HomeMy WebLinkAbout0147 AUGUSTA NATIONAL DR - Health 447 AUGUSTA
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TROY WILLIAMS �, N
SEPTIC INSPECTIONS Rf'llwn
Certified by MA Department of Environmental Protection Y 1 (508) 385-1300
19 Hummel Driver4 1998 i
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSE T�;
EXECUTIVE OFFICE OF ENVIRONMENTAL�AFFA1:RSp "
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617.292-5500
WILLIAM F.WELD
Governor
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
L' CERTIFICATION
Property Address: i7 AV JS�c /�1�,�-iuv 1 L �uwn,c u•�I ,
op rf 51 f/�g y Address of Owner: / /\ K
Date of Inspection: f (If different) � O rH v �
Name of Inspector: Troy Will i a m s t 7
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Troy_ .Williams Septic Inspections V •J MG
Mailing Address: _19 Hummel Drive- South Dannis , MA 02660
Telephone Number: T5 0 8) 3 8 5-130 0 U2 is 3 7
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection'was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
— Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature:. Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 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 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
61 SYSTEM CONDITIONALLY PASSES: 1,114
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 approved by the Board of Health, will pass.
Indicate yes, no, or not determined(Y,IN,or ND). Describe basis of determination in all instances. If'not determined',explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a 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
�•� ..d 04/7s/1 " Paq• 1 or 10
f
\J e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
147 Augusta National Drive,Barnstable,MA
Property Address: Tom O'Keefe
Owner: May 11, 1998
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
4 obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the it public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, 11=APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone 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 soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 147 Augusta National Drive,Barnstable, MA
Owner: Tom O'Keefe
Date of Inspection: May 11, 1998
,/
D) SYSTEM FAILS: /v /4
You must indicate ei;,.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15,303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water,supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: Al
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area.I
public water supply well) WPA) or a mapped Zone II of a
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
147 Augusta National Drive,Barnstable,MA
Property Address: Tom O'Keefe
Owner: May 11, 1998 c
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes/ No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up. -
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
V _ 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 tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
/ The size and location of the Soil Absorption System on the site has been determined based on:
V _ The facility owner (and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal System.
n119 Existing information. Ex. Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) 115.302(3)(b)]
r.�i..d 04/25/97) ,. -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
147 Augusta National Drive,Barnstable,MA
Property Address: Tom O'Keefe
Owner:
Date of Inspection: May 11, 1998
FLOW CONDITIONS
RESIDENTIAL:
Design flow:33v g.p.d./bedroom for S.A.S.
Number of bedrooms:yg
Number of current residents:o2
Garbage grinder (yes or no): YF S
Laundry connected to system (yes or no):
Seasonal use (yes or no): ND
Water meter readings, if available (last two (2) year usage (gpd): _�7 gg R vpU 7 _ ;7 7( GoJ f4//041
Sump Pump (yes or no):_A/V
Last date of occupancy: e d .
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: Qallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or-no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and[s/ourr[e of in(prmation:
42
System pumped as part of inspection. (yes or no) ,/u
1(yes, volume pumped: gallons
Reason for pumping:
TYPE pF SYSTEM
✓ Septic tan soil absorption system
Single cesspool
Overflow cesspool
Privy
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) /V6
i
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 147 Augusta National Drive,Barnstable,MA
Owner: Tom O'Keefe
Date of Inspection: May 11, 1998
BUILDING SEWER: A1119
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
t
SEPTIC TANK:
(locate on site plan)
i
Depth below grade:
Material of construction: �Zconcrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:_ S �k 9 x 6 /6 y
Sludge depth: 1 ,,
Distance from top of sludge to bottom of outlet tee or baffle:_/6
Scum thickness: S-6NE
Distance from top of scum to top of outlet tee or baffle: /Vy —Sc—
Distance from bottom of scum to bottom of outlet tee or baffle: V J L w.
How dimensions were determined: iora L c,•
Comments:
(recommendation for pumping, condition of inlet and outlets or baffles, depth of liquid level in relation to outlet invert, structural `
inte ity, evidence of leakage, etc.) Cc, t c-c_
J J
4 L.. �,•�
GREASE TRAP: A�
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: {
Date of last pumping:
Comments:
(recommendation for pumping,•condition of inlet and outlet tees or baffles, depth of liquid level In relation to outlet invert, structural
integrity, evidence of leakage, etc.)
Ir.vi..d Obi 75/971 " ,,. _ •"
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
147 Augusta National Drive,Barnstable,MA
,
Owner: Tom OKeefe
Date of Inspection: May 11, 1998
TIGHT OR HOLDING TAN K:// (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; No
Date of.previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:-Z///g
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carry ver, evidence of leakage into or out of box, etc.). k A
�! 1 L..1L 1.J 1 �- H,p - �O.t' u rt�( �✓rL { �. '-. '�"
PUMP CHAMBER: A//�
(locate on site plan)
Pumps in working order: (Yes or No)
Alamo in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
f -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 147 Augusta National Drive,Barnstable,MA
Owner: Tom O'Keefe
Date of Inspection: May 11, 1998
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type: leaching pits, number: bh Q.- p w. 4-t a /S
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note,condition of soil igns of hydraulic failure, level f ponding, condition of vegetation, etc.)
o wo ✓��( i d y LK
< < / 1 GG7loh.
CESSPOOLS: _ZZI 4
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: /V
(locate on site plan) .
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
1!•�1••d 04/75/97) 4
F•9• E of 10 I
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 147 Augusta National Drive,Barnstable,MA
Owner: Tom O'Keefe
Date of Inspection: May 11, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
14' /
3/ �y
1000 ll��
(r—i..d 04/25/97) - ..
P.Q. 9 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 147 Augusta National Drive,Barnstable,MA
Owner: Tom O'Keefe
Date of Inspection: May 11, 1998
Depth to Groundwater _S Heet adjusted high groundwater level
Please indicate all the methods used to_determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
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)
L G. t�/ U� �`. /l Gv % Yvr1•h � Yh .Jw,
L)1 3 V �r� /o y ✓C.- e. 11-P w
roC, y -4 , � C .JyZy
Ir..t..G C1 2 5/9'1
TOWN'OF BARNSTABLE
LOCATION / 17 JS .)-X- / k,) d WAGE
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. /
SEPTIC TANK CAPAC=
LEACHING FACIL=: (type) /0 cN� (size) X` o-1 -e .
NO.OF BEDROOMS 3
BUILDER OR OWNER 6 � c
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300> ` eaching facility) l' Feet
Furnished by / W. , s .5/ (/
jig
IN
3®
THE COMMONWEALTH OF MASSACHUSETTS
�( BOARD Z H H
Appliration for 13itiposal Vorks Tattfifrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indivi ual Sewage Disposal
System J
. --� .
k p .
ocati ddress or No.
.. e
ner ddre
Installer Address
U Type of Building Size Lot.3 ..7 �..Sq. feet
Dwelling z No. of Bedrooms___-_-.-___••_-._�......................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtu e ___
---------------------------------------------------------------------------------------------------------------
W - Design Flow................... �Iloys-��r person per day. Total daily flow___......__ _....._..._......_.._._._gallons.
WSeptic Tank—Liquid capacit. allons Length................ Width___..____-_-_ Diameter---------------- Depth__._-___--__.__.
x Disposal Trench—No..................... Width____.___ _ _ .. Total Length------------- _____ Total leaching area....................sq. ft.
Seepage Pit No.... ............... ��-- Diameter��.._______ Depth below inlet........ ....... Total leaching area._6"..dA4sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by:......................................................................... Date-----------------------------------------
a
Test Pit No. 1................minutes per inch Depth of Test Pit___-_-____-.__---__- Depth to ground water_-__________________-_--
�14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................__..-__.
P' -•••-----•• -- -- --------
O (� // ,�
Description of Soil___________________ GJn,`:.rz ......_..
...................................................................................................................................... _................................................................
��/
U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------_-----------------------------------------_--------
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforede ribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitar e—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b issued b t , rd of health.
Signed....................
/atAPPlication Approved BY -----------------------•--- ...
Application Disapproved for the following reasons--------------------------------•---------------------------------•---------------------------------------•---•-
------•----••-•••------•--------•-•-•--••---•----------•------•-••-----------•------------•---•••--......•••----•-------•---------------•-•--------•...--------•-----•-•------------•----•-------...-•--
�° Date
PermitNo......................................................... Issued...... ( ?...................7.1
Date
No........ ••-*11----- Fxx.. .....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEM- H
.4
Application is hereby made for a Permit to Construct (- ) or Repair ( ) an Individual Sewage Disposal
System at
f
ocat"n- ddress or�?` No
,ta /"`.. '' ..__4. -'-- ,+tee":-' n_-,E' "j ---•-- - --�---- -t----------
r �- .. ner �dd're
.;
Installer Address
Q Type of Building Size Lot- .. . ..1.... ..Sq. feet
U. Dwelling No. of Bedrooms...............�_._.__._.-----._..-..-.-.Expansion Attic ( ) Garbage Grinder ( )
Other-T e of Building ....... No. of persons............................ Showers — Cafeteria
Other fixture __-.
---------------- -
....-••--• y ....... ------------------------------
W Design Flow__.____..__•....... ......................galloper person per day. Total daily flow-----------_V..----:--.-:----------._.--gallons.
WSeptic Tank—Liquid capacity,.__-_" gallons Length................ Width...........----- Diameter---------------- Depth................
x Disposal Trench—No..................... Width' ..._ _ Total Length.......__ _...... Total leaching area.... -------.-.-sq. ft.
Seepage Pit No.;_. --_-_.._..__. Diameter, !__. De th below inlet........3p _______ Total leaching area.. .x0_ _sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date----------------------------------------
,� Test Pit No. 1................minutes per inch Depth of Test Pit....._._•._.-_-----. Depth to ground water..-.._-..:_._.-.._..-.-.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...___._.._..._..•...-.-
C4 •--------• z ------. ------------------
Description of Soil K --- ----------------------------------------
V ----------------•---•-•-•--••-------------•......
W
VNature of [repairs or Alterations—Answer when applicable.....................................:.........•....---------------------_-._---------..-.---
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the afored cribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitar- /de—The undersigned further agrees not to place the system in
,t operation until a Certificate of Compliance has n;issued k t1i rd of health. ,
Sined ------ ---•-------------- ---------
Dat`
%
r f -- •------------------
� ate
Application Approved BY-
Application Disapproved for the following reasons:.................................................................................................................
•--•--•••---••--••---•--•••-•---------•-•-•-•------------•••---•------•--•----•......-•--•-••------•-••..--------------•.--=-------------•-------....----------------------------------•-•-------•----
2.1
Date
PermitNo......................................................... Issued---=-- _ ='
Date f
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H E A T
t
oF..... .:.. ................
Tutifiratr of Tompfi tna
THI ,I ,rT CERT hY, T at th idual Sewage Disposal System constructed ( rc or Repaired ( )
,�
:by....... �� -------
AIritaller ...
ate• /. � - ---------------- ------------------------------------ ---------
has been installed in accordance with the provisi ns of rticle XI4 The State Sanitary Code as descr• ed in the
application for Disposal Works Construction Permit No _ ......... dated__A*% ..�.... :---
THE ISSUANCE __. _
®F THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A�GUARAIdTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY. ram., /
DATE . _.. f ' Inspector ',`
p �.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
NO-•-- = 2....... B FEE--, ---•-
.
Permission is hereby granted...... _
to Constr ct or Repair ) an Individual Sew Disposal S em
Street
s shown on the application for Disposal Worlcs Construction e"r�nit Dated .._ -__:.........................
,�a +"r. x oard'of Health
DATE---�?-- `......
'° -
FORM 1255IOBBS &-WARREN, INC.. PUBLISHERS `'"'"`'-�