HomeMy WebLinkAbout0023 HILLIARD'S HAYWAY - Health (2) EHILLIARD'S HAYWAY,W. BARNSTBL
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TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS:
BUSINESS LOCATION: ,)3 ,ii c INVENTORY
MAILING ADDRESS: TOTAL AMOUNT-
TELEPHONE NUMBER: S ak �7 f
CONTACT PERSON: la l pia
EMERGENCY CONTACT TELEPHONE NUMBER: �o� 317 67W MSDS ON SITE?
TYPE OF BUSINESS: Al(,-
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene,#2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Sqq/, Other chlorinated hydrocarbons,
Lacquer thinners / (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil & stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash �-
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
YOU WISH TO OPEN A BUSINESS? �' 3 ( —6 c�9
For Your Information: Business certificates (cost $40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L. - it does not give you permission to operate.] You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE- Fill in please:
,.. APPLICANT'S YOUR NAME/S:
BUSINESS YOUR HOME ADDRESS: �' `�rz� i.✓G�
Sy 3.( 2 tro S-7 Cyr/t S b p L
TELEPHONE # Home Telephone Number
NAME OF CORPORATION: T A_I
NAME OF NEW BUSINESS TYPE OF BUSINESS 711V
IS THIS A HOME OCCUPATION? YES NO I
ADDRESS OF BUSINESS ,e MAP/PARCEL NUMBER i (Assessing]
When starting a new businessthere are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have,the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COM SSID ER'S OFF CE
This individu I h's e n.i.nfor e of p mit requirements that pertain to this type of business.MUST COMPLY WITH HOME OCCUPATION
ad RULES AND REGULATIONS. FAILURE TO
Au or' d ignat COMPLY MAY RESULT'IN FINES.
MMENT
c 7 �- 0 n S
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2. BOARD OF QALTH
This individual has.�eenlq�rogY pf the permit requirements that pertain to this type of business. MUST ,OMPLY WITH ALL
1 6 V l HA7ARD00S MATERIAL S RECJi,AT!1W1
Authorized Signature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signaturo** r
COMMENTS:
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
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r � — St1BSLfRRACE SEWAGE-DtSPOSA SYSl'£M'INSPEGTN I� FORM -
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I CERTIPICATIOIV—
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Property Address: 23 Hilliards HaLWay W. Barnsble Address of Owner: 2 9 19g
Date ofrinspection:10125195 _ (If different) �� `b fj
Name-of Inspector:John Gracl Jannelll
Company Name, Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
_ Conditionally Passes
Needs Further E luation By the Local Approving Authority
Fails /
Inspector's Signature: Date: 10125196
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair, passes inspection.
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, 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 11115195)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
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:Propetii�Address_ 2iI lfllardsHayLaYW Barnstable }
"§ett[� e'�'et�dlst>;tbrjt'�-'�)te",syste�m�sudss-�eetl'or�rautth-app���r � � �= -
Et10R-IS-r�11'fOYHE� _
— = distributrort box is leveled or-replaced `
r
Ttie s� tern regwred pumping more:than four times a year due to broken or-0bstructed _ipe(sj The -
system will pass inspection if-(with approval of the Board of Health) k
_-- - �•' ,.�,. "broken pipe( )are replaced _ _
- - obstruction is removed '� - y-
- - - - 4.
C] FURTHER EVALUATION IS'REQUIREDBY THE BOARD OF HEALTH:
Cc nditio.ns.exist which require further.evaluation by the Board of Health In order#o determine if;the
system is failing to'protect the public health, safety and the' n enviroments
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 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 APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT.THE PUBLIC'HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of watersupply or tributary to a surface water supply. -
The system has aseptic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of'a private water:
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well, unless a:well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system 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.
_ Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
l
(revised 111151951
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SUBSUBFAGESEWAG�DLSPOSAL_SYSTEM INSPECTION FORM
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�._.__�_.,rt< ..._'-.._ ...a:�..1... ,-,..-.ems ... .: ':9^'zss+�-.�''xf.". _�v•w... ._'�--.._v ......_ �.`�;r
ProperLyA€kd[ess 2itinti Ws HayYslaytl�kBarnstable -
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�= - °- .1:0l25f96.__ ...,.: �. -r--��'. '=5;��'�----a'-•�- "`f- .-r--.��— .�».e � �—.z3— -c—
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cess ool..:
ate iqu�- .e
Liquid depth.in cesspoo.Hs Iessthan 6"below invert'or.aV.ailabie volume is less than 112 day. flow
Required pumping.more than<4 times in the last year NOT,due to clogged or obstructedpipe(s):,,
tJumbers of times pumped
V Any.portion:of the Soil`Absorpbon System cesspool or-privy is below the high groundwater elevation
Any portion of a cesspool or privy is within 100 feet of a surface water supply,or tributary to a surface.,water supply
Any portion of a cesspool or privy is within a Zone 1 of,a public well.
4nyportiom-of a cesspool or.pnvy Is.within,50 feet of a.privat6 waterrsuppiy well;
Any portion of.a cesspool or privy is'less than 100 feet but greater than'50 feet from a.private watersupply well with no
acceptable water quality,analysis...if the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen:
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition.to the criteria: :
The system serves a facility with a design flow of 10,000 gpd or.greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the. following conditions exist
_ the system is within 406 feet of a surface drinking water supply
_ the system is within 200 fleet 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 I:I of a
public water supply well)
The owner or operator.of any such system shall bring the system 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 11115!95) __
-
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Fropert}rRddtess�23 Htmards Ha}__WaK W Bamscabls Y - -
_
Check.if the following have been done:-'
X :Pumping information was-requested of the owner,occupant, and Board of-Health
x None of the`system.components"have been'pumped`for at least two weeks and the andahe system has been,receiving normal"
flow rates during that_penod__Large volumes of water•-have not been introduced info the'systemrecently.or as partof this
inspection: -
NaAs built plans have been obtained and examined. Note if they are not available with N/A _
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does-not receive non-sanitary or industrial waste flow.
X The site was inspected for:signs of breakout.
X All system components, excluding the Soil Absorption System,have been located on the site.
X- The septic tank manholes were uncovered;opened, and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions;depth of liquid;depth of sludge, depth of scum. `
X The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
X The facility owner(and occupants,'if different.from owner)were provided with information orrthe proper maintenance of Sub-
Surface Disposal System.''
(revised 11115185) _
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DPSPSALSFENIPCTIffi1:EORPIk t
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Prope ty Address 23.HUUards flay Way W Barnstable —
v �-
Number, curie`-""nnt re'iaeeff r-
Sar.age gFmder
_Cau#io--connected to..system yes or nod
Seasonal use-(yes of no) No-:.: -
�Watermeter readmgs,rif available nla "
_ _
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL: .:
-Type of establishment: n1a-
_Design flow:n :gallons/day'
Grease trap present:(yes.or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system (yes or no) No
Water meter readings,if available: Na
Last date of occupancy: Na
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information.
System has not been pumped in the last two years.
System pumped as part of inspection:.(yes or.no)No
If yes,volume pumped: u gallons
Reason for pumping: n/a
TYPE OF SYSTEM.
X Septic tank/distribution.box/soil absorptions.system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
1993 w
Sewage odors detected when arriving at the site: (yes or no) No
(revised 11115195)
if:.,_ __' -:_-......n.—.._�_. __-"-� .-.:.'—"y.-__ '.�1i.e. eY-`.ate-rr...'...—•._ .+... .-'K'= _ :..- a. —_.- � �..
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F;:��Taca�o_-t't-site�tarrk ,� - � - - � _ = - `°�- �'� •--
y
Depth below grade 2 - _
Ma4eaal of cnnstructwrr X concreate metal FRP other(expfatn�
L111'8'H5-T'W5 Sm,
Dimensions: -
Sludge depth:1'
Distance from top of-sludge=to bottom of outlet tee or baffle 20'
Scum thickness:
Distance from top of scum to top of outlet tee or baffle.6'
Distance form bottom of scum to bottom of outlet tee.or baffle: o
Comments'.
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
eviSepticnce tank end all components are structural sound.Recommend um m tem eve iwa ears for maintenance.
p ly p. P 9 ry y
,
GREASE TRAP:_
(locate on site plan)
Depth below grade: nla
Material of construction: concrete_metal_FRP_other(explain)
Dimensions: nfa
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:rya
Distance from bottom of.scum to bottom of outlet tee or baffler nla
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.)
nla
(revised 11115195)
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SUBSUktF/4CE SEkVAGE4LSPOSAL SYSTEM INSPECTION FOf2M _
Pro{�arty_Address 23_HlllrardsHaiway4V.Bamstable: -- _
~ n- Janelll
wned -O _ -
_- -� .a '-`��`� _•arm.==-"--�+ ��.��':'—_..
IOCDIdGTAN1t
;_Depth below grade: Na
Material of construction:_concrete_metal_FRP_other(explain) - =
Dimensions: .Na
Capacity n/a- gallons
Design flow: Na gallons/day
Alarm.level: nla -
Comments
(condition of Inlet tee condition of alarm and float*switches etc ) .
wd
DISTRIBUTION BOX:X
(locate on site plan)
Depth of liquid level above outlet invert: Liquid level with bottom of pipe.
Comments:
ut of bo
x etc.
' en ce of leaka
ge into or o )
vid
v of so
lids carryover, e 9 . .
i ence
-note if.level and distribution is equal, evidence rY
6-box is structurally sound.
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)_
comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc)
Na
(revised 11115195)
7
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. -— _„ ,_,s '-ems'—^�__.�___,t ..�;e�..o...^�- •��- ���5`" '-'"T,� '-' —
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s-�—E.roper}N•Ldd�ess�Z3:fuulardsfia;r_�.II��I��e---�` ;-/- _"�.."�• _� � .» _ -".� � -�-=•--�-..,�
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e a a a oo ihtrastve methods}
— f. ossr6le :exec`vatiot>nnot.reguiredO-1�t�'►?�.�_,� p„�• .,rowm
etermmedto be pFesent�explarn: 2
leaching pits,-number: nta ` - -
leaching chambers,number:2'Flow.diffusers I
leaching"galleries, number: nfa
leaching trenches,number,"length; nla M; _
leaching fields, number; dimensions:n1a
over flow cesspool, number:nla
" Comments:`('nofe"condition of`soil,'signs"of hydraulic failure, level of-ponding condition of vegetation etc) 7
The sas is functioning properly. -
1
CESSPOOLS:_
(locate on site plan)
Number and configuration: n/a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer: Na'
Depth of scum layer* n1a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of grou
ndwater dwat er:
n1
a
inflow(cesspool must be pumped as part of inspection)
Na
Comments: (note condition of.soil, signs of hydraulic.failure,level.of ponding, condition of vegetation, etc`)
nla
PRIVY:_
(locate on site plan) _
Materials of construction: n1a bimensions: n1a
Depth of solids: nla
Comments:(note condition of soil, signs of hydraulic failure, level of ponding;condition of vegetation, etc.)
PrivyComments'
, I
(revised.11115195)
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DEPTH TO GROUNDWATER
Depth to groundwater:10 feet
method of determination or approximation:
Test Hole dug when system was put in 1993;10'no water encountered.
(revised 11115,95)
9
�4- OWN OF BARNSTABLE
LOCATION EWAGE # '73 e 61— L
VILLAGE ASSESSOR'S MAP & LOT 131n Oct
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) E10 lhfflL—' Al (size)
NO. OF BEDROOMS— PRIVATE WELL OR PUBLIC WATER/(O�
BUILDER OR OWNER--),'
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ( O/ '
VARIANCE GRANTED: Yes No
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No FEB ......
THE COMMONWEXLTH OF MASSACHUSETTS
_ BOAR® OF HEALTH
Ow N o f.. ►2
ApplirFatiou for Diipniial Works Tomitrnr#inn ramit
Application is hereby made for a Permit to Construct (K ) or Repair ( ) an Individual Sewage Disposal
System at:
.....
t+®T 3q41LLkArZ_r,>-S k �Y... kll c�t� 5. ................................................
Location-Address or Lot No.
2An�1C. L.L. `s1.C.1��0` c.l�P .......................
Owner Address
Installer Address
Type of Building �( Size Lot.35.2.L_ b......._Sq. f t
Dwelling—No. of Bedrooms..___ lht
__________________________________Expansion Attic 0 Garbage Grinder
aOther—Type of Building ............................ No, of persons............................ Showers ( ) — Cafeteria ( )
0.' Other fixtures -------------------------------- -
W Design Flow..........�55--------------------------gallons per person p r day. Total�ily flow----.__'9a_O........................gallons.
WSeptic Tank—Liquid capacity .gMW allons Length.._t6.. Width5-.d........ Diameter................ Depth._ .G1 /
x Disposal Trench—No...... ........... Width..._1 Z--___-__-_ Total Length.__.......... Total leaching area_91.Q.........sq. ft.
Seepage Pit No--_----------------- Diameter.................... Dep h below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosin ank,(��� 1
`" Percolation Test Results Performed by.............................. .---------------.--------.......... Date.---------- -±--•---- ------------ l
�a Test Pit No. 1-------S.....minutes per inch Depth of Test Pit----!5...... Depth to ground water--- ms,
'Test Pit No. 2.......&......minutes per inch Depth.'of Test Pit...... 4 t---_---- Depth to ground water._E-C -_3_- --!}_�
O Description of Soil.........Cam---`-!Ct-.5-----)Awl--.
W ••---------------------------------------------------------------------------------------•--------------------------------------------------------------------------•----------•----------•-------------
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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance been is y t id of health.
Signed :............................ ........................................
Date
Application Approved By ..........f11 -- - ..... ------40 �.e A
Application Disapproved for the following reasons:
......... .. ................................................... ....... .................................................................................. ....... ................. . .. .... .......................
qq ...........Date
Permit No. .-5-57Y.................... Issued ......... �. .:...1..
Date
FEs.......14 0.........
THE COMMONWEALTH OF MASSACHUSETTS
'"j� BOARD OF HEALTH
I Gvi !j OF..��k2lc a Lei I
App ira#iun for Diipus al Workii Tonstrurtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: I
-•-• ...... ... ...................................... .................................................
Location-Address _ or Lot No.
F IZ tt \> .; n IV nJ i L `? �ti !i 9!.'Ia �,U.E,-'1• r1 I? 7F{.fe:}> i 4� t }
........................ ..... ................._.._.._... ........... ............................................
Owner Address
W
Installer Address
Type of Building Size Lot_3 .Z�---------Sq. ,feet
Dwelling—No. of Bedrooms...... ..................................Expansion Attic 0(-) Garbage Grinder
p, Other—Type of Building ............................ No. of persons-__--__-.-__-_-___._____-_ Showers ( ) — Cafeteria ( )
Q' Other fixtures ............................
Design Flow.........`.).5..........................gallons per person pqr day. Total ally flow....... .. _..............._...•._gallons.
WSeptic Tank—Liquid capacity gallons Length._.. ��''6.. Widh1 ". __.._..... Diameter____________ __ De th..T-:v-it
x Disposal Trench—No. .......:............ Width.....I. Total Length------��........ Total leaching area.-.. _.........sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Other Distribution box _ Dosing-tank,(6<) _
1" ...�c .�;...L ... Date--------•1-............................
Percolation Test Results Performed bY---_-'------------------------•--.--t----------.�--..........--- -- �% ..
1.4 Test Pit No. 1....... =.....minutes per inch Depth of Test Pit---- ^.?..._._. Depth to ground water-_L_! _i_--(.
14rU
44 Test Pit No. 2.......IS......minutes per inch Depth of Test Pit.................... Depth to ground water__�.5....�.��..(.(� S
a ............................................................................................................................................................
0 Description of Soil......... =-l c�: 3 l �.:�.� ^�I>uC j_ `L r` -= 1�"' ,--� i i'.c':, `tip _�3
U .......................................-•••......'Li-....-----------------------•----------------------------------------------•--•----•-•--------------------......-----------•---•--•--------
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 TITLE 5 of the State Environmental 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 --------- .---_-----------------------------------............................................... .............--------------------------
Dare
Application Approved By . lls�s. ------40...-...LL/ ..0- nk
Date
Application Disapproved for the following reasons: ........................................................... .. ........ .. . .. .. ... ... ................................
.................................................... ................................. .......................................................... .. ....... ................................ ........................................
Dare
Permit No. r /
,�..-..... --------_-------.. Issued ....... l �Y �
Dare
THE COMMONWEALTH OF MASSACHUSETTS
! BOARD OF HEALTH
!�- ! -------------- ----
Eltifirate of U antyliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by -------------- ------------- ------------------------------- ----------- ---------------....---------------------------------------------------------------------------------------.......-----------------------------
L� 1 I I Installer s --�.,
at .. C?.� �� } .�.....I_:...� �:�...`% rt-..,iz-''�`,..../..-,_� �.-f.....� �1.�21�}�a Yo -?...................
has been installed in accordance with the provisions of TIRE 5 oc�f The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .......Z-)n........
dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------------.?.....�-lo ................... Inspector . , e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
1 cam........................................�...� OF.......�.�� ...,. . �f-.,
No.... . 7:. tc 1 ��//
3 ��1. FEE.. .!l.Q......----
Dhipos al Workii Cnunitr iun amii
Permissionis hereby granted..............................................................................................................................................
to Construct (,,<) on Repair ( ) an ,Individual Sewage Disposal System
at No tC- ' LC_k E` ti----, �. -;tr, !��.f !! ,� �3E�• IE�`,�, r '�,c_f:r...........................................................•......... ,...._._....._....__Street..........q.. - ' =
as shown on the application for Disposal Works Construction Permit No.l,.3 Dated..........................................
---------------------•-•---•----------•------•---------------------------------•-•••••........_•••.•...
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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