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HomeMy WebLinkAbout0604 CEDAR STREET - Health 604 Cedar'Street 'W. Barnstable P A<= 109 045 } 0 (a —4-vt to cars— ✓ LOCATION SEWAGE PERMIT NO. VILLAGE L© l 3 9" /1 Q-00-9 37 W c BA IZ /Y rS( AL INSTALLER'S NAME i ADDRESS C' A-QL J3NiP1, 30 ce.,OAA 5F f3,dgy BUILDER OR OWNER 1 DA. E PE MIT ISSUED DATE COMPLIANCE ISSUED ��� _ __ ____ � ��tf 2 � , � �` \ w-�CL �-- I ____.�_.._.... 1 __-___- G � ,� �l? S �._..._._...�_____ _ Ck' -�- CClv log��Tx OF INLASSAC� USETT Tz EXECUTIVE OFFICE OF Elv'VIRON'MEN'I`AL IR"; B. .�k _ T 1 DEPARTMENT OF ENVIRONMENTAL, PR CTION SrABL.E 1 � aPR M V Q� TITLE 5 OFFICIAL I SPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 07 C t V t ¢s AP � -I Owner's Name: UC- -AR1 Owner's Address: i Date of Inspection: 0 Name of Inspector: pl e Tint) e'( e Company Name: . : ✓ i�' NtCiy{a+l �s16 ooKS Mailing Address: a / baoa6 el Telephone Number: • .3 $ 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. 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 I5.000). The system: i 1 ( Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority j Fails I � Inspector's Signatu�e: Z���Da�te: The system inspector shall submit a copy 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 I 1 I ****This report only dgscribes conditions at the time of inspection and under the conditions of use at that time.This inspection d es not address ltow the system will perform in the future under the same or different conditions of use. i i 16/1512000 Title 5 Inspection Form page I i i f Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IHSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: y G" r S`f Owner: Date of Inspectio : Inspection Summary: lCheck A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have-not four any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR�5.304 exist.Any failure criteria not evaluated are indicated below. Comments: j i B. System Conditionally Passes: One or more sy em components as described in the"Conditional Pass" ection need to be replaced or repaired_The system, on completion of the replacement or repair,as appr ed by the Board of Health,will pass. Answer yes,no or not etermined(Y,N,ND)in the for the fo wing statements.If"not determined"please explain. The septic tank s metal and over 20 years old*or a septic tank(whether metal or not)is structurally unsound,exhibits sub tial infiltration or exfiltratio tank failure is imminent.System will pass inspection if the existing tank is reply with a complying septic as approved by the Board of Health. *A metal septic tank will pass inspection if it is aurally sound,not leaking and if a Certificate of Compliance indicating that the tanl is less than 20 years oI available. ND explain: Observation o sewage backu r break out or ingh static water level m the distribution box due to broken or obstructed pipe(s)or a to a broke settled or uneven distrrb on box.System will pass inspection if(with approval of Board of I lealth): broken pipe(s)aae.xeplatced obstructim isremoved distri6utiari boot is Ieueled or replaced ND explain: The syste a iced pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection i approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND exp, ' : f 2 1 Page 3 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS: =7S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspectio : C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in or to determine if the system is failing to protect public iealth,safety or the environment. 1. System will pass unless Board of Health determines in accordance ith 310 CMR 15.303(I)(b)that the system is not functioning in a manner which will protect public Ith,safety and the environment: Cesspool or p ivy is within 50 feet of a surface water Cesspool or p ivy is within SO feet of a bordering vege ed wetland or a salt marsh 2. System will fail u less the Board of Health d Public Water Supplier,if any)determines that the system is functioning in a manner that protec the public health,safety and environment: _ The system hgs a septic tank and s . absorption system(SAS)and the SAS is within I00 feet of a surface water supp y or tributary to a ace water supply. The system h s a septic tank d SAS and the SAS is within a Zone I of a public water supply. _ The system his a septic and SAS and the SAS is within 50 feet of a private water supply well. 1 The system h a septi and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supp well . Method used to determine distance "This system p if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and vo organic compounds indicates that the well is free from pollution from that facility and the presence of nonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteri are riggered.A copy of the analysis must be attached to this form. I I 3. Othe 1 I 1 3 i Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SIBS ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 2 PART.A- CERTIFICATION(continued) Property Address: Owner: AAf Date of Inspection: ;IF-5 D. System Failure C ' eria applicable to all systems: You must indicate"y "or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge _r ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool r Static li d level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool A" Liquid dep h is cesspool is less than 6"below invert or available volume is less than'/z day flow A- Required p amping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times ped _ Any portio of the SAS,cesspool or privy is below high ground water elevation. _p( Any portio i of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water sM ly. _ 0( Any portio a of a cesspool or privy is within a Zone I of a public well. Any portio ii of a cesspool or privy is within 50 feet of a private water supply well. of Any porti of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply we 1 with no acceptable water quality analysis.(This system passes if the well water.analysis, performe I at a DEP certified laboratory,for colifom bacteria and volatile organic_compawads indicates hat the well is free from-pollution from that facility and the presence of ammonia nitrogen nd 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.] AU (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 letermine what will be necessary to correct the failure. E. Large Systems: To be considered a h rge system the system must serve a with a design flow of 10,000 gpd to 15,000 gpd. i s You must indicate eitl er"yes"or"no"to eaclr of owing: (The following criteri. apply to large systems tion to the criteria above) yes no the system is within 400 f of a surface drinking water supply _ the system is within feet of a tributary to a surface drinking water supply _ the system is 1 in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone H of a lic water supply well If you have answe 'yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section ab ve the large system has failed.The owner or operator of any large system considered a. significant thr and Section E or failed under Section D shall upgrade the system in accordance with 310 CUR 15.304.The system otna should contact the appropriate regional office of the Department. 4 i 4 s Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSUIpFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM j PART B CHECIMIST i Property Address: oy S� Owner: Date of Tnspec 'on• O I Check if the following have been done.You must indicate es or no as to each of the following: Yes No _ Pumping in ormation was provided by the owner,occupant,or Board of Health Were any o F the system components pumped out in the previous two weeks? — Has the sys ern received normal flows in the previous two week period? 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 NIA) i — Was the facility or dwelling inspected for signs of sewage back up? _ Was the si inspected for signs of break out? — Were all s m components,excluding the SAS,located on site? Were the s ptic 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? X _ Was the fa ility 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 no Existing ix formation.For example,a plan at the Board of Health. _ Determin in the field(if any of the failure criteria related to Part C is at issue approximation of distance unacceptable)[310 CMR 15.302(3)(b)] i 1 5 Ri Page 6 of I I { I OFFICIALU SPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBS ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION i Property Address: _ Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL I Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based oz�310 CMR 15.203(for example: 110 gpd x#of bedrooms):__ O Number of current residents: e2 Does residence have a,Wbage grinder(yes or no):Ab Is laundry on a separate sewage system(yes or no):*44b [if yes separate inspection required] Laundry system inspec-.ed(yes or no):AV Seasonal use:(yes or no):1W Water meter readings, f available(last 2 years usage(gam): Sump pump(yes or no :A149 Last date of occupancy COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 10 CMR 15.203): Basis of design flow(s ts/personslsgtetc.): Grease trap present(ye or no):_ Industrial waste holdin tank present( or no):_ Non-sanitary waste die barged to itle 5 system(yes or no):_ Water meter readings, f avai e: Last date of occupancy ii OTHER(descn 1 GENERAL INFORMATION Pumping Records t_ Source of information: vV �L°csv Was system pumped part of the inspection(yes or no):i*0 If yes,volume pumpe • gallons--How was quantity pumped determined? Reason for pumping: TYPE OF=dis EMY Septic tri ion box,soil absorption system _Single cesspool _Overflow cesspoo _Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _InnovativeJAltemi tive technology.Attach a copy of the current operation and maintenance contract(to be obtained from system er) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of al components date installed(if known)and source of information: f 2 $.6 f. Were sewage odors de ected when arriving at the site(yes or no): 6 1 Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address- �bv er i f Owner: — Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade: /9 a Materials of construction: cast iron �Y40 PVC_other(explain): Distance from private water well or suction line: Comments(on condition ofjoints,venting,evidence of leakage,etc.): SEPTIC TANK: a (loc to on site plan) Depth below grade: to Material of construction: concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: /dOOrG� Sludge depth— `— Distance from top ofsludge to bottom of outlet tee or baffle: ,?0 a Scum thickness: Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee car baffle:� How were dimensions determined: �ewowre Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet' vert,evidence f leakage,etc.): W141 teer i a `t cp i -o 'hv GREASE TRAP:_(lo�ate on site plan) did Depth below grade: Material of construction: concrete m _fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from to;' ert, to t of outlet tee or baffle: Distance from bof s to bottom of outlet tee or baffle: Date of last pum Comments(on pr ommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outl vidence of leakage,etc.): a 7 4 . j Page 8 of 11 { OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 60f f ♦n Owner. Date of Inspection: D TIGHT or HOLD IN TANK: (tank must be pumped at ' e of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal berglass_polyethylene other(explain): Dimensions: Capacity: aalions Design Flow: day Alarm present(yes or no): Alarm level: Alarm in orking order(yes or no): Date of last pumping: Comments(condition of and float switches,etc.): DISTRIBUTION BOX: eC (if present must be opened)(locate on site plan) Depth of liquid level bove outlet invert: _+!l Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage Wo or out of box,etc.): '7W be ,r t 1 PUMP CHAMBER:; (locate on site pl ) Pumps in working or�er((yes or n Alarms in working order(yes no): Comments(note conditio f pump chamber,condition of pumps and appurtenances,etc.).- 8 Page 9 of I I i . I OFFICIAL LEI PECTION FORM—NOT FOR VOLUNTARY ASSESSME-'.`TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f PART C SYSTEM INFORMATION(continued) Property Address: 6 tA,, 5*- r Owner: Date of Inspection: SOIL ABSORPTIONS STEM(SAS): _(locate on site plan,excavation not required) If SAS not located explain why: I Type IC .� leaching pits,nLm leaching chambers,number. leaching galleries,ni imber: leaching trenches,ni imber,length: leaching fields,num er,dimensions: overflow cesspool,i umber innovative/altemati a system Type/name of technology: Comments(note conditio of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ! � n lir ".S IC 6x : Kd Ir L c ! CESSPOOLS: (ces�pool must be pumped as p7ofinspeoi6n)(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 constmction: Indication of groundwat w(yes or no): Comments(note conditi of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): i PRIVY: (locate on Cite plan) Materials of construction: Dimensions: I Depth of solids: Comments(note conditio of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBS ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 0 ed, IL �S Rr Owner: 461,91 Ins Date of pection: O SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all i vells within 100 feet_Locate where public water supply enters the building. i i I I y,y I I i �5 { 67 r i 1 ' sn f Page 1 I of 11 i ! OFFICIAL,INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAPE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C j SYSTEM INFORMATION(continued) Property Address: 6 oy � � t Owner: M Date of Inspection: 3 O SITE EXAM Slope Ve* Surface water IWO Check cellar YCS Shallow wells ND i Estimated depth to ground water�2 Q_feet Please indicate(check)all m-.thods used to determine the high ground water elevation: Obtained from system i lesign plans on record-If checked,date of design plan reviewed: Observed site(abuttio property/observation hole within 150 feet of SAS) Checked with local Boird of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS datab��-explain: You must describe_hoow yo_ullestablished the high ground water elevation: r� I - i s I i i 4 11 No..�d.� ..a:.�.D.... ., Fns...... ..�............. -. THE COMMONWEALTH OF MASSACHUSETTS i BOAR® OF HEALTH ...................OF...............------........---..................................................... �Y Appliration for Bi_qpnnal lRurkii Tnn,itrnrtion vanfit Application is hereby made for a Permit to Construct ( for Repair ( ) an Individual Sewage Disposal st --- --- cation- ddre sor Lot N10. Own Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..............�......._._._._..._...._Expansion Attic ( ) AJ Garbage Grinder ( ) ' Pk Other—Type of Building persons............................ Showers ( ) — Cafeteria ( ) PaOther fixtures --------------- --------------- - --------- ------------------------------------------- ----•------------------------------•---•-------- W Design Flow..............:f�s............_.......___gallons per person per day. Total daily flow.........1.3.0......................gallons. WSeptic Tank—Liquid capacityJO,"-._gallons Length................ Width................ Diameter-------_-------- Depth................ x Disposal Trench—No. .................... Width_...____._.__._.... Total Length............. Total leaching area....................sq. ft. .__..... Depth below inlet..... ..... Total leaching area._.Z c?_v.....sq. ft. Seepage Pit No....../_------------ Diameter.... z Other Distribution box.( ) Dosing tank ( ) .-4 Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1.. .�__-____minutes per inch Depth of Test Pit_____�_2_........ Depth to ground water---/_V_/,-........... Test Pit No. 2_[.L...._minutes per inch Depth of Test Pit__-L........... Depth to ground water__6?IA.........___ .............................................-................................................................................................................ 0 Description of Soil---------------. .:---... ...........................•---------- U ---•-------------------•-----------------•-------.--.------------------------------ ..................... •--------------------------------------------- •-----------------------------•------•---------- W -------•----------------------------------------•--------- •----------•------------------•-------------•-------------------------•------------------•---•----------•---••-••----•--------------.....---- UNature 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-T:L' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued,,by the •oard of health. Signed .......WCE55�.--� ...... ---- ✓C ...... •. Da e Application Approved By. -- / � - ---...------•-----................ -------..�? i`. .. .....----- Date Application Disapproved for the following reasons-......................................................---------_---------------............................ ---------------------------------------------------------------------•-•----•--..... Date PermitNo......................................................... Issued...--•---•---------------------••-----••---..._--•--- Date s N 9/. 10... n Fps..... . ... ._, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..---- . ..._.............. ........OF.........................-----........--------------------.....................---------- Appliratijau for Uiinuoal Works Tonstrorfiort ramit Application is hereby made for a Permit to Construct ( le<or Repair ( ) an Individual Sewage Disposal System at: f ovation-Addr s ,, ,p ./✓ CJ XoLo tN V.. -•--l`- -----. . ...y lo S�-��Cl, ........ a 8 W �%!'7f'. .. W � ..._ C�'a X)' .S' ...........................................�Address 7/�/ .. Installer Address Type of Building Size Lot............................Sq. feet , Dwelling.,-No. of Bedrooms.............."?.......................Expansion Attic Garbage Grinder ( Other—Type of Building persons............................ Showers ( ) — Cafeteria ( ) A14 Other fixtures ................ ................ . .411 WDesign Flow.............5_.�t�............._...._..__.gallons per person per day. Total daily flow---- 30.......................gallons. Ix Septic Tank—Liquid capacitylP%,'*..gallons Length................ Width---------------- Diameter---------------- Depth................ W Disposal Trench—No. .................... Width__---______--_-_-_-- Total Length_........_..__...... Total leaching area....................sq. ft. x � , � , � Seepage Pit No-----/------------ Diameter_____ ____________ Depth below.>nlet_____............... Total leaching area..�v k._...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.................................................... Date..._.................................... Test Pit No. 1_- 1-__-____minutes per inch Depth of Test Pit.....f............. Depth`to ground water...evl. 1............ fs, Test Pit No. 2.4.1r.....minutes per inch Depth of Test Pit...-,L......_._.. Depth to ground water.-f/A............. P4 -----------------------------------•-----------------------..._.....------------•-------------------•--•--------------------•--............................ 0 Description of Soil--------------- A 0-1�$ 9 �"t L'r��'`�b'P � �1 � ----------------- -------- -----•--------------------•------------ x w ------------------...................................................................................................................................................................................... UNature of Repairs or Alterations—Answer when applicable______________________________________________......................_.......................... ------------------------------------------------------- --------------------------------------------------------------------------------------------•-------------------------------------------•------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with f-1 /'1' the provisions of TE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in 'gperation until a Certificate of Compliance has been issued th oard of health. q Signed ---------- -- '^ ,� � Date Application Approved BY X,--- a/_..... L,r ---------- Date Application Disapproved for the following reasons-----------------------------•---------------- --------------------------------------------------------•--------- .....................•-------•---••-•------------------------•-----------••-•-------•---------------•--•-----------------------------------------------.---...-----------------------------------_.---•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............OF....... ...��.?��varr� ...................................... Trrtifiratr of Tootpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by........ T.... ` " C.E ast ----� ----------.........._ �11_!v----------------- ----------------------------------------------------------- i Installer at............ �^: .......... •--•------------------------•-•-----------------......------------------------------ has been installed in accordance.with the provisions of T r of The State Sanitary Code as described in the application for Disposal Works Construction Permit N ._9/y__. f d................ dated---------- ..................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A dUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. .... `' �`'.. Inspector : '_ u �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH V ......... ................OF...... ............ . ... ....................................... FEE " .. No............. ..- ___3C� ............ Rououul Vorkii oturtion rroit Permssio hereby granted........C ........ -------- ------------------------------------•---••----•---........-•-••_.. t or Repair ( ) an Individual Sewage Disposal System atNo..........49;r......3!/r z,A......---•__n ...----.... % ...........4°- � ---------------------------------------------•----••-- Street as shown on the application for Disposal Works Construction. Permit No..................... Dated.......................................... ...-. -. - ., , ................................................. 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