HomeMy WebLinkAbout0040 CHURCH STREET - Health (2) 4.0 ChurchStreetprstBanable
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COMMONWEALTH,OF� .,�;!SSWRMUSETTS
C
EXECUTIVE OFFICE OF ENVj?.YMENTAL AFFAIRS
DEPARTMENT rP# VIRONMENTAL PROTECTION
RECEIVED
19 2004
PARCEL : 6 — AUG
t d V� �� TOWN OF BARNSTABLE
TITLES HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: /
66 aA
Owner's Name:
Owner's Address:
Date of Inspection: C�-y-
Name of Inspec (pleas print) 0 a� � � ? 9
Company Nam
Mailing Address:
U�(P
Telephone Number:
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
1
Inspector's Signature: Date: (0ey
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
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l 1
s
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
dt
Owner:
Date of Inspection: aoov
Inspection Summary: Check A,B,C,D or E./AL.WAYS complete all of Section D
A. ,System Passes:
y I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 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.
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 exfiltrati.op 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 b'ox due to broken or
obstructed pipes)or due to a broken, settled or uneven distribution box. 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:
2
Nee 3 of 1 l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: A - /
Owner:
Date of Ins ection:
0.
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 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
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a one 1 of a public water supply.
_ The system has aseptic 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 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection: //. 0. G'
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes N
J Backup of sewage into facility or system.component due to 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,
it Static liquid level in the distribution box above outlet invert due to an overloaded`o.r.clogged SAS or
cesspool
_ Liquid depth in cesspool is less than 6"below invert or available volume is less than!/z 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 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.
/ water supply.
PJ Any portion of a cesspool.or privy is wiihin.a Zone 1 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. (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.)
(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,the 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..facilitywith a design flow of.10;000 gpd to 15,000
gPd•
You must indicate either"yes"or"no" to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Pate 5 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address:
Owner:
Date of Inspection: /
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
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 ?
Have large volumes of water been introduced to the system recently or as part lof 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?
f/ 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 sewacie disposal systems
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
V Existing information.For example, a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
5 '
Page 6 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
,PART`C
SYSTEMINFORMATION
Property Address:
Owner:
Date of f Ans4pectio n' &44S //
FLOW CONDITIONS
RESIDENTIAL. ✓
Number of bedrooms(.design): Number of bedrooms(actual):
DESIGN flow based on 310 C AR)5.203 (for exa ple: 11.0:gpd x#of bedrooms):_ lb
Number of current residents: _
Does residence have a garbage grinder(yes or no): ,
Is laundry on a separate sewage system ( es or n [if yes separate inspection required]
Laundry system.inspected(yes.or.now
Seasonal use: (yes or no): —
Water meter readings,taillabble(last 2 years usage(a d)): W Gll�''WSump pump(yes or noLast date ofoccupancy
COMMERCIAL/INDUSTRIAL/
Type of establishment:
Design flow(based on 310 CMR 15203): gpd
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
Source of information: QG
Was system pumped as part of the inspection(yes no
If yes, volume pumped: gallons--How was g antity pumped determined?
Reason for pumping: _
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):
proximate age of AI component date instal d(if own)an source of information:
Were sewage odors:detected when arriving at the site(yes orr no)/11lJ
6
Pacle 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: o
Owner:
Date of Ins ection:
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _40 PVC other,(explain):
Distance from private water supply well or suction line: `
Comments(on condition of joints,venting, evidence of leakage, etc.):
SEPTIC TANK: o/ (locate on site plan)
Depth below grade:w 19
Material of construction: .,/concrete_metal fibergl ass._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: `���
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: Z
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: L I/
Distance from bottom of scum to botto of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendation , inlet and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert, evi ence of leakage, etc.):
f 4 �a
GREASE TRAv% ocate 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(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:)�z . )
Date of Inspection: // SL
TIGHT or HOLDING TANK:ZXi ank.must be pumped 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(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:Zif present must be opened)(locate on site plan)
Depth of liquid level above outlet invert. L'U
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
akage into or out of bo etc.): XVIV
/r
Al
PUMP CHAMBE J 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.):
8
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATI2ON(continued)
Property Address:
Owner:
-V,4.
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): Zoocate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries, number:
leaching trenches, number; length:
leaching fields,number, dimensions:
overflow cesspool,number:
.innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
CESSPOOLS✓'=`L(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.):
PRIVYz ��
✓'��`9`_ococat eon 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.):
C Q
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection:
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 wells within I00 --Locate where public water supply enters the building19
L
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V 1/
Woo
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(J
low lion
10
Page 1 l of I l
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORM TI0N(continued)
Property Address:
Owner:Az.
Date of Inspection AGO
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water Meet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting:property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators, installers- (attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
4?
e
11
-
�i:'Fix`
..8.1�x;::.::.•>,?..::.'ram:�'�:.%:.,n.� _ _ _ _
_ t i�
11' i Number:m- ber: Date: - -
' - - - C o rnP 1 et e d, by:
_v 1.
-
'%*r.".':FBI..-
�� L,R O j(�D-.V/ T E=a EVE N .I T
�.. L /,. ,i _. Lti . __ C;)„1f vT�`•.i'ION
Y`..x. _ v ✓_, Site Location: (� �'!�'C CJ�' / .
Lot N o.
< wner: dI Address
t 'Contractor: .v ^ddress•
y' _ `Notes:
STEP 1 Measure � o water table
�---_
_
c z _ `/day/`/ear_ mono �.
`£'f STEP EP 2 Using Water-Le.ve! Rance Zone
and Index:Well Map locate
' site and deterrn.ine:
OA7•rirOJrlcte index.V✓eJl.................................W:.I�... Z53 �-
•. � 1IU3't2C-leVgl f"ang^c zone ........................................... !
STE- .. Using monthly report "Current
I
Water ^esources Conditioner'
det-=rmine curretlt cep:n to
Water level -ior index well ......................
monthl;/ear l
-S 4 Using Table of V ater-ievei Adjustments
for index well (STEP 2.11-), cua-rent dept!�
to water level for index: vvell (STEP 3),
and water-level zone (STEP 2S) L>
determine water-level adjustment ..............:...........................................................................
!
STEP 5 Estimate depth to high water
by subtracting the water-
,
level adjustment (STEP e)
from measured depth to water
level at site (STEP 1) V/
I Z
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L'0 CAT 10-N S E PI A E P E R M I T NO.
VILLAGE
I H S T A LLER'S NAME & ADDRESS
® U IIL}D E R OR OWNER
1 L✓�c�ice^ �-a ��� �
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED ///� 24
du,
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t
T9 t` ,•
C A J
tp t AMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.................. ...................OF..........................................................................................
Apli iratiun for Diupuual Works Tonstrnrtinn amit
Application is hereby made for a Permit to Construct (j( ) or Repair ( ) an Individual Sewage Disposal
System at: _
1,V&.14---.......�..(..---�-°- PI.S1.-- .=�---------------------------------- .........
..... __.
Locati n•Address or Lot No.
.....� 0 .....�....... 4 _� ..........................
Owner Installer p � -•-•-•--•.......................Address Address
--•--------••-•--•---•-•-----------------
14
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............... -----_-------___--___-_--Expansion Attic ( ) Garbage Grinder (!✓
PL4Other—T e of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures ------------•---••-----••-----•• -
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.,4r.p-egallons 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ ------------•--------------------•-•----•----------•------....--••-•------------•---•-......•..••............................................................
0 Description of Soil....................................................................................................------------------••--•.....-------••--•-•••-••---•----•-----.-•---
W
V ....-•••---•--••-•--••-••--•------•-••---•.................••-•---------•-••------••-••--•-••••-•....._.....-•--•••--•--•----••-•---------•--•._....•-•---•------•-•--------••---•-----•......-----•-----
W
U Nature of Repairs or Alterations—Answer when applicable.............................•....._...____.................._..............................__.
--•-----•-------------------•-----------------------•-----.........--•-----------------...........------------------------------------------------------------------------------------------.....--•••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE 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 board of health.
Signed-• IG�O( ! � -�-
• ------...
._-.Date
Application Approved B _
Date
Application Disapproved for the following reasons:..-----•----------- = �.._
•----......-•-•-•----•----------------------•-------•-------........--•-----------....---••--------.........----------------------------------•-----•----------------------•7---.._. -----.....----
Date
e
PermitNo......................................................... Issued-.......................................................
Date
7/ /• f r �_
_ �
o...-•='-.)J. ..... V" FEB.............................
N . �,,
•FfRE MMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.......................".--..-.---.-.---...OF..........................................................................................
Appitration for Disposal 10orkii Tonotrur#ton Prrutit
Application is hereby made for a Permit to Construct Q( ) or Repair ( ) an Individual Sewage Disposal
System.4.v_-('Jj / e(.� � i ....�'�.:>����;-9!!� ...............................................
--------------------------- ---- ------
-
Location-Address or Lot No.
..................................A.........DE%a V-t ,_t--------------•-------•---- -------.........---------------•----.-....-...------
Owner Address
Wf ---------•------------------------
�"� ' install i Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................. _:__---___ •Expansion Attic ( ) Garbage Grinder (A)a
�-+
'k Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' 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.
4
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed bY---••••••-•••••••-••••-•-••---•••-•-•---•-•-•••--••-•-••-•-......-•••••... Date........................................
Test Pit No. I................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........................
a ...................
----------------
•....
••-•--------
•-------
•------------------------------------
----
---------------------------------
•-------
•---------------
0 Description of Soil........................................................................................................................................................................
x
W ...............................................................---•-----------------•--•-••-•--••-••--••-•-•••------------------••••--•-------•-•••-•-•-•..................-••••-•--••• --•-•---•---••-
U Nature of Repairs or Alterations—Answer when applicable............................................................................I..:_._..____......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 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 board of health.
Signed. : # 3Z
,- C& - ........
Date
Application Approved BY•--••. •E P 1 .........................
Application Disapproved for the following reasons:._._ L ------------•______________________________________________________________Date
---•-•--•-•---•-•-•••................•--••----•-•---•••----................_..-•---------••--...-•----._..._...•--•---•-•-•=•-••--•-•--•-•-•-•••••----•-•-------•-------•••---.........................
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
(Irrftftratr of Tontpltonre
THIS IS TO CEt , That e Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------------------------.............. . .• ---- ``.=----------------------•-----------------.._....._.....----------._....-----...........----...........•-•----•--••------•--
Installer r
has been installed in accordance with the provisions of TITLE J5,of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.__......_�_�_.�.��_y..._.. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATIS ACTORY.
DATE......................................... ..... ---.. ........... Inspector....... IL-1-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........................................-OF..................................................................................... f.
NO......................... FEE...__---Z.............
Disposal Workii Tonotrur#ton rrnttt
Permission is hereby granted..................... ----•---••--------•----•-••••-..........--•-•••---...........-------•-----
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No. - T-•-•--.....-•••1--v..... h-
Street I
as shown on the application for Disposal Works Construction Permit/jNo..................... Dated..........................................
Board of Health
DATE.........--•--......---•-•--------•..................•--...........---------_..
FORM 1255 A. M. SULKIN, INC., BOSTON
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