HomeMy WebLinkAbout0391 LAKE SHORE DRIVE - Health 9999 Sandwich — Barnstable Town Ogle
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL.AFFAIRS
?-:L:r" f- o 4 n TABLE
DEPARTMENT OF ENVIRONMENTAL PROTE'C�TIO�'�
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner's Name: Ruth Lino
Owner's Address:
Date of Inspection: 4/6/2005
Name of Inspector: (please print) Patrick T. Sullivan
Company Name: Ready Rooter
Mailing Address: P.O. Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
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:
—Zpasses
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: Date:
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.
F
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
C. System Passes:
_ZI have not found any information which indicates that any of the failure criteria described in 310 CMR
15.=103 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 apprc v+ed by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for the fo),Fo/i ing statements. If"not determined"please
explain. f/
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 exfiltration 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.
i
ND,explain:
Observation of sewage backup or breakout or high static water level in the distribution box due to broken or
obstructed pipe(s)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 app val of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
i
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by th oard 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 wwhhith will protect public health,safety and the environment:
Cesspool or privy is within 50 fe�et'`c f a surface water
_Cesspool or privy is within 50,f6et of a bordering vegetated wetland or a salt marsh
System will fail unless the Board of Health(and Public Water Supplierr.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)4nd the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply. `
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
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_The system has a septic tank and SAS and the SASns within 50 feet of a private water supply well.
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The system has a septic tank and SAS and the AS 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 analys'is,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
rhe presence of ammonia nitrogen and nitratenitrogen 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.
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3. Other: i f
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Pag.-4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge 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 and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
_,Z 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.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
Any portion of a cesspool or privy is 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.]
./J0 (Yes/No)The system fails. I have determined that one or more of the above criteria exist as
described in 310 CMR 15.303,therefore 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 facility with a deign 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 crite ziabove)
yes no �✓
the system is within 400 feet of a surface drinking fwater supply
the system is within 200 feet of a tributary to a u face drinking water supply
_ the system is located in a nitrogen sensitiv area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well s
If you have answered"yes"to any question ' Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system as failed.The owner or operator of any large system considered a
significant threat under Section E or fail d under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should co ct the appropriate regional office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
.Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
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?
yZ _ 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 of this inspection?
,Z_ 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?
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 than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_ Existing information.For example,a plan at the Board of Health.
,,Z _ 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)J
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3J<D<;;,- _
Number of current residents: 1
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):,�if yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use:(yes or no):jjL0
Water meter readings, if available(last 2 years usage(gpd)): :�t-�`�. c� 4
Sump Pump(yes or no):_p,
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.)/
Grease trap present(yes or no): `
Industrial waste holding tank pres_ent V(yeor no):Non-sanitary waste discharged to the5 system(yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:cz),�� ��,,�,� � cam,v„yv� '' t� �✓ -s-
Was system pumped as part of the inspection(y s or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_.,,,�eptic 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):
Approximate age of all components,date installed(if known)and source of mforma ion: /^
7/ 0!1
Were sewage odors detected when arriving at the site(yes or no):n.7c
f
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
BUILDING SEWER(locate on site plan)
Depth below grade: :0--')"
Materials of construction:_cast iron✓40 PVC_other(explain):
Distance from private water supply well or suction line: "7
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Jv�oocate on site plan)
Depth below grade:
Material of construction: f ncrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
cerificate)
Dimensions: C% : x
Sludge depth: ?,
Distance from the top of sludge to bottom of outlet tee or baffle:
Scum thickness: a"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
eiA-
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions: f
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.):
i
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
TIGHT or HOLDING TANK: (tank must be pumpecdat 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/ayy
Alarm present(yes or no):
Alarm level: Alarm in wor mg order(yes or no):
Dare of last pumping:
Co_ments(condition of alarm d float switches,etc.):
DISTRIBUTION BOX: v (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan) rr
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.):
i
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type _
— �eaching pits,number: i �"-� �+•� `"'l �' `� "'`z
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Continents(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
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CESSPOOLS: (cesspool must be pumped as art 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 in (yes or no):
Comments(note condition of soil,signs of hydraulic failure, level
of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs,/hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
1 benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
C.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 391 Lake Shore Drive
Marstons Mills/Sandwich
Owner: Ruth Lino
Date of Inspection: 4/6/2005
SITE EXAM
Slope
Surface water
Check cellar-""
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
_L/-�&tained 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 the 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:
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Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
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Installer Address
d Type of Building Size Lot..9Pr®O6-.___.....Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic (<--- Garbage Grinder ( )
Other—T e of Building ___.... No. of persons............................ Showers
a YP g -------••---.._.__... p ( ) — Cafeteria ( )
Otherfixtures ..---•--•----------------------•------........------------•-•••--•---------------•---•--•-----•-•-----•-----------•----------........._..--------•---
W Design Flow........... .....................gallons per person Der day. Total daily flow------ - _•__-_---..............gallons.
WSeptic Tank—Liquid"capacity/_L O..gallons Length_ `O...... Width'`.°....... Diameter________________ Depth.... ........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------- Diameter.......FF--------- Depth below inlet..t. ...... Total leaching area....?_ F ..sq. ft.
Z Other Distribution box ( ) DosiVk-e
~' Percolation Test Results Performed by.-__--____I--- ___---..... Date........................................
Test Pit No. I____•---___---_.minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minl tes per inch Depth of Test Pit.................... Depth to ground water........................
a ••--••-•----•--•••---•--•---•-•--•..............••---•-----•-•-.....----------•-••••-------...-----.....--•---.........-•------•••-•-•----------=---------••-
0 Description of Soil.........7.................
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U Nature of Repairs or Alterations—Answer when applicable--------------------------------...............................................................
.........................................................................................................................................................................................................
Agreement:
T_ze undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITi 12 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
op ti.on until a C ,tificate of Compliance has b n issued by the bo of health.
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Apption Approved By.................... ................. -•--.--.....---/............--------
Date
Application Disapproved for the following reasons------------ -----•---•--•-----•----------•-----------••--•-•---------•-------•......------...•-------•--------
-------------------•------------------•--•-•-•------•-•...-•----------•---••-••••-------.......----•---------------------•------....-•-----•---••---•---•----••---•----•-•--••---•---•-•--•-----------.
Date
PermitNo......................................................... Issued.......................................................
Date
No... �j:. FES.............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O. HEALTH
E...�4 sr..--------------------0F...............�.�cc�-.vb.�/,jl'..--z_-..........................
Appliration for lliipnsttl Works Tnnitrnrtion Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at f /
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Installer Address
UType of Building N Size Lot.00-r.t:.,=.............Sq. feet
I—I Dwelling—No. of Bedrooms.._........f. ......................Expansion Attic (t--) Garbage Grinder ( )
a Other-Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures
W Design Flow........... C .....................gallons per person per day. Total daily flow....... = .......................gallons.
WSeptic Tank—Liquid*capacity/e-.L Z-_.gallons Length_.6....... Width-.I .�._...__ Diameter________________ Depth_... ........
x Disposal Trench—No_ ____________________ Width.................... Total Leng th.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter......_c�........... Depth below inleet.�%_--_�_;-:_.... Total leaching area....���- ..sq. ft.
Z Other Distribution box ( ) Dosing-tank) A
Percolation Test Results Performed by..... .0 -4..... -:!�_- .................... Date.............._..........................
Test Pit No. 1................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........................
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•----------------------------------- ------•-----------•-------------------•-------•--
Description of Soil .......j--------------------
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-•-•--------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------.----------------
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 TITLI 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certdicate of Compliance has b en issued by the board-of health.
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A-100
Applic`t n Approved By................. ..... .... 1. --- ........................................Date
Application Disapproved for the f ollowang reasons---------------••------------------------------------------------------------•--------------------•--•••---.._._.
----------•-.....---•-------••-----•-•------•------•-----------•----------------•---------------•--•----------------------•---------------------...-------------•------•----------------------•---•-•---
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF...............................................................
vorrtifirat a of Tompltanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by '= .�;;�� 'w^- ._.... ----•---- 1• _..
�. Installer }•�
at
has been installed in accordance with the provisions of TIT F. �
r of T e tate Sanitary Code as described in the
application for Disposal Works Construction Permit No............./'!!n. ........ dated----------------------------------..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WIL FU TION SATISFACTORY.
DATE..../...;' .`l........................................................... Inspecto�--/---------•----------••---------•-------------•----•------•-•---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0 F......................
No...._.. FEE......... .4.........
Disposal Works Tnnstrnrtion amit
Permissionis hereby granted.................. -------�....----•--------•---------------------•---•-----------•--••-------.......-----.....---...._...............
to Construct ( ) r air ( an Ind' i al Sevtr ge Disp al System
at No
-- --------•..................•-•-••••-•--.•-----•------------------------------------•--•-----------•------•----------------.............
Street
as shown on the application for Disposal Works Construction Pe o ______ Dated..........................................
------------------------------
----=- ------
+ �, oard-9f Health
DATE................•--------------•-------••-•--•--------••••--•------
FORM _1255 A. M. SULKIN, INC., BOSTON
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LOCATION SEWAGE PERMIT NU.
PILLAGE
( INSTALL R'S JAM1E A ADDRESS
s
6 UILDE R OR OWNER
Ste � is
DA T E P E R M I T I S S U E D
DATE C 0 M P L I A
N C E ISSUED
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