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Home My WebLink About0240 MAIN ST./RTE 6A(W.BARN.) - Health 240 Main Street! k . West Barnstable A= 134 - 8 I �p I I' ' I t t °F"nay \ CERTIFICATE OF ANALYSIS Page: 1 of 1 .; Barnstable County Health Laboratory (M-MA009) Report Prepared For: Report Dated: 12/23/2011 Sally Desmond Desmond Well Drilling Order No.: G1166048 P O Box 2783 Orleans, MA 02653 Laboratory ID#: 1166048-01 Description: Water-Drinking Water Sample#: Sample Location: '240-Mai6.St.�W."Bamstable;MAT--� Collected: 12/22/2011 Collected by: Customer Received: 12/22/2011 Routine ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 12/22/2011 Copper ND mg/L 0.10 1.3 SM 3111B 12/23/2011 Iron 1.6 mg/L 0.10 0.3 SM 3111B 12/23/2011 pH 6.8 PH AT 25C NA 6.5-8.5 SM 4500-H-13 12/22/2011 Sodium 6.1 mg/L 2.5 20 SM 3111E 12/23/2011 Total Coliform Absent P/A 0 0 SM9223 12/22/2011 Conductance 110 umohs/cm 2.0 EPA 120.1 12/22/2011 Based on the results of the parameters tested, the water is suitable for drinking, but may present aesthetic problems (taste, odor, staining)due to Iron. Attached please find the laboratory certified parameter list. Approved By: (Lab Director) -� _ _ ,-4 J Z; . io it ..,.. ...s C3 r-- W MY ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 I _ �a CERTIFICATE OF ANALYSIS ' Barnstable County Health Laboratory (M-MA009) Recipient: Sally Desmond Matrix: Water-Drinking Water Desmond Well Drilling Sampled: 12/22/2011 14:30 P 0 Box 2783 Received: 12/22/2011, 15:10 Orleans, MA 02653 Collection Address: 240 Main St.W. Barnstable,MA Order#: G1166048 Sample Location: Lab ID: 1166048-01 Description: 2day-240 Main St. Date Analyzed: 12/22/2011 @ 16:32 Sample#: Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste, odor,staining)due to Iron. EPA 524.2- Volatile Organics by GC/MS Result MCL MDL Result MCL MDL Parameter ug/L ug/L ug/L Parameter ug/L ug/L ug/L Dichlorodifluoromethane ND 0.50 Chloroform ND 80 0.50 Chloromethane ND 0.50 ds-1,2-Dichloroethene ND 70 0.50 Vinyl chloride ND 2.0 0.50 ds-1,3-Dichloropropene ND 0.50 Bromomethane ND 0.50 Dibromochloromethane ND 0.50 1,1,1,2-Tetrachloroethane ND 0.50 Dibromomethane ND 0.50 1,1,1-Trichloroethane ND 200 0.50 Ethylbenzene ND 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene ND 0.50 1,1,2-Trichloroethane ND 5.0 0.50 Isopropylbenzene ND 0.50 1,1-Dichloroethane ND 0.50 Methylene chloride ND 5.0 0.50 1,1-Dichloroethene ND 7.0 0.50 Methyl-tert-butyl ether ND 0.50 1,1-Dichloropropene ND 0.50 Naphthalene ND 0.50 1,2,3-Trichlorobenzene ND 0.50 n-Butylbenzene ND 0.50 1,2,3-Trichloropropane ND 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyltoluene ND 0.50 1,2,4-Tdmethylbenzene ND 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND 0.50 tert-Butylbenzene ND 0.50 1,2-Dichlorobenzene ND 600 0.50 Tetrachloroethene ND 5.0 0.50 1,2-Dichloroethane ND 5.0 0.50 Toluene ND 1000 0.50 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 0.50 1,3,5-Trimethylbenzene --- - -- - _ND 0.50 _._ trans--1 2-Dichloroethene- ____ ------ND._ __ 100- --..--0.50- 1,3-Dichlorobenzene ND 0.50 trans-1,3-Dichloropropene ND 0.50 I 1,3-Dichloropropane ND 0.50 richloroethene ND 5.0 0.50 1,4-Dichlorobenzene ND 5.0 0.50 richlorofluoromethane ND 0.50 2,2-Dichloropropane ND 0.50 2-Chlorotoluene ND 0.50 4-Chlorotoluene ND 0.50 Benzene ND 5.0 0.50 Bromobenzene ND 0.50 Bromochloromethane ND 0.50 Bromodichloromethane ND 0.50 Bromoform ND 0.50 Carbon tetrachloride ND 5.0 0.50 Chlorobenzene ND 100 0.50 Chloroethane ND 0.50 Attached please find the laboratory certified parameter list. Approved By: a (Lab Director) ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, P0. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 Page 1 of 1 s Massachusetts Department of Environmental Protection Bureau of Resource Protection WELL DRILLER j Please specify work performed: Address at well location: New Well Street Number: Street Name: 1240 —� MAIN STREET—� Please specify well type: Building Lot#: Assessor's Map#: Domestic Assessor's Lot#: ZIP Code: Number Of Wells: 1 102668 City/Town: Well Location BARNSTABLE In public right-of-way: GPS Yes G No North: West: 41.43180 170.23210 Subdivision/Property/Description: Mailing Address: click here if same as well location addres Property Owner: Street Number: Street Name: ONEY 240 MAIN STREET City/Town: State: Engineering Firm: IBARNSTABLE MASSACHUSETTS ZIP Code: 02668 Board of health permit obtained: {!'Yes G Not Required Permit Number: Date Issued: W2011026 12/20/2011 -� r Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Well`Driller---General Well form DRILLING METHOD Overburden Bedrock Auger --Choose Bedrock WELL LOG OVERBURDEN LITHOLOGY From _ _ - a Drop in Extra fast or slow Loss or addition of To(ft) :Code Color Comment (ft) _ drill stem drill rate fluid F2_6___1 IMediurn Sand jBrown r Ye r Fast r Slow r Loss Addition 20 40 Medium Sand L Brown Ye ( Fast GO Slow r Loss r Addition BROWN r Slow Loss Addition 40 55 Fine To Coarse Sand Dark Gray Ye Fast _.. 55 70 Fine To Coarse Sand ]Brown 0 Ye r Fast r Slow (� Loss r Addition WELL LOG BEDROCK LITHOLOGY Visible, Extra From Drop in Extra fast or slow Loss or addition of To(ft)- Code Comment .-Rust Large (ft) drill stem.drill rate fluid Staining Chips. Choose Code Ye (-0 Fast r Slow r Loss Addition Ye Ye ADDITIONAL WELL INFORMATION Developed Yes r No Disinfected— Total Well Depth 170 1 Depth to Bedrock —� Fracture Surface Seal Type None Enhancement Yes No CASING` Is Casing above ground. From: - 1 To.. 10 From To Type :Thlc-kness Diameter `Driveshoe 67 jPolyvinyl Chloride Schedule 40 0 03 Ye SCREEN I LJ No Scree From. To Type Slot Size. Diameter 67 70 Stainless Steel Well Point 0.012 0 WATER-BEARING ZONES L DRY WEL From To ' `t Yield ) .'(gpm 70 12 ...._ PERMANENT PUMP(IF AVAILABLE) 2 Wire Constant Speed Pump Description Horsepower Submersible 3/4 P Massachusetts Department of Environmental Protection Bureau of Resource Protection—Well Driller Program Well Completion Reports(General) Pump Intake Depth(ft) 166 Nominal Pump Capacity,(gpm) . 110 . ANNULAR SEAL/FILTER PACK :Water:' From To Material 1 Weight Material 2 Weight(gel� Batches Method Of Placement Choose Material lChoose Material = E --Choose One WELL TEST DATA Time Pumping ':Time To - ; Recovery (ft' Date Method Yield(gpm) Pumped ... Level (ft -Recover (HH:MM) BGS) .._ .(HH:MM) r 12l22/2011 Constant Rate Pump 12 100 19 0:01 0 WATER LEVEL .Date Measured Static Depth BGS (ft) Flowing Rate(gpm) 12/22/261 18 12 COMMENTS WELL DRILLERS STATEMENT This well was drilled or altered under my direct supervision, according to the applicable rules and regulations, and this report is complete a knowledge. Driller PATRICKDESMOND Registration# 877 Monitoring[M] Supervising Drill Firm I DESMOND•vVELL DRILLh. Rig Permit# 1023 Date.Job,Compl NOTE:Well Completion Reports must be filed by the registered well driller within 30 days of well completion. if 12/23/2011 FRI 15: 27 FAX 5083627103 Barnstable CTY HealthLab �� Barnstable Health Z002/002 -- - .........................._.-._..---..-_.....-.-.... -- - - ............. .........._. C>�� vim'.► Fgs : CERTIFICATE OF ANALYSIS 8 iQ Barnstable County Health Laboratory (M-MA009) Recipient: Sally Desmond Matmc Water-Drinking Water Desmond Well Drilling Sampled: 12/22/2011 14:30 P 0 Box V83 Received: j12/22/2011 15:10 Orleans, MA 02653 Collection Address: 240 Main St.W.Barnstable,MA Order#: G1166048 Sample Location: Lab ID: 1166048-01 Description: 2day-240 Main St. Sample#: Date Analyzed: 12/22/2011 @ 16:32 Analyst: yn Method: EPA 524.2 Dilution Factor: 1 Comment: Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste, odor,staining)due to Iron. i I EPA 524.2- Volatile Organics by GC/MS Result MCL MDL Result MCL MDL Parameter ug/L ug/L ug/L Parameler ugtL ug/L ug/L Dichlorodifluoromethane NO 0.50 Chloroform NO 80 0.50 Chloromethane NO 0.50 ds-1,2-Dichloroethene NO 7D 0.50 € Vinyl chloride NO 2.0 ' 0.50 ;ds-1,3-Dlchloropropene NO 0.50 Bromomethane NO 0.50 Dibromochloromethane NO 0.50 1,1,1,2-Tetrachloroethane NO 0.50 Dibromomethane NO . 0.50 1,1,1-Trichloroethane NO zoo 0.50 Ethylbenzene NO 700 0.50 1,1,2,2-Tetrachloroethane ND 0.50 Hexachlorobutadiene NO 0.50 1,1,2-Tnchloroethane NO 5.0 0.50 Isopropylbenzene NO 0.50 1,1-Dichloroethane NO 0.50 Methylene chloride NO 5.0 0.50 1,1-Dichloroethene NO 7.0 0.50 Methyl-tert-butyl ether NO 0.50 1,1-Did1loropropene NO 0.50 Naphthalene ND 0:50 1,2,3-Trichlorobenzene NO 0.50 n-Butylbenzene ND 0.50 1,2,3-Trichloropropane NO 0.50 n-Propylbenzene ND 0.50 1,2,4-Trichlorobenzene ND 70 0.50 p-Isopropyholuene ND 0.50 1,2,4-Tnmethylbenzene NO 0.50 sec-Butylbenzene ND 0.50 1,2-Dibromo-3-chloropropane ND 0.50 Styrene ND 100 0.50 1,2-Dibromoethane(EDB) ND O.so tert-Butylbenzene ND 0.50 i ( 1,2-DicNorobenzene ND 600 0.50 etrachioroethene ND 5.0 0.50 1,2-Dichioroethane NO 5.0 0.50 Toluene ND 1D00 0.50 } 1,2-Dichloropropane ND 0.50 Total xylenes ND 10000 D.50 1,3,5-Tdmethylbenzene NO 0.50 trans-1,2-Dichloroethene ND 104 0.50 1,3-Dichlorobenzene NO 0.50 trans-1,3-DicMoropropene ND 0.50 x 1,3-Dlchloropropane NO TricHoroethene ND 5.0 D.50 1,4-Dichiorobenzene NO 510 0.50 Trichlorofluoromethane ND D.50 2,2-Dichloropropane NO 0.50 2-ChtarbtAluene ND 0.50 i Chlorotoluene ND 0.50 EBenzene _ ND 5.0 0.50 4 j Bromobenzene ND 0.50 Bromochloromethane ND 0.50 j 3 Bromodichloromethane ND 0.50 Bromoform NO 0.50 . .� Carbon tetrachloride NO 5.0 0.50 µ j Chlorobenzene ND 100 0.50 Chloroethane ND D.50 " o Attached please find the laboratory certified parameter list. Approved By: (Lab Director) i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, P0.Box 427, Barnstable, MA 02630 Ph:508-376-6605 Page 1 of 1. i 12/23/2011 FRI 15: 26 FAX 5083627103 Barnstable CTY HealthLab Barnstable Health 2001/002 CERTIFICATE OF ANALYSIS Page: 1 of 1 Barnstable County Health Laboratory (M-MA009) sacrru ' Report Prepared For: Report Dated: 12/23/2011 Sally Desmond Desmond Well Drilling Order No.: G1166048 P 0 Box 2783 Orleans, MA 02653 Laboratory ID#: 1166048-01 Description: Water-Drinking Water Sample#: Sample Location: 240 Main St.W. Barnstable,MA Collected; 12/22/2011 Collected by: Customer Received: 12/22/2011 Routine ITEM RESULT UNITS RL MCL METHOD# TESTED Nitrate as Nitrogen ND mg/L 0.10 10 EPA 300.0 12/22/2011 Copper ND mg/L 0.10 1.3 SM 3111E 12/23/2011 Iron 1.6 mg/L 0.10 0.3 SM 311113 12/23/2011 pH 6.8 PH AT 25C NA 6.5-8.5 SM 4500-H-B 12r22/2011 Sodium 6,1 mg/L 2.5 20 SM 3111B 12/23/2011 Total Coliform Absent PIA 0 0 SMM3 12/22/2011 Conductance 110 umohs/cm 2.0 EPA 120.1 12/22/2011 Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems , (taste, odor, staining)due to Iron. Attached please find the laboratory certified parameter list. Approved By: (Lab Director) F F l i i 1 i i F + {SS4 i ! 1 5 E i 3 i s F i ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level F Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph:508-375-6605 F No. o i'�_U Fee-- ----------- BbARD OF HEALTH TOWN OF BARNSTABLE � �/ Applicat ion-*r Well Co0tructioni3ermit Application is hereby made for permit to Construct (J ), Alter ( ), or Re air ( )an individual Well at: Location — Address Assessors Map and Parcel _ Owner Address Installer — Dril — Address Type of Building J Dwelling Other - Type of Building—=------------ No. of Persons-- _--_ Type of Well ytt KAH L) -- Purpose of Well--- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Signed -------- _I 20 .tI n •de J Application Approved BY �4 (Z �t d Ve Application Disapproved for Sfollowing reasons: ---------__--_---_ __ �— date PermitNo. __ —_ ---- Issued-----------------------______--._____--------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed 0 ), Altered ( ), or Repaired ( ) by hp SM n k� - 5- / —Installer ,.t 6- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------Dated---------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE -__ __ _ Inspector--------_--_-_-------____---____-- No. — °l!=�°2b Fee-44—---------- i&ARD OF HEALTH TOWN OF BARNSTABLE C-C - ZippCication for WellCon0truct ion Permit Application is hereby made fora permit to Construct Alter ( ), or Re air ( )an individual Well at: f, Location — Address — Assessors Map and Parcel -6(c�t�ab 266 B r Owner Address �k`_i--�X��M.� �-------- �.U-�U y. 2�l $�j V�S tOZ653 - - -- .-------------------- ---------t------_---r- ------•--------- Installer — E;jL r Address Type of Building. J Dwelling—--__--- --------__----____-- i Other - Type of Building—=---------___—_ No. of Type of Well ye t SC-�-I� � —--— Capacity--------------.------------ ---— Purpose of Well- — Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed - 1, — -- _-- _1 20�1 date Application Approved By. (�/ �/�—_-_ U_ date Application Disapproved for Sfollowing reasons: -- _— ----_—_—__-------------. date --- Permit No. — ----- Issued--- --------------- - date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) by— Installer at—___— 214 �/�U 1 e a i r� has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ____—____--__Dated----------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED_ AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--_____— __ Inspector --___--- i BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5tructiouPermit No. _ �_ n 1 Fee---� Permission is hereby granted No. — to ConstrucZilO, Alter— Gle)� S Repair —�A ividual ell at: }r ( �e----------------------------------------------- Street as shown on the application for a Well Construction Permit I I� No.- -- -- Dated—�-2' f�— -- --------------------------------- 14,12 je-L---—------------- -- ------- Bo�a� rd of Health DATE f THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA 1 J � 1 4-9 a i "C- ..>r: �` - F•+^ Cam✓ _r �..:_t:- .�- U I PL A Al _ l l�lo� e PLAA/. 2EFEQE A/C.E : �E0Y CEPT/FY TL/AT T/-/E EX/.57-- 1- -FOUn/DA Ti0A/ L 0CLI Ti ,V /S Q7P.P�1� O w M N THE TOWN OF ;ems.�d'wz� Sue✓z y o� THE COMMONWEALTH OF MASSACHUSETTS BOARD O H E A TH ApplirFation -fur Uispwial Workii C onstraartion Vrruift Application is hereby ade for a Permit to Construct (k') or Rep -r ( ) an Indivt ual Sewage Disposal 2 System at: `Yyt Cl lm 7 �- ,v y � c— %i1 ----- --------- Location-Address or Lot No. ?Gi?....._...&�l__1op_C.11.............................. •-RL•7......czl -:f .V...... 1tiz �. Owner Address Wty, J— pe of uilding"��✓ , Size Lot............................Sq. feet V Dwelling—No. of Bedrooms---------3..............................Expansion Attic (J-7- Garbage Grinder ( ) per, Other—Type of Building __. ------ No. of-persons._____ ---------------- Showers Cafeteria ( ) Q' Other fixtures .................. W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. P4 Septic Tank—Liquid capacity/04©_gallons Length---------------- Width................ Diameter---------.------ Depth---------------- xDisposal Trench—No-___________________ Width......... "Jot Total leaching area--------------------Sq. I. Seepage Pit No.....�--------- Diameter... .?_ ----- Depth Blow inlet................... Total leaching area.____._.__-_.-____sq. it. z Other Distribution box ( ) Dosing tank ) '-' Percolation Test Results Performed b �'�-� E ___-?'!4y...... _ Date___ a Y - --- ,� Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground fzq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-_-_.-____________--_- --------------- O V Eke ca - �� Description f Soil -F ...... --- -- --•- --- -- --- ---- ------------ ----- _ ... ...... ... � -�------- i-- ---- ------- ---- -- . 46-------cam - - ------------------------------------------- �xj Nature of Repairs or Alterations—Answer when applicable._-.. e�.1 -.b, TP. ---- -- Ce zu Agreement: , The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI 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. Sign e ..• -••--•-•-- -- -- -•--- ... Date Application Approved BY----- -�r -/ Dat/ Application Disapproved for the following reasons------------------------------------- - - -•-•----------------•..._...•------------•------•--•---------•-•••-- ............................................... ------------•••---........------•--•-•--•••••-••-•-••-•----•---•------------- •--•----------- --....................... Date f — - Permit-No._. Issued...._.._.1.. .... _ Date nswsaww�s��wwwo� - • 1 i No..-.- ._._._.. Fss... f .. THE COMMONWEALTH OF MASSACHUSETTS BOARD O I-6 -A)T. ' � r i OF........ . :.... ..:. .--- ........ Applirtttion -for IN-4puottl Works C onotrurtion Vrru it Application is hereby made for a Permit to Construct O or Rep/a• ( ) an Individual Sewage Disposal System at:00 Location-Address or Lot No. Owner Address WI al �' T pe of Building Size Lot_..-•_______________________Sq. feet U Dwelling—No. of Bedrooms_________ ___________•____-__---____-Expansion'attic ( Garbage Grinder ( ) per, Other—Type of Building ._.�..* �....._.. No. of persons....... --------------- Showers (.-?—) — Cafeteria ( ) QI Other fixtures w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/0_P-gallons Length_______________ Width................ Diameter.......--------- Depth---------------- x Disposal Trench—Nov . ____________________ N�Iidth.._..... a n f� ._ .. Total leaching area-.._.__._-__.___---sq. ft. Seepage Pit No...._.__------------- Diameter____________________ DeptUelow inlet.................... Total leaching area..................Sq. it. . Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed b w t---t- --�--•.�.'�*"4: ___-----__-_ ----------------- Test .G .... Y Date a Pit No. 1....._..........minutes per inch Depth of "Pest Pit.................... Depth to ground water.... . .--___. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__.-.-_-___--__.--__-__. O . /i! l�i�C+C r+tJ d ---- -•--------- -------- -------------------------- Descriptio�o6f Soil � � � , ...,�'rt � V ------- `-- --- - �! -- _-t`---- ---- -- ------- ---- s.. . -----— �� W ------------ ' .. ------ l - ��. U Nature of Repairs or Alterations—Answer when applicable.--__ .A�_1776�_ ___ 7-6.__ ...dA 4) _.'_._____..___._ --- -------------------`'�' Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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. Stgne ! '".' - .. . ...... 3 1 r Date Application Approved BY------ �.-. .------- Dat Application Disapproved for the following reasons---------------------------------------- --------------------------------------------------•-•--•••--••-•-••-- ...................................................... --------•--------••--•-•----•-•-•-•-••--•------•-------••-•••----•----------•---•-•------•---------•--•-•-••-•--••-••-•----------•---•----•••---- / Date PermitNo......................................................... Issued.-- {---- ----� --------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..�. Z, .......OF.......' ..:.... . f- ...... ... IvErrtifirttte of ""tomplitturr TIC IS TO CERTIF , That the Individual Sewage Disposal System constructed (�) or Repaired ( ) w.. by.. - I � 1 -- --------- -----------------------•-------=•------------------------------------------_--_-_----_-------- 100 I lle �l..at t .- -. has been installed in accordance with the provisions of Article XI T e State Sanitary Code s de tribe in the application for Disposal Works Construction Permit No...................... ... ............... dated.., ._/ ..., .. ._ `................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM YdILL^NCPON SATISFACTORY. DAT1✓- ; J�=f--------------------------------------- Inspector.----- -------- . ..................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT J _ Q ` ..........OF......... ................................................................. No...�.._/�..------•--•-• FEE.../--J' --••-------- �i�p>a tt ork,i L fstrurtilait rrutit Permission ' ereby granted•_••_ _ :-_.'._ __ ....... ..._+ �tw __ .......... ..-------------------------- to Construct/. )/or Re air ) an In ividu Sew tsposa �1tem /' at •---1-"tJ-- --------- - ---- ,,S� �/ as shown on the application for.Disposal Works Construction ernfiit N ..:_ �.._ Dated__ __.f _._.7X......_. •••-• C11� t_ ............................ �J Board of Healt DATE.......0olees -- -----•-_/-- ----------------------------- FORM 1255WARREN.-INC.. PUBLISHERS r Jb L i t I ' o\-E! 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