HomeMy WebLinkAbout0272 CEDAR STREET - Health 272 CEDAR STREET,W. BARNSTABLE
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.\ COMMON W&kLTH OF �.VL--1SSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
PROTECTION
DEPARTMENT OF ENVIRONMENTAL PR T C N^} O E
ONE WINTER STREL-T. BOSTON. ',1A 02108 617-292-5500
WILLIA.Nt F.WELD /rf'�'�TRUDY c.,E
Governor ✓�`- F/�j�O Seeretar%
04
ARGEO PAUL CELLUCCI Pr ro AVID B.STRQJS
Lt.Gacemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM y`W6A �1e9 Commislonter
mQP �3l PART A � yoFpsrge 98
CERTIFICATION
Property Address: Z.
Z G���1 °� Q/7
p M Address of Owner: � _
Date of Inspection: i (If different) Z'1 Z GECR- �ST2r�E '
Name of Inspector: J� Sel;�Alg�� 10, BAQ_NkSTA13LE MA - 0716(0$
I am a DEP approved system inspector pursuant to Section 13.340 of Title 5 (310 CMR 15.000)
Company `dame:
Mailing Address: O . Bo "—1 1 P� `1" 0� O 2(03
Telephone Number: (o 44 l
CERTIFICATION STATEMENT
I certify mat I have personally inspected me sewage disposal system at this address and that the information reported below is.rue, accurate
and complete as of the time of inspenon. The inspecti n was performed based on my training and experience in the proper funcion and
maintenance of on-site sewage disposaal systems. The s s em-
X Passes I
Conditi al asses
= Needs u e Evaiva on By t ; ocai 1p i ving Authority
Fails
Inspector's Signature: \ / �. �. Date:
The System Inspector shall sub' it a copy of this inspection report to the Approving Authority within thirty ::30) days of compieting this
inspection. If the system is ats�ared 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.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 31n CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI 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 conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep
Z� Printed on Recycled Paper
SUBSURFACE SEWAC DISPOSAL SYSTEM INSPECTION FORM
PART A
CE 71FICATION (continued)
ZZ Z C A& �StI2MQ7
Property.Address:
Owner:
Date of Inspection:,';rj,%j", /!��
61 SYSTEM kCONDITIONAIL`LY'�OOPASSES continued)
Sewage",backup or breakout or high star-- .pater level observed in the distribution box Is due to broken or obstructed
or'due to a broken, settled or une•:en distribution box. The system will pass inspection if(with approval of the
-�' Board*of Health). Describe observations.
broken pipe(s) are rep:aced
obstruction is remove^_
distribution box is let:e--d or replaced
The system required pumping more than :.our times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with acoroval of the Boarc .i Health):
broken pipe(s) are rec aced
obstruction is remove:
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
a 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 sur ace water
Cesspool or privy is within 50 feet of a _�crdering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS•THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) 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 absorotion system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil abs rption 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 acility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to deterr-me distance (approximation not valid).
3) OTHER
F
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: l Xl G�kArL �oal�PS
Date of Inspection:
DI SYSTEM FAILS:
You must indicate ew er "Yes" or "No" as -o each of the following:
I have determined that the systerr violates one or more of the following failure criteria as defined 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 -acility 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 cesspoc:.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the iast year NOT due to clogged or obstructed pipe(s).
Number of times pumped _
Anv 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.
a
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, volatiie organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
You must 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 hreat 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 Zono II of a
public water supply well)
The owner or operator of any such system shall bring the systern and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Z�� (��JQ)Z. ST'�gA�-`�jTA �•
Owner: �E`ti L �A(J�.�EL 1 a0lA�
Date of Inspection:
Check if the following have been done: You must indicate ner "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by:r.e owner, occupant, or Board of Health.
_ None of the system components have be<^ pumped for at least two weeks and the system has been recer:ng normal
flow rates during that period. large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note f they are not available.with N/A:
X _ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitar. or industrial waste flow.
_ The site was inspected for signs of breakc�:.
All system components, excluding the Soii.absorption System, have been located on the site.
X _ The septic tank manholes were uncovere . opened,and the interior of the septic tank was inspeced 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 Sj'siem on the site has'been determined based on:
_ The facility owner (and occupants, if different from owner) were provided with information on the proper -aintenance of
Sub-Surface Disposal System.
X Existing information. Ex. 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 :s
unacceptable) [15.302(3)(b)]
P
(revised 04/25/97) ?ago 4 of 10
L y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
//� SYSTEM INFORMATION
Property Address: 2�7i, �¢� e 11�
Owner: L t,0--
Date of Inspection: J l�
�l FLOW CONDITIONS
RESIDENTIAL-
Design flow: II D g.p.d./bedroom for 5..;.5.
Number of bedrooms: Z
Number of current residents:
Garbage grinder (yes or no): 0
Laundry connected to system (yes or no): YIiS
Seasonal use (yes or no): �10
•.eater meter readings, if available (last two 2) year usage (gpc: N al??L.1LA,gl.f✓ '�Qo-a�k � WSO—
Sump Pump (yes or no): �b
Last date of occupancy: OI.LU)?�Slp
COMM ERCIAUINDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
iNon-sanitary waste discharged to the Title : system: (yes or no;—
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
-n-i-t► - ?V YA p C-�-n 1 l�o 14l1 • - I F �o Q 1 A t'J� � lD 'rq.0- k o rn E ok"-�E R
System pumped as part of inspection: (yes or no) t-�D
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. Copy of up to date contract?
Other
a
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/2S/97) Page S of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertv Address: Z'lZ GA(1✓ A�-�5��° '('�
Owner: AL,,•kA S lv
� Win- L
Date of Inspecn
BUILDING SEWER: �D
(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: ���`"�
Material of construction: Y concrete _metal._Fiberglass _Polyethylene —other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No)
1t 5►pE) Dimensions: LONG X Zj W\Ord ,4 � t Ll&.u+0
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: Z.3
Scum thickness: 214 p "
Distance from top of scum to top of outlet tee or baffle: V )�
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: FA ASu R-re O
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.) NU�Y AWO OJTLG ` SG �Yla�
(ZS d m 0
GREASE TRAP:-VV.
(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 battle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid !evel in relation to outlet invert, structural
integrity, evidence of leakage, etc.) -
(revised 04/25/97) Paga .g of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propertv Address: —r4A(Z-", VC
Owner:
Date of Inspection: )
TIGHT OR HOLDING TANK:�`t' (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/dav
Alarm level: Alarm n working order_ Yes; — `o
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.;
s
DISTRIBUTION BOX:VC'
(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.)
N" 0 a I;-- UT 9 t lv 1 0 =V 0
of SoukoO� Sor`OP o PpI MMSt4b y
PUMP CHAMBER:—iAO
(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 04/25/97) Page 7 of 10
SUBSURFACE SEWAGE" DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
4 �onL S
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS)NT-'�
(locate on site plan, if possible; excavation not required, bu; -nay be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: 1 '
leaching pits, number:._
leaching chambers, number:_
II _
leaching galleries,s, number: .
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 ponding, condition of vegetation, etc.)
6rl A�r1 u �-
►.I G 1-"cil 1 U L n t-o KSPA 9-5
rri O 1 . a
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth o s y f solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of insaec ion)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: 9�
(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 04/25/97) Page a of 10
i
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7,1 Z
Owner: /
Date of Inspecctio l (y �C00 LAl�(�d
L.r ELL
SKETCH'OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
eto . t
?F•s` , -rs.s
"13
SIG � G
Ll 7D n ��
S�2 �
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property p yAddress: 2111- Grrt)a(1.- 5�• STAB
Owner:
Date of Inspection:
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
" a
Describe in your own words how you established the High Croundwater Elevation. (Must be completed)
U S64 Q'V(QC)2/Jn�lr � f7'1V IohL,C) �1��►.t�u✓p�ciZ.
a�jLCe SAP-( D
(revised 04/25/97) Page 10 of 10
TOWN OF LARNSTABLE
LOCAT'►ON 2_;12 �' �� j ST :'' SEWAGE
VILLA& ASSESSOR'S .MAP LOT 3 ,D
INSTALLER'S NAME & PHONE NO. j, ' ✓�
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ZAP '-}`� l ,� (size)
Nth. ON I3EDROOMS__2__PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 74
VARIANCE GRANTED: Yes No �!
DRAW Sr
CAA L L A1411,51 VIP
,
C�
THE COMMONWEALTH OF MASSACHUSETTS Fimz
(3 BOARD OF HEALTH
Applirativai for Dispaii al Workii Towitrurtivai ramit
Application is hereby made for a Permit to Co struct ( /or
Repair ( ) an Individual Sewage Disposal
System at: P 17
*�oo,
--------------------------------------------------
Location-Address � y............
-------- ...... or Lot No.
.....-----..•_�._ „. .:-, ..------- ---------------- -- ...................---
Owner 4�- a `. 1 dd
a �V T �p p�' ...._ .....................
� �......... ________ S 9_ ..... W _i a __.._...._.. _. _ _ __ _ ... _
Y Installer Add ess
UType of Building . Size Lot............................Sq. feet
Dwelling:--No. of Bedrooms.......... ...........................Expansion Attic ( ) Garbage Grinder )
4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a' 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. 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---_•___-__-____-----_-
--- --- - ------• .----•-- ------------ ---- -•--................�......
-- -- -- ........
O Description of Soil........ •. -- •,�'.` �. ••. --- . . . ----•-. --•------ - .------•-
- --. . --
W _
-------
UNature of Repairs or erations—Answer when applicable...........................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITI � 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be i ued th oard of ealth. s
Signed...
Date
Application Approved BY -------------------------------- ........ .......
Date
Application Disapproved for the following reasons-------------------------------------------------•-----------------------------------------......-•-•--••--•••---
--•-•----------------•-•-------•-----••-------•-•-••••---••--•---•-•••-••-----••---•••••-•-••-•••--•••.....•-••••---••---••-••-------••-•••--••----•---•----•----•-------•--•--••-•---------•--•---------
Date
PermitNo......... ..._4C)----------------- Issued.......................................................
Date
No...... y ...V_vo �i FRic......0.....
.�-�......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................O F.......................................
ApplirFation for Disposal Works Tonstrnrtion rranit �1
Application is hereby made for Permit to Q=struct ( ) or Repair ( ) an Individual Sewage Disposal
System at: �^
-........ .�/ ..- C..-- -- •--•---•- ---- --- "'=-•--•--------------------- ----- ------. •j . --- .....
ation-Addres ` or Lot No.
.......•. •... .. .........f-�...._........__ ..j.. ......................
W •....... ... .. ...... .. caner.. ........................... .....•. -.f-•-.(�..,_.- 1:•:.. d
Installer d
UType of Building Size Lot............................Sq. feet�..
�-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder
Other—Type of Building ----------------........... No. of persons............................ Showers ( ) — Cafeteria )
alOther 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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,4 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..t.....................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water............ ..........
_ _ _______........................ _ .--. -------....A.._...... _ _..__....__
________ _ _ _
p /, ... .
Description of Soil------• // _.. L''
x a AA
- ................ f •-•----• ••-�- — -
W z b G/
------------------- - �- -------- �'�
U Nature of Repairs or terations—Answer when applicable.......................................................................................
. ••••••-------•-•----••••••--••-•-••-•....--••-------••--....--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT1E 5 of the State Sanitary Co e— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n sued t o"oiealth.
Signed• ' ................ ..........................
Date
Application Approved BY2 ------- '!` ^Y------.
Date
Application Disapproved for the following reasons----------------------------••------..__...-------------•----------------------................................
--•••••---••••-••••-•••-•-----•------•---•••••-••-••----•••-•------•••--•--•--•••---•-••--...••----•••.....
----------------------------------------------------------------------------
Date
Permit No........ =......L/!_//�....•-----•...... Issued---------------•---•----•-----•--..._.......--•.....---
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......... ... .....OF.................... ah��.:ut!� r�
yr-
. ............. .....................
Tntifiratr of TompliFanrr
THIS TO�ERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b _�..'.........�.-.._.�.�. ---- ------•.................•---...............-----•--------------------•---..........------
-----------------
Installer
at------------------3-7-a......� - ---•---------�•------.._.I' ��-k.------..i9 ",- -'"has been installed in accordance with the provisions of TIr_IZ 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------ _-___ '.,fEl2........ dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................... .. .................. Inspector................... ..........................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No.. ..C/.`y......®... ..............OF.......... :.,n:r �Pk[�s..` ..................................... �}
c�4�--
. ...... FEE. _ •-•---^"---
j3iip. s al Works TInustratuan ramit r/
Permission is hereby granted.......•-•-.r�.�..�.------•C 5�,� ,��------..;r... ......... !/I ....1�I)."������� G..
to Construct I ) or Repair ( an Individual Sewage Disposal System
at No.............A.7-- ...._ �r � -._. ../........... 1 n_:_K-K.
Street �: f�
as shown on the application for Disposal Works Construction Permit No. ._,-.:....._V ated..........................................
..................................... --t•-•-• ------ -••---•-•-••--••---••--......•--_.....
/ oard of Health
DATE..............
... -- ---
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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