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HomeMy WebLinkAbout0301 LAKE SHORE DRIVE - Health 301 LAKE SHORE DRIVE,M. MILLS pp- I 4 COMMONWEALTH-OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI �` DEPARTMENT OF ENVIRONMENTAL PROT O ONE WINTER STREET, BOSTON, MA 02108 617-292-5500 T < r`�© `9I9 � WILLIAM F.WELD.. - .TKUD Governor ARGEO PAUL CELLUCCI B. UHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM missioner U 3 PART.A CERTIFICATION Property Address: 3O1 LAKZ 5,00MG 'bM.,nAP*7b t%I L rsess of Owner: Date of Inspection: lG ' 3 — $ (if different)- Name of Inspector: I-15 a TR w n 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310.CMR 15.000) Company.Name: MailingAddress: T7 IkC8V6 125--Q�. .E-Faaajj!t 02.z17 Telephone Number: 50, 7/3=39 Z 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 SAuthority Fails z . Inspector's Signature: JAI Date: L-Z.7 The System Inspector shall submit a copy 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, B, C, or D: A] SYSTEM PASSES:. I have-not found any information which.indicates that the system violates any of the failure criteria-as defined in 310 CMR 15303. Any failure criteria not evaluated are indicated below. COMMENTS: I B]_ SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass"^section need to.be replaced'orrepaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no,or not'determined (Y,'N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The tank is metal _ septic unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is,replaced with a conforming septic tank as.approved by the Board of Health. (revised 64/25/97) � Page i.o! io / DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep - r.1 Printed,on Recycled Paper . SUBSURFACE SEWAGE DISK&kL-SYSTEM INSPECTION.FORM PART A ' " CERTIFICATION (continued)',.. ra 1Q�� _ ` R �►ArRsTo a n I Gc.oat 5 . Property Address:3 Y, I .IQD S 5 owner: 'TO �,?,SSa � Date of Inspecti on:, �t Z 3 ., Y ' '-B]_SYSTEM°CONDITIONALLY PASSES (continued) ,�. . ` m will ass inspection if(with approval of the • backup-0 breakout or high static water level observed' the distribution box,is.due to broken or obstructed Sewage. P . 1 pipe(s) ordue to a broken, settled or.vneven distribution box. he system Board of Health). Describe observations: replaced s are - broken pipe(s) _ obstruction is-'removed distribution box:isjevelled or replaced in more than four times a y rdue to broken or,obstructed,pipe(s)• The system'will pass _ The system required pumping 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 EALTH: determine if the system is.failing to protect the Conditions exist which require further evaluation by t Board of Health in order to public health; safety and the environment. 1 SYSTEM WILL PASS UNLESS BOARD OF HEALT DETEfEMTIYNAND THE ENVIRONMENT: OT'FUNCTIONING IN 1A MANNER ) . WHICH WILL PROTECT THE PUBLIC HEALTH D SA _ Cesspool orprivy is Within 50 feet of" surface water _ Cesspool or.priv_y is within 50 feet o a bordering vegetated wetland or a salt marsh. `SYSTEM WILL FAIL UNLE SS THE BOARD F HEALTH.(AND. WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A NER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY.:AND THE,_, ENVIRONMENT The system has a septic tank d soil absorption system (SAS) and the 5A5 is within 100•feet to aaurface Water-supply or Y P p well. tributary to a surface water s pply• and the SAS is I well. _ The system has a septic tan and soil'a system and the SAS. is within 50 feet of a private-water y _ The system has a septic to and soil absorption s than _ -from a The system has a septic t k and soil absorption system analysis for of fo mA is leia and volatile eorganic0compounds feet or indicates that private water supply we , unless a well wale . ' the well is free from p lution from that facility and.the presence of(aPp'oximati n nitrogen notand valid)nitrate nitrogen is equal to or less than 5 ppm. Me od used to determine distance 3)- - OTHER .,__ •- pages 2 of 30 (revised 04/25/97) SUBSURFACE=SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: _ Date of Inspection: D] SYSTEM FAILS: a w You must indicate eit+.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 0 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine- at will be necessary to correct the failure. Q Yes No Backup of sewage into facility or system component due to an overloaded or clo ed SAS or cesspool. Discharge'or ponding of effluent to the surface of the ground or surface water due to an overloaded or clogged.SAS or cesspool. Static liquid level in the distribution box above outlei invert due to an o erloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available vo me is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or pri is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet o a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zon of a public well: -" Any-portion of a cesspool or privy is within 50 eet of a private water.supply well. Any portion of a cesspool or privy is less.t n 100.feet but greater than 50 feet from a private water supply well-with no acceptable water quality analysis. _If.the elf has been analyzed to be acceptable, attach copy of well water.analysis.for• coliform bacteria, volatile organic com unds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each f the following.- The following criteria apply to large sy ems in addition to the.criteria above: .The system serves a facility with:a esign flow of 10,000 gpd.or greater (Large System) and the system.is a significant threat to public health•and safety and the,' vironment because one or more:of the following (onditions exist: Yes No f r _ the system is w' in 400 feet of a surface drinking water supply the system i within 200 feet of.a tributary to a surface drinking water supply the syst is located in a nitrogen sensitive area (Interim Wellhead Protection Area.- IWPA) or a mapped Zone II of a publi ater supply well) The owner or operat of any such system shallbring the system.and facility into full compliance with the groundwater,treatment program requirements of 31 CMR 5.00 and 6.00. Please consult the local regional office of the.Department for further information. (revia*d 04/25/9.7) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - CHECKLIST e11t.C.S Property Address: 3 D 1 . LIA1�C�. St��E �R■� 11'��2SION � • -r :. Owner: SOS'. Date of Inspection: Check if the following have-been done. You must indicate either "Yes" or"No" as to each of the following: YY No Pumping information was provided by the owner, occupant, or Board of Health: — I ed for r at least two weeks and the system has been receiving norms stem coin onents have been pump into the system,recently or _ None of the sy P flow rates during that period. Large volumes of water have not been introduced as part of this inspection:. ._ As built plans have been obtained and examined. Note if they are•not'available with N/A. was inspected for signs of sewage back-up. rd dwelling p facility o g _ The fac ty _ sanitary or industrial waste flow. The system does not receive non µ / The site was inspected forsigns of breakou t: All system components, have been located on the site, cted The septic tank manholes were uncovered,.opened, de th of I quid,depth ofsd.the interior of the tludgec tankdepth•ofas lscum. for condition of baffles or tees, material of construction, dimensions, p The size and location of the Soil Absorption Itiif different from owner)n the �ite has were been with based fo information on the proper maintenance of The facility owner (and occupants, Sub-Surface;Disposal System. V•i--S C A 1..." lh SPi&c'T1 Existing information: Ex. Plan at B.O.H. — , not c Determined in the field (if any of the failure criteria related to.Part C is at issue, approximatio distan a 1is unacceptable) [15.302(3)(b)] LOGIgTtON'• SNOWS �' p' i N Fr IDS Stt.O UU S D-BOA Not 1.oc.PeT&a PLAN ... . - - �E6 AIT Pre-to page.4 of 10 ireviud 04/2S/97.) SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTIONFORM PART C SYSTEM INFORMATION . Property Address 3 D 1 L!'eK�'S�oR�r""A R .h YtQ.STo 1►1: 1"1J t l.L 5. Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:_jg.p.d./bedroorri for S.A.S. Number of bedrooms:y3 Number of current'residents:_Z Garbage grinder (yes or no): Q Laundry connected to-system (yes or no):� `Seasonal use (yes or no):' ,1 _ Water meter readings, if available (last two (2) year usage (gpd): L Z O G Sump Pump (yes or no):_ Last date of occupancy: . lJ - COMMERCIAUIN DUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank p�esent:,(yes or n - Non-sanitary-waste discharged to the Title5 sy em: (yes or no) Water meter readings, if availab'le:.. . ' Last date of occupancy: ' - OTHER: (Describe) - Last date of occupancy:' GENERAL-INFORMATION PUMPING RECORDS and source of information: _ ,- owwGR• 'e PUN.WGD -.. C2 —lb— 47,. M System pumped as part of inspection: (yes or no)�.3 If yes, volume pumped: sallons Reason for pumping: TYPE OF SYSTEM.+ Septic tan k/diopibnfie.Fimwjsoil absorption system Single cesspool Overflow cesspool Shared system (yes or no)`(if yes,attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) k (rwisod 04/25/97). Page'S of 10 4 -' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. .PART C SYSTEM INFORMATION (continued) L I,ttioR.s Property Address: Owner: : 100 As, 2�3 • € M Date of Inspection: to / SOIL ABSORPTION SYSTEM (SAS):v (locate on site plan, if possible; excavation not required, but may approximated'by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: l leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. Alternative system: Name of Technology: e tc.m e Co mments: n ) (note-condition..of soil, signs of hydraulic failure, level of•ponding, condition of veget�rago 54-tifilli0s. OP o 1.1 CESSPOOLS:.. (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids 4 layer: Depth-of scum-layer: Dimensions of cesspool: rs: - Materials of construction Indication of groundwater. - inflow(cesspool.must be pumpe as part of inspection) Comments: (note condition of soil, signs of ydraulic failure, level.of pondin condition of vegetation, etc.) PRIVY: (locate on site Dimensions- Materials of nstruction: Depth of s ids: • Comme (note ndition of soil, signs of hydra c failure, level of ponding;condition of vegetation, etc.) Page„s of 10 (revised 04/25/97) ri 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) t: 4< Property Address: Owner: Date of Inspection: w TIGHT OR HOLDING TANK: (Tank must be pumped rior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction: _concrete_metal _Fiberglas _Polyethylene —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order es; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float witches, etc.) DISTRIBUTION BOX:— (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and.distribution is equal, a tdence of solids carryover, evidence of leak a into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or o) Alarms in working order (Yes or o) Comments: (note condition of pump cham r, condition of pumps and appurtenances etc.) Ysga:_7 o! 10 (revised 04/25/97) ;� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM :PART C SYSTEM INFORMATION (continued) Property Address: 30 c.,4,ti1G S bto ME �R•, MIA tZ S To N i'�1 Lt.S Owner: T•05• SMEPI't$Si.� Date of Inspection: 2.3 _Ct BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron 1140 PVC _other (explain) - Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) O'b eup U h 1 1 fr., SEPTIC TANK: (locate.on.site plan) Depth below grade: 2 / Material of construction: )concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age Is age confirmed by,Certificate of Compliance (Yes/No) Ave'D 6— Dimensions' Q x 4 X- q' 1,900 C�s CS 6 Ata Sludge depth:�s _ �� Distance from top of sludge to bottom of outlet tee or baffle.-WA Scum thickness: " 21f - Distance from top of.scum to*top of outlet tee or baffle:,_ �� Distance from bottom of scum to bottom of outlet tee or baffle:_Y How dimensions were determined: P�P6 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-. A 6 L; C 0#-t 50063 PAM MS 1132 G OO t� 13 GREASE TRAP: (locate on site plan) Depth below grade: Material"of construction: _concrete _meta _Fiberglass _Polyethylede _other(explain) Dimensions: Scum thickness: Distance from top of scum to top of o let tee or baffle: �~ Distance from bottom of scum to bo om of outlet tee or baffle: _. Date of last pumping: . .... Comments: (recommendation for pumpin , condition of inlet and out t tees or baffles, depth of liquid level in relati to outlet in, structural integrity, evidence of leaka , etc.) 10 ') p6ol (revised 04 25 (r 9/ / SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION (continued) - Property Address: �O �� 5 H 6Q���� Owner:' �S LIP048 SttO-" �'Rtdb MRRsTo1�s 1�tlLC.S, nA;. Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) SSCR AT 5 ,T'c - 5 � -�o�� ��TG t2 5 v4Q L.. t� S P►lvE R Z . (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM ':-PART C SYSTEM INFORMATION.(continued) Property Address: a� Owner: 'SD S • S�' 1r4^1�1Z•� Date of Inspection: 1,11 Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: . Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions " Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS-Data Describe in your own words how you established the High.Groundwater Elevation. (Must be completed) _ l9 S l Co 1•3Tc PrP,12(y ►n o Vnl G t'�' D l a7�.. Ns L�-��� d 'CMG u��c'�R"C Pr1al , z i t Nt• tT�' ET G-2-cP�B� AT 501 w► Lp S!{oQ,e �TZLJ To r3� G,:FkzPCTgP_atfCP 2- page. ;0 of 10 (revised 04/23/97) -- -- t}y f� rrm�:.: .jT':e�1R�}S:- ce , 7,.a�•»fi-r '-.a sL .• .i:- •;:::r -i, .^,5"`,-... `r•`x-!�a.t'�t',�,c�~'r;K j'{,n t -li } •� it ' j'r x r� t!�eL$�i .5a i1x ,• e t "ttr IrD `,,,��./yp R.N�.f`�•��� ��,`•^�`�bo�� �,.��#��' .'� jk�. -��-n...,�jc'�P ••���c��,N"j�'."�:, r r.• '�:'rw. - '� � ��� ��. ,�''Jfl� y �/`r�i'. M-,�.!'�.f �h-i. t '!'{,.P •h ;. �I' cY�.',y Trf�:�,j..�`y A�� '�f�' h� � 'r _ •.J4.a 74 .t� 3• rr00 �. �, Y Ripp Ke � L e / . PL oRiCSIA94 �► o r• mc ey CmN,�iQ t 40 17 �y►yo 1,�� 10.0 '17. 1 0lk IDJG` "� ;. whT05 ta:Yk •�. - . � f T 6ILATZ w p�G L I �. ' +. ", -T. • = FRANK CONERY • �r Q�1,• .1,'e �ts, . I: j p�Na 6573 O C \c��CISTFP i — No.-......---2 d F.Es......2 . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ® j�v �, e �..... .�7.................OF........ 1.............-..�`'-......------.............................Appluation for Disposal Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal S stem at --........._._._.._..................... -- ------------------------......._... ---••--------------------------------- - ............-- .._. Lo ion-Address o Lot No. / ems IaZ /'a�aS%�Yz 1�.-_ /�&vs - . .. - ........ �a --- -------------- -7... ----. .......... ---•-- ----•........ ... .ll Wi Wa Owner %C�ay�i✓' Ad es ----..Ld.--� 1------Install-------------------------------------------- ----••. . =............................ � er Address �� � ,/® Type of Brilding Size Lot------------------- -----Sq. feet U Dwelling—No. of Bedrooms___..4 .................................Expansion Attic �) Garbage Grinder (A/p Other—Type of Building No. of persons............................ Showers — Cafeteria dOther fixtures ------------------ --------------------•------...--•---•---------.---------...-o------......... - Design Flow....._...� _- u ..................--gallons per person peday. Total daily flow-------- gallo W P q P y/• g -•- P ns. WSeptic Tank—Liquid Ll uld ca acit �n�. ]tons Len h.�..__ idth._.�s,._...._ Dlameter._._g_...._.._ Depth _._.. Disposal Trench—No. ............. Width._. Total Length._............_..... Total leaching area_._........._.......s . ft. Seepage Pit No....../............ Diameter....... ----- Depth below inlet......6.......... Total leaching area_?R. ....sq. ft. Z Other Distribution box (/) Dosing tank '~ Percolation Test Results Performed by...... /�.�._.._..._ -_ ._.__ oO��................. Date_._..'V���',<___��-------__---_... � Test Pit No. I.....a......minutes per inch Depth of Test Pit......... ?..�._.. Depth to ground water.. ... ✓ � Idd. fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-___--____-_-_--_..____ �+ ------- -------- ------ ----------------------•---- O Description of Soil.............. in. ...._. x 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 iITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by th9_b`oar of health. g Si d. { Date Application Approved By......... ..... ... . . •--•- .......; _�.a.�-.'.7 . Date Application Disapproved for the following reasons_______________________________________________ ---------------•-.......................... ---........... .............................•---•------••--------•--------.....-•---........-------•-----•-•-------...----------...........•----------------------------•--•-•------•--------•-----------------------•- A I Date PermitNo......................................................... Issued-. ....... .............r................ Datteo ^' No.- Ficz THE' COMMONWEALTH OF MASSACHUSETTS BQARD OF HEAL H ,��r�lutt#flan fir �i��u��a1 �ark� C��a�,��r�r�Uan r�uti� Application is hereby made for a Permit to Construct (X) or Repair ( ) an Individual Sewage" Disposal Systemm at, /� / *, / / .... a Xec le e -----•-----------•----•--•---- ----•-•-•........ - Lone ion Addresrs� +� t g Lot No . `"'r � c �1�. CAL G` 4 fig Q.j -�r /7 t ''!►.. dIf/'t fif'`Y, 0 ....... ...... ..... ..........................2°�•----•••-•...-•----••--••---• ••...__............._....••-....... .. ........................................... Owner Address {I�> +r W Installer Address y j � CIA dType of Building Size Lot_(-.[_____________---. _____Sq. f t' U Dwelling—No. of Bedrooms-__--1pm.r..................................Expansion Attic Garbage Grinder } Other—Type of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures .............:. ---- d W Design Flow..........* __44r........ gallons per person ier day. Total d 11 fl ........ � ..................... lens. WSeptic Tank—Liquid capacityl gallons Length-!'t_�!.' .... Width.. ..__..... Diameter................ Depth.... x Disposal Trench -'No. .......:............ Widthyy__�__ :........ Total Length_.__....._ ....._ Total leaching area....................sq. ft. Seepage Pit No.' i_._..___..... Diameter......IC+._._ Depth below inlet...... ..... Total leaching area.! 5�L..sq. ft. Z Other Distribution box ( )` Dosing tank P ' Percolation Test Results Performed by _ � � "� #- ---- Date --- ' a Test Pit No. I...._Ac_......minutes per inch Depth of Test Pit.........6_T_._...._. Depth to ground water. �?..__....!'�s Test Pit No. 2—.............minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil........... I _ _.... ...__ _`" 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 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 by the board of health. Date A lication Approved By_.— ._.. 7�:__- PP PP " ' = G ` - Date Application Disapproved for the°following reasons:.............................................................................................................. •-•--•----------------------------•-•-------•---------------.......--------••-----------•-••----••------•-----•. ---------------•--------------......•-•---------................................. Date PermitNo. - =-----------------------•--- Issued....................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ..� .........OF. .... ....."`.......................................... Currtgf iratr of Tl mptiana T V IS T CERTIFY, That the Individual Sewage,,Disposal System constructed or Repairedp by ' g --- - - y ( > ( ) ---------- Install � r at. - � : ----------'------••-•---------------- has been installed in accordance with the.provisions ofW.-R.K 5 of The State anitary Code as described in the application for Disposal Works Construction Permit No _________________ dated___ _"~_ .. "_% .............. THE ISSUANCE .OF THIS CERTIFICATE SHALT. NOT BE CONSTVED AS GRANTEE THAT THE SYSTEM 1L1L NCTION SA FACTORY DATE.•. •_-•-•_ :... ......... ........... Inspector. ............. •----•---------= ......................... �------••-•' THE COMMONWEALTH OF MASSACHUSETTS ,BOARD OF HEALTH s0 ............ /'?-�!�'i..........OF........... .. � 1 ...._...._...:---.........•-•-•......••••--.... NO......................... FEE.........._............. Bgllplifal 0 kv mitr Uan amit Permissioa i ereby granted..!:::........e-• •--•- -•-- ------------------•-•----•--•----•••---•------------•- to Constru ) o R ) an Zifdu.al Sew D posal stemat No.� --- 1 .'XX'--- t� ---p � ----� ---•. ....'.A---- ........................ '. .;< treet as shown on the application for Disposal Works Construction Pe No._/_ ,, ... Dated__, _'. . .' ........... Board of Heal DATE--- :.. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS •� - , r, s .5A04_777 077 AZ4 77 1/Ze al CDN3 �'2v� �� rovco/ jy OwrnjisIle q .3 8e r/�''0o»�r 12,31240 �' , ��/ ,� ,/ 11 Zoo S C., �G. `e/ss 2� /i4 z7 7-771 7)A r+c A 4 f �, 1'4e P� �L Des/ r � Cc r !I 'S !vaC //v77 VCZSs, EP ✓/ia7777) frl 00 cle 7 44 Le vf. �x //0 x /, S = 4 959 A,d /'98 / f v... z / ' st0, � o fi Q i,�.tk6fe V k 0.0 I �1 S, 10 f 6J Q i f - Q,J � ��Fi OFM'�J' ZM OF V� y XFRANK rn� a FRANK a CCNERY CONERY tA No. 65)3 O 1 o p� No. 6232 O v� /STS zoo ONAI SUt��y� Z4,it,E %514one L'g�. �, ��t s �o° �Vl //QOFif4F_Alt, Sct/c ��- 9 B Sty p• VLF zr �c� . 88 Jif d '707! Eel F — — _ .,?¢ . P L.A Nl OF LAND ,2b' 6 /t!D �rcK�+ct k�U�PY OWNED BY t, FRANK GONERY 5 TRENTON-ST. I HYANNIS. MASS. 02601 ReGfVWMW 67+oni�aw a tJ1PtD duRVErcK+ SC ,Q W IN a,7 0 FT. IS//9/76 dti� /a d1l