ,+y-- `. -- l �J./' �'�l�" ,,i------!"'4'd-- - L_ ...............
Street �1 _ �� .1
as shown on the application for Disposal Works COnstructiOlrz:PeT / __ .......... Dated_________________________________________
Board of Health
DATE..................- .........................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS.
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I CERTIFY THAT THE PROPOSED BUILDING hW_
SHOWN ON THIS PLAN CONFORMS TO THE
ZONING W§ OF.,, s2:`g �- ,, MA.
4
LEGEND DATES
EXISTING SPOT ELEVATION x
PROPOSED SPOT ELEVATION coo %tl�\��e` r �`t\+ocM� ,
EXISTING CONTOUR ---0——— �a ``�; e a. yN
PROPOSED CONTOUR 0 vio P. Pa,u�
JANO LE - fi
NOTE: THE LOCATION OF ANY UNDERGROUND c•
SEWERAGE WELLS OR OTHER UTILITIES SHOWN ON No.311-15
THIS PLAN =IS APPROXIMATE ONLY AS DETERMINED ��° ^'• �� `�I ��
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FROM RECORDS AND/OR VERBAL INFORMATION. `t� s�' 4��ta'y �`�,
THE CONTRACTOR IS RESPONSIBLE FOR THE
VERIFICATION OF THE EXISTING LOCATIONS IN
THE FIELD.
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