HomeMy WebLinkAbout0100 ACRE HILL ROAD - Health 100 ACRE HILL RD.,
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FROM WM FRRR I NGTON PHO`4E NO. 503 477 0150 Rug. 07 2000 10:45RM 02
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COMM ONWEALTZ.i OF "iSSACHUSETTS
EXECU'1'I6F, OFFICE OF ENVIRONMENTAL Ar,FAIRS
DSrAW11M,NT OF EN IRONIUN AL PROTZCTION
ONE WINTER STREET.BOSTON MA()2108 (8I7)292.5500
TRUDY COXE
ARCED PAUL CZLLUCCI setrptary
Governor bAVID B.STRUfiS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICA7tON
ProOae'tY Addrou-10 O G 0 e. (y r f'
Name of Owner Q'(ZIJt)l,e -I�IZ04.+,tJ
Date of Inspection: Address of Owner: p `k
Marro of Irnpector:(Please PrintrT" o _c t't *e
I am a DEP approvod aystens inspector pursuant to Section 15.34o of rMe 5(310 CMR 15.9001
Company Name:
MaSM Address. U G <e(�. aA
Telsphorre Number: 3 o
CERTIF!gC TION STATFM04T
f certify that I have personalty 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 trpining and experience in Alto proper function and
maintenance of on•site sewage disposal systems. The systom:
!/ p8sses
Conditionally Passes
Bleeds Further Evaluation By the Local Approving Authority
Fails
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Inspector's sipnehtre: n h-o ►�► Dale: ZZ-6/06 .
the System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEp)wlthin thirty(301 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 ttrp
system owner and copies sent to the buyer.if applicable, and the approving authority,
NOTES AND COMMENTS
revised 9/2 f 9® Pvtr I oftI
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FROM WM FARRINGTON PHONE 503 477 0150 Rug. 07 2000 10:46RM P3
SUIS$URFACE SLWAGE DISPOSAL SYSTEM IrispE.cTiON EOnM
PART A
CER7I11"ICATIDN fcoertirwmd)
Property Address: Ji 0 (NAQ hQ 14(i n f d
Data of Inspection: & 1./a Q
INSPECTION SUMMARY: Check A. 8, C, or U:
A. SYSTEM PASSES:
l have not found any information which indicates that any of the failure conditions described in 310 CNIR 15.303 exist, Any failure
criteria not evaluated are indicated below.
COMMENTS: v?n. q t> ( (P�
B. SYSTEM CONDITIONALLY PASSES:
One or more system conrponants as described in the "ConditirMraj Pass" sacljon used to I>e rppjtrced or repaired. The system, upon
completion Of the replacement Of repair,as approved by the Board of Health, will pass,
Indicate yes,no,of not determined(Y,N,or NDl• Describe basis of determination in all Instances. If Trot determined',explain why not.
The septic tank is metal,unless the owner or operator has pravldcd the system Inspoctof with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty 120)years prior to the date of the inspectiorl,or
The septic tank,whether of not metal,is cracked,structurally unsound,shows substantial infiltration or extiltration, or tanfS
failUte is imminent, The System will pass inspection if the existing Septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box Is due to broken or obstructed pipets)
or due t0 a broken, settled of uneven distribution box. The system will pass inspection If(with approval of the Board of
Health)•
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 pipeis)are replaced
obstruction is removed
is
• •ozri Dort O /'7 /Oq
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FROM WM FARRINGTON PHONE NO. 509 477 0150 Rug. 07 2000 10:46RM P4
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SUBSURFACE SEWAGE DISPOSAL SYSIEM INSPECTION FORM �
PART A
CERTIHCATION 1con6twed)
Propevty Ad4tass: /AM
Owner:
Date of ImPerction:
C. 1FUR7HER EVALUATION 15 REQUIRED BY THE HOARD OF HEALTH: t
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 DEMMINES IN ACCORDANCE WITH 310 CMR 16.30311)lb1 THAT THE SYSI
IS NOT FUNCTIONING 04 A MANNER WHICH VaLt PROTECT THE pUBLIC HEALTH AND SAIT I V AND THE ENViRONNedT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool at privy is within 50 fuel of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTER
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT;
The system has a septic tank and soil absorption system ISAS)and the SAS is within 100 feet of a surface water supply
tributoty to a surface water Supply.
The system has a septic tank and soil absorption system and the SAS Is wittan a Zone I 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 suit absorption system and ilia SAS is less than 100 feat but 50 feet or meta from e
private water supply well.unless a Weil water analysis for conform bacteria and volatile organic compounds indicates the'
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or lees
than 5 ppm. Method used to determine distance. )approximation not valid).
3) OTHER
revised 9/2I98 Nge3or11
FROM WM FARRINGTON PHONE N0. 508 477 0150 Aug. 07 2000 10:49AM P1
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SUDSl RFACE SEWAGC DISPOSAL SYSICM WSPEC110M FORM
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FART A
CERTIRCATION(cgrttiinued)
Property Address:
Owner.
Date of(nspod0011:
D. SYSTEM FAILS*
You must indicate either"Yes"or"No" to cacti of lite following:
I have determined that one or more of the following failure conditions exist as described in 310 C44R 15.303. The basis for INS
determination is identified below. The hoard of Health should be contacted to deterrnine what will bo necessary to correct lire failure.
yes N�
Backup of sewage into facility-or system component duo'to an overloaded or clogged SAS or cesspool.
Discharge or pending of effluent to the surface of the ground or surface watoryr due to an overfoaded or clogged SAS or
cesspool,
Static liquid level In rite distribution box'above outlet invert due to an overloaded or clogged SAS or cesspool.
T f/ Liquid depth in cosspool is less then 6" below invert or available volume is less titan 112 day flow.
Required purnping more than 4 tunes in the last year NOT t9ue to clogged or obstructed pipe(s1-
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 ptivy is within 50 foot of a private water supply well,
Any portion of a cesspool or privy Is less-then 100 feet but greater titan 50 feet from a private water supply well with no
.r acceptable water quality analysis. If Ilia well has been,analyzed to be acceptable, attach copy of well water analysis for
eoliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEVA FAILS:
You must indicate either"Yes" or"No" to each of the following:
The following etitede apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or gtoater(Large System)and the system Is a significant throat to public
health and safety and the environment because orte of more of the following conditions exist'
Yea No
,T the system is within 400 foot 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 tlntorittf wellhead Protection Area=IWPAI of a mapped Zone II of a public
water supply Weil►
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regibnal
office of the Department for further information.
revised 9/2/98 roacaortt
FROM WM FPIRRINGTON PHONE NO. 503 477 0150 Rug. 07 2000 10:49RM P2
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I SUBSl3RFACt:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART u
CHECKLIST \
Property Address:
Owner:
Date of Inspection.,
Check it the following have been doge: You must indicate either"Yes" or 'No' as to each of the following:
Yet;, No
Pumping information Was provided by the owner,occupant,or Board of Health.
• _ None of tho system components have been pumped,forat least two weeks end-the system has flow
rates during that period. Legge volumes of water have not been introduced into the system recently or as part of this
/ inspection.
Y _ As built plans have been obtained and examined. Note If they are not available with NIA.
The Cecil&/or dwelling was inspected for signs of sewage back-up-
Tito system does not receive non-sanitary or industrial watte flow,
v _ The site was inspected for signs of breakout.
All system components,excluding the Soil Absorption System,have been located on the site.
_✓ _ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
or toes,material of Construction,dimensions,depth of liquid,depth of sludge,depth of scum.
The size and location of the Solt Absorption System on the site has been dotortnirnod based on:
(% Existing information. For example,Plan at B.O.H.
Determined In tfra field lif any of the failure criteria related to Pert C is at issue,approximation of distance Is unacceptable)
11s.302(s)tb)]
The facility owner{and occupants,if difterent from owner) were provided with info►matior►on the proper lrWritenance of
Subsurface Disposal Systems,
roe+� eer7 0 0 R
FROM WM FARRINGTON PHONE NO. 503 477 3150 Aug. 07 2a3a 1O:5OAM P3
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SUBSURFACE SEWAGC DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
vV A&-111-0 [-.► (t '2 0
Property Address:
Owner: 9,11A . "f
Ditto of Inspection:
FLOW CONDITIONS
RESIDENTIAL-
Design flow:ij—c? g•p•d./bedroom.
Number of bedrooms(design):3 Number of bedrooms iactuel):
Total DESIGN flow -Z3 �
Number of current f9sidents:.j6—
Garbage grinder(yes or no):-N 0
Laundry(separate system) 11 3 or no): D if yes.separate inspection required
Laundry system inspected ra or no)
Seasonal use Ives or no):tje-)
Witter meter feadings,if O silable(last two year's usage 14Rd1:
Sump frump(yes or no).-Zk
Last date of occupshcy:_,,,__
COMMFRCWIANOUSTRIAL:
Type of eatablisbmant:
Design flow: s►vd 1 Based on 75,2031
Basis of design flow -
Grease trap present:(vox or nol_
Industrial\Neste Bolding Tank present:Iva* or nol_
No
n-sanitefy:waete discharged to the Title 5 system:Ives or no).
Water miler readings.if available:
Lett ditto of occupancy:,,,,,
OTHER:(Describe)
Last date of occuponcy:
GETII;JiLAL INFORMATION
PUMPING RECORDS and source of Information:
System pumped as part of inspection:(yes or nv)_Ko
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tenkidistribution boxlscil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Yank _Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date Installed iif known)and source of information:
SeWf10e edgy detected when arriving at the site-Ives or me)
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..�... ...�.7 ft n /lb Veto 6„r Tl
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FROM WM FRRRINDTON PHONE NO. 50B 477 0150 Aug. 07 2000 10:50RM P4
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SVoSURFACC SEWAGE DISPOSAL.SYSTEM INSPECTION FORM L
PART C
SYSTEM WFORMATYON(continued)
Pyepefty Address:
Ownw:
Dots of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:____
Material of construction: cast iron 40 PVC other texplain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting, evidence of leakage,etc.)
SEPTIC TANK:
(locate on sits p_lan)
Depth below grader
Material of construction:keoncretO_metal_Fibergiass _Polyethylene_othcr(exploin)
If tank is metal,list age_ .I9.ag4 confirmed by Certificate of Compliance_ (YeslNo)
r
Dimensions-, i y
Sludge depth: 2=1
L
Distance from top of sludge to bottom of outlet tee or baffle: tf'3
Scum thickness:
" Dis linpe'from top:of scum to top.of outlet tee or battle:_ �y
Distance from bottom of scum to bottom of cutlet tea or battfe:$0^.
How dimensions were determined:
Comments:
itecornmendation for numpinq,condi n of't t and outlet teas or baffles, depth of liquid level in relation to outlet Invert,structureFintegrity,
evidence of leakage.etc.) o S`�oY I,.Isr
(IRFASE TRAP:
(locate on site plan)
Depth below tirade:_
Material of construction:_concrete,,,_,metal_Fiberglass _Polyethylene_ctherjokplain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet lee or baffle:
Distance from bottom of Scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumAing,condition of inlet and outlet tees or baffles,depth of liquid level In relation to outlet Invert,strpctural integrity,
evidence of leakage,etc.)
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rotrvaAr� Q/7/Ali _ _--
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FROM WM FARRINGTON PHONE NO. 503 477 0150 Aug. 07 2000 10:51RM P5
SUBSURFACE SEWAGE 01SPOSAL SYSTEM INSPECTION FORK{
PART C
{l SYSTFJyt INFOR114ATION(cw►tirwed)
P.opertr Addrasa: f 0 v 14�11� t�(r �4
Owns►: . 3/1 W b I/C-( - (3'1 o c-
Oata of 4upecfmm. ,
TIGHT On 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_ottrer{explain)
Dimensions:
Capacity: _..._...... ..._....,_.
_..,._„��,gallons
Design Aovr: gallons/day
Alarm present
Alarm level:-Alarm In working order:Yes No
Date of previous pumpino: ^-
Comments:
(condition Of inlet tee,conditiotr of alarm and float switches,etc.)
DISTRIBUTION BOX:..
tlocateo►r,.aifepian) � ..
Depth of liquid love)above outlet invert:
Comments:
(nOte•if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, eta.)
PUMP CHAMBER:_
(locate on silo plan)
Pumps in working order;(Yes or No)
Alarms in working order{Yes or Nol`
COMMOnls:
(note condition of pump chamber,condition of pumps and eppurtcnencos,etc.)
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SUBSURFACE SEWAGE DISPOSAL SYST M INSPEC'nON FOftaa
PART C {_
SYSTEM INPQRIINA'fION(eaettinuedl \\
Property Address:
Owner:
Dow of b"pect;on.
SOIL AnSORPTION SYSTEM(SAS)`
poceto on site plan,If possible:excavation not rcauircd,location neey bo e0proRimatcd by non-intrusive methods)
If not located.explain:
Type:
leaching pits,number:,,
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,nveiber,length:
coaching fields, number, dimensions:
ova►vow cesspool,number.
Alternative system:_._..... __"."
Name of Technology;
Comments:
(note condition of soil,signs of hydraulic failure,level of pending,damp soil, condition of vegetation, etc.)
CESSPOOLS:r
(locate on alto 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 inspcctiorl)
Comments:
(note condition of soil,signs of hydraulic lallure.level of pending,condition of vegetation,etc.)
PRIVY:
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids' '
Comments:
(note condition of soil, signs of hydraulic failure,level of pending,condition of vegetation,etc.)
.revised 9/2/98 Page yof11
Gd WbTS:L? OOOE Le '6nd OSZO LLB 8ES : 'ON dNOHd NOIJNI dHd WM1 : WOud
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FROM WM FARRINGTON PHONE NO. 509 477 0150 Aug. 07 2000 10:52RM P7
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1 SUBSURFACE SEWAGE DISPOSAL SYSTEM iNSP✓ CnrjN FORM
PART C
SYSTOW INFORMATION(corrlinued)
Property Address: (()0 p C n V 1•{((( N'V
Owner: , t�,,-(� (1 `
Date of Wmection?
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to 41 least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public vaster supply comes into house)
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FROM WM FRRRINGTON PHONE HO. 503 477 31517 Rug. 07 2000 10:52RM P9
1
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SUBSURFACE SEWAGE"DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEfM INFORMATION(continued)
Property Addraae: J..6 n A d_h'c
Owner: q'1 A41`f-f
Darts of knspec"n:
NRCS Report name
Soil Type_,,, /1"u
Typical depot to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate___ 1/ Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
� Obtained from Design Want on record
Observed Site•(Abutting propertt•,observation hole,basement sump etc_)
✓D ermined from Inca)conditions
Checked trh local Board of health
Checked FEMA Maps
77,
Reeked pumping records
�4ecked local excavators.installers
ulzed USGS Data
Describe how you established the High Grouri;lwater Elevation. ( v:t be cpmpietets)
'R2 h tq4h fit.0_c4p {- t U S C S M4 (=t
revised 9/2/98
L CATION !-c'4'IS tSEWAGE, PERMIT NO.
A®4CRC lu. 7tq0to 03
VILLAGE
/6a a�b �e ty.
INSTALLER'S N E i ADDRESS
�/h�,2S�1U5 hI/C C S
BUILDER OR OW R /�
-v�-ncE U' cv
DATE PERMIT ISSUED .
DATE COMPLIANCE ISSUED
tT � � -.._.._.._
n� _
K. _
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{A r � ��-vim • �.':•' • �h • V
THE COMMONWEALTH OF-MASSACHUSETTS
S
BOAR® OF HEALTH.
TAW .._..................OF...... ..............................................................
Applirativit for Uhipvii ai Workii . 11witrurtion ranfit
Application is .hereby made for a Permit to Construct ( V<or Repair ( ) an Individual Sewage Disposal
System at:
......jc0 � �.I.1--Rdo�e---------- 1- 5
8� �t� „�k. t
----...l,aw st .!Mre's
......................... ..................................................... .........----------------
9 p ....................Ad ss
Installer Address
dType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms.___ ____________________________Expansion Attic (tya Garbage Grinder
Other—T e of Building . No. of persons..........................__ Showers — Cafeteria
Otherfixtures -------------------------------------= . ---------------...-------------------------.._..-•-•-•._...---..__...---••-••.
W Design Flow_____________.95........................gallons per person per day. Total daily flow__..;._._.�_®_.__________.___________gallons.
W Septic Tank—Liquid capacitylWO...g g g _ g '4?�_........ Diameter________________ Depth__G..........
Width___ Total Length ________ Total leaching area_...__._____._.__...s ft.
gallons Length __._. Width_
Disposal Trench—� o_ _________________ _ _ _ ____. g q.
x ,,,�/ o
Seepage Pit No.® _ '-.94 Diameter...... Depth below inlet._.____.......... Total leaching area._ZW.___sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date...........a =`r7 1--=••----.
a Test Pit No. 1_____.7.......minutes per inch. Depth of Test Pit____________________ Depth to ground water......-------------
.
Test Pit No. 2.....3_______minutes per .inch Depth of Test Pit____________________ Depth to ground water........................
- ------BOA-------------------•-•----------------------------------_____-••-•-----------------••------___________-----_
Q .........-•-•-•-•---
Descriptionof Soil-----1 --....... ..gdwy.l.-•------•----------------------------------------------------------------•---------------------._.._..---------
.".?_P.._.._..!4 'v 'j! -------------------------------------------•------__-------__-•-•--------------•-------
a
w 7(-_.3•------- •-• --�9-•-.._dick _,g►`''Yv-------------------------------------------------------------------------------------
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 LIT?.; 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance een by the bo f h
Date
Application Approved By---=- .................... 1 7� ---
Date
Application Disapproved for the following reasons-----------------------•---------._...------------------•-------------------------------------•-------...••-••---
Date
PermitNo......................................................... ' Issued--••----------------------------------•--••-•--•••-••--
Date
L
No......6:.__........ ..........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........V..... ...............OF.. ..........f.....................................................
Appliration for Diapasaal Worbi Tomitrnrtion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�etb� fGL .Ld1 �4' �' ....................................:.............. --- - ......................... .... .........( ..--
cat n-Address x'_ or No.
'4`✓re /vim �,�Q /ham-draw ar•tt;�
..... - - - ` •.............................•---........... .............................................. `.R . .................
caner ddress
----------- --- .................................
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.. ®...............................Expansion Attic (NO) Garbage Grinder *a)
a4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures -----•-•--------------------•-.... .
W Design Flow...........vr2Z..........................gallons per person per day. Total daily flow.........1112........................._gallons.
WSeptic Tank—Liquid capacity.100'.gallons Length......9....__. Width._�:-Z...... Diameter---------------- Depth_____..........
x /�
Disposal Trench—No..................... Width............._...... Total Length.............._..... Total leaching area....................sq. ft.
Seepage Pit No. Diameter.......6.......... Depth below inlet.......6.......... Total leaching area.24=.......sq. ft.
Z Other Distribution box ( j' Dosing tank ( )
Percolation Test Results Performed bY--...-- ........._.. -----------•---•- Date.........................................
a� Test Pit No. I...... ......minutes per inch Depth of Test Pit------�!.......... Depth to ground water----NY? ..........
Test Pit No. 2.........3_..._minutes per inch Depth of Test Pit.....!' ........... Depth to ground water----!vim._......_...
-----------------------------------•----------•--•-•------------•---------------•-----------•-----...........................................................
0 Description of Soil.......1:7-�----- ..�a�! 41� -.----•---------------------------------
UW ---...••---------••--•-----•-•--•-•-••:1:=l...---- E.. �----.-Q--'----•---------------•-•------••------------•--------------------•------...--------------•-••-•--------•-••....
-----•-------------------•-•------•---
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
•-•--------------•.--------•---•---•--------------•-----------•----------------------..............--------------------------------------......-------------•-------------•••-•--•-----..........•----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewa Sys in accordance with
the provisions of T IT i.ta'. 5 of the State S ' e— The undersigne urther agree o o place the system in
operation until a Certificate of Complia ce has b ec�itis by t oard o healt .
Date
Application Approved By..... ..
—Or
Date
Application Disapproved for the following reasons------------------.....................----------------•----....................................................
--•----------------------•••-------•------•-------•......•---•---•--••--.........._._.......------......_"--•-••-----•---•-•---•--•---------•-----•------------------ ------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
C -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0= HEALTH
y}
... .. ......OF..... ... :G+ ....•................................
Trrtif iratr of Tautph aatrr
THIS fS TO qATIFY -That Ae Individual Sewage Disposal System constructed or Repaired ( )
by.. .{P.:. ................................................. ..............................................................
stallas been installed in accordance with the provisions of T5 f The State Sanitary Code.as described in the
application for Disposal Works Construction Permit No.., .._.___..... da.ted__.. "f _'. �"'.�_.____._._.
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.........................................................:....................... Inspector....................................................................................
...7THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
..........................
FEE... .............
i �rnatl �n Permit
Permission i ,ereby granted---------- - - - ....... -........-- • . ------
to Construc ( g Re r ( ),On In ' i 1 SevcTa ysposal S
1
Stet _�.
---/A
as shown on the application for Disposal Works Construction P No.___ .' . � bated.__.��:� _.��.....:..
Board of Health
-e:
DATE-- . .
FORK 1255 HOBBS WARREN. INC.. PUBLISHERS
.i
THE FOLLOWING
IS/ARE THE-' BE-ST
IMAGES FROM BOOR
QUALITY ORIGINALS)
m A-
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