HomeMy WebLinkAbout0012 HOLDER LANE - Health 12 HOLDER LANE, MARSTONS MILLS
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TROY WILLIAMS8t ,r 1
SEPTIC INSPECTIONS
'.Y M
Certified by MA Department of Environmental Protection ab JUL08) 85-1300
19 Hummel Drive Ca
L 11998
South Dennis,MA 02660
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTECTI [Fly
ONE WINTER STREET. BOSTON, MA 02108 617.292-5500
WILLIAM F.WELD TRUDY CORE
Govcmor
Sccrctan•
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
n CERTIFICATION
Property Address: l� HOf'd�r LK. '�✓hsf`"b/`' Address of Owner:
Date of Inspection: 6�ay��8 Of different)
Name of Inspector: Troy Will i a m s1.2 4o /edG✓ h
I am a DEP approved system inspector pursuant to Section 1S.340 of Title S(310 CMR 15.000)
Company Name: Troy W111 iams Septic Inspections �5� (34.✓Hsi b /t M4
Mailing Address: 19 Hummel Drive. Snttth ppnnis , MA 02660 '
Telephone Number: T5 0 8) 3 8 5-13 0 0 0,?6 3 g
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:
,Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fail '
Inspector's Signature: /Lts!� !�✓Ay�-C�f�cGt Date: 8
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 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, 8, C, Or D:
Al SYSTEM PASSES:
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 1 S.303. '
Any failure criteria not evaluated are indicated below.
COMMENTS:
el SYSTEM CONDITIONALLY PASSES: NI/)
One or ore system components as described in the 'Conditional Pass' section need to be replaced or repaired. The system,upon
com more
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 Ceitificate 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. -
(—i—d 04/25/97) P�q• 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
12 Holder Lane West Barnstable,MA
Property Address: Edward Yalmokas
Owner: June 24, 1998
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued) JV//9
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
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 the
public health, safety and the environment.
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, 1T 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 absorption 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 absorption system and the SAS is within a Zone l 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 facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection: June 24, 1998
DJ SYSTEM FAILS: /V119
You must indicate ei;,.er "Yes" or "No" as to each of the following:
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.
Yes No
Backup of sewage into 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 SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ 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 last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any 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.
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, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: /V�/�
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 threat 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 Zone II 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.
Ir"v1v"d 04/25/971 P.O. 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
12 Holder Lane West Barnstable,MA
Property Address: Edward Yalmokas
Owner: June 24, 1998
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes, No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
/ as part of this inspection.
-IL _ As built plans have been obtained and examined. Note if they are not available with WA.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_31 _ The site was inspected for signs of breakout.
✓// _ All system components, excluding the Soil Absorption System, have been located on the site.
aL _ 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.
t✓ The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ 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 is
unacceptable) [15.302(3)(b)j
(r.vis.d 04/25/97) v"v. ..♦ in
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection: June 24, 1998
RESIDENTIAL: FLOW CONDITIONS
Design flow-.MQ p, /bedroom for S.A.S.
Number of bedrooms:
Number of current residents: o
Garbage grinder (yes or no): /&
Laundry connected to system (yes or no):—�6-5
Seasonal use (yes or no): IV6
Water meter readings, if available (last two (2)year usage (gpd): s7 000
Sump Pump (yes or no):_�(Q
Last date of occupancy:_�ec�P
COMMERCIAUINDUSTRIAL• N14
Type of establishment:
Design flow: ¢allons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title S 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:
System pumped as parf of inspection: (yes or no/Vb
If yes, volume pumped: gallons
Reason for pumping:
TYPE ¢F 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)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known).and source of information: /O J�Es J8S/
�w ems,-S_ h✓� )�. � 5� l/ �
Sewage odors detected when arriving at the site: (yes or no)
(r.vi..d 04/25/92)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection: Lurie 24, 1998
BUILDING SEWER: A1119
(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 grader
Material of construction: �oncrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:_ S'X C( /X41 /000
Sludge depth: —T—
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: q
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom f outlet tee or baffle:
How dimensions were determined: /'a bx- ,
Comments:
(recommendation for pumping, conditi�f inlet and outlet to or baffles, depth of liquid level in relation to outlet invert, structural
integri , e idence of leakage etc.) Lc J Gs�.,` ,, h a rce cc�, o y 1
GREASE TRAP: ?�L/4
(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 baffle:
Date of last pumping:
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.)
(—i—d 04/25/97) P.Q. 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection: June 24, 1998
TIGHT OR HOLDING TANK:/(��� (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/day
Alarm level: Alarm in working order_Yes;_ No
Date of previous pumping:
Comments:
(cond.ition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and d' ribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
f..) ri—S J H Tll tl ee
6 tr � t� C, b)�d��.✓
PUMP CHAMBER:_//�
(locate on site plan)
Pumps in working order: (Yes or No)
Alamo in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc)
(r�vi•mod 0{/7S/971 s.... _. ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection:June 24, 1998
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: r
leaching pits, number: Ok e-
leaching chambers, number:_
leaching galleries, 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.)
c � t✓ y S a L,
a19 1k Ad
CESSPOOLS: _ 1119
(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(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: 1i9
(locate on site plan)
Materials of construction:
Depth of solids. Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(r—is.d 04/25/97) d P.q. ! or 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection: June 24, 1998
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
P pp y comes into house)
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(revised 04/25/97) pa9. 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 12 Holder Lane West Barnstable,MA
Owner: Edward Yalmokas
Date of Inspection: June 24, 1998
Depth to Groundwater _ Feet adjusted high groundwater level
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.)
V/Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
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(rwl.•d 04/25/97) Pao• 10 of In
AsBuilt Page 1 of 2
LOCATION Id ea SEWAGE PERMIT NO.
VILLAGE•
M
l� INSTALLER'S NAME, i ADDRESS
BUILDER ^OR OWNER
G�1'l}e L 11 I t
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
ld
l �
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CO CATION SEWAGE PERMIT NO.
VILLAGE '' ff
INSTA LLER'S NAME i ADDRESS
® UILDE R OR OWNER
Gr-eeo bC.-cCA C--
DATE PERMIT ISSUED "
DATE COMPLIANCE ISSUED JLa1-0- 99
�'�e.��-
`�,
� .� ._
�,
�r�.�� ���� � .
No...Q o� �.: Fes$ ..............
THE COMMONWEALTH OF MASSACHUSETTS
t6 BOARD 'OF HEALTH ,
v----...OF......................� �' ........................
, pplirFatinn for Dispas al Vorkii Tnnntrnrtion runfit
Application is hereby made for a Permit to Construct (�or Repair ( ) an IndjidV-ewage Disposal
System at:
-•- � l -... ------•----.....�------------- .........!��.
Location-Address //�� or Lot No.
•-•----•--------------. .. .
Owner p Address
-•-•..........•`-------------------- ..------- �. (.S.�.A�f.----.-_:._. ----------------•----...� -••---......
Installer f Address
Q Type of'Building Size Lot__`!_(f•0 W......Sq. feet
U Dwelling No. of Bedrooms-- -- __ _Expansion Attic Garba e,Grinder
p� Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..................................
W Design Flow....................... . ........... per person:.per day. Total daily flow...............�x_.2.0...........gallons.
WSeptic Tank—Liquid capacityj4?v.j;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........................................
aTest Pit No. 1.41 Jf_---minutes per inch Depth of Test Pit........... ..... Depth to ground water________
fs, Test Pit No. 244__2-.minutes per inch Depth of Test Pit.................... Depth to ground water--------------.-----___.
a' --------------------------------------------------------•----.f--------------------------------------.-.----- ......................................
O. Description of Soil.................................................0..�.--7 -------------- ✓1 ----¢----��-.4C4....i t--.---- .................
W ---- -- - ----- •-----------------
f
W - ------------------------------------------------------------ ..--•---2 ,,,�;c G cf= �'9
x �a=- ry ----------------
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 TITLE 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 the boa health...;:
Signed- r ................................................ �(-•-••-
Application Approved BYQ_`"'`�
Date
Application Disapproved for the following reasons-------------------------------------------------------------...................................................
....................•-----------••-•-------•----------------•--•------------------------------•••-•-•--•-•------------•--•----••----•-----------••---------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratiun for Eliopoiial Works Toustrurtion ramit
Application is hereby made for a Permit to Construct (J�)-`or Repair ( } an Individual Sewage Disposal
System at:
................-...................................--••---•-------.._..........:................ -•--•-•---------...---------------•--------....__.............._..._........-=----------------=--
�Location-Address or Lot No.
—........... .............. r........................ z !J...............--...............::_.. ..! C d .2............ .E.!....-
Owner Address
IWj 1 t rrfi l �%' t ra ._-0 l r-•--•--•-•--•.................... .al.....:�= •=--------------......-•-•--•-
.......................••_••--- --•••-•--------........... -
Installer i Address
Type of Building ,.. Size Lot.../44__6 `-_____Sq. feet
U Dwelling No. of Bedrooms............................. .. _Ex anion Attic .t.- Garba e Grinder
p, Other—Type 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 ( )
aPercolation Test Results Performed by________________________________________________________________________ Date........................................
Test Pit No. 1__ _t___minutes per inch Depth of Test Pit--------- _____ Depth to ground water________rr_ __. _... -
I--
Li, Test Pit No. 22E_:_?_._minutes per inch Depth of Test Pit..............'__:. Depth to ground water__-__-------------------
P4 •••------•-•-••-...•••-•-•---------------------------=----•--=-.....---•-------•---•-••••-•-•_::.••--••••..._.._._._...._..•-------•--...._...-•••••...-•-
D Description of Soil................................................../"7..._,,_ j = 6'4 F_, '.l r . o ' -
V --••-----------•------------------------••-------•-----•---•---••--•------- ........: -•-----------= -- ` '_.. :'.¢. t ......:_ ...................
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 TITIL- 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.
SI d :__ - r
Date `�'
Application Approved B .���✓�..
Date
Application Disapproved for the following reasons:________________________________________________________________________________________________________________
...............•••-•---------••-•--_--••••••-•--••-•-------•-•----••--•-------••-._......._..-------_-_....
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(9rrtifiratr of Toutpliunrr
THIS IS TO CERTIFY, That the Individual'Sewage Disposal System constructed (...i;) or Repaired ( )
b „, t-------- -------
y_________________________________________________________ f p f r. �; f_ _ -._____. �,._. a-
Installer
at...............••••--••---•---•••----••----•-•----•-----•••---••Z nT -� / s. l; -a.,d I :_ -----------------------------•----------------------------------------------------------------------
has been installed in accordance with the provisions of TITI0415 fa'P �!State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................... .L' g I __ Inspector.......... •-------------••--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
// .?..........OF.......................... . i. _..
No......................... FEE........................
Disposal Vorkii TY.onotr ion parAft
Permission is hereby granted ......
:-rt rt..-------------- ` s' r1-�-----••----..._...__...-------
to Construct (-�)t,or Repair ( ) an Individual Sewage Disposal /System t'
at No _ ,-
rStreet
as shown on the application for Disposal Works Construction Permi�fo,,�________________ Dated..........................................
....................................-....................................................................
J /R I Board of Health
DATE -----•--••--•---7---• - -•---•-•-----•-•---•
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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LEGEND ! •
CERTIFIED PLOT PLAN
EXISTING SPOT ELEVATION 'Ox0
EXISTING CONTOUR --- 0 ---- ys -� `" oT �Z r( >• i f-rnrr
FINISHED SPOT ELEVATION Q� N , _,.�.E<r „Y� c"� f, , / ; • / J
FINISHED CONTOUR 0
i ELDREf I N
:APPROVED , BOARD of HEALTH `�' � !� SAJIki S-fA 3l.A M ASS*
5u`���j
DATE AGENT SCALE, / "-_ �0 DATE '
I.DRE®GE ENGINEER " Co IN
C6.IENT.,___�_____ I CERTIFY THAT THE PROPOSED
EGISTERE RE(iIST�RIED DR. t JOB NO, 83 Z.. �� BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
•� . /�/.
E G NEER URV OR OF 9ARNSTA®LE , MASS;..�,f
762 MAIN STREET CH. 8Yt ��, .-/ t ' ....�
HYANN I S, MASS. � Z � � �- ...
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