HomeMy WebLinkAbout0050 BUNNY RUN - Health 0 Bunny Run
Barnstable
= 234 - 034
J
i
TOWN OF BARNSTABLE 1
LOCATION ° ; �lU'�U�I �Dil� SEWAGE #
VI1 AGE ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHOI NO. I
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) C"S e0 (size) \o
NO.OF BEDROOMS
BUILDER OR OWNER &C,KC Wd
PERMFTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Rd 1 Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) t`'�f� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) 14, Feet
Furnished by �. t��C
1
Y
At 6 �
A 3u b33- 3c
t 1'
- COMMONWEALTH OF I�LkSSACHUSETTS
- -l=
y EXEC
OFFICE OF E\�"IRONI�4E\T.�I AFF.-��,
M
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE RI'TER STREET. BOSTON ',L-%0210S (617) 292-5tiUl)
TRUDY CORE
Secretary
ARGEO PALL CELLUCCI DAVID B. STRUHS
Governor DISPOSAL SYSTEM INSPECTION FORM Commissioner
��y"n`t�j _,/lal� SUBSURFACE SEWAGE
v J ` PART A ID
CERTIFICATION
Properrty, Address: Name of Owner LUcittJR�
Address of Owner: N /� t
Date of Inspection: - �`�j / 1 / 1`I'(.1�p�1�Z •-�6�1 l RQ/ try
Name of Inspector:(ease Pnml I [ Cat a c� �F`�EC K U ��-`N�3.Rll.=
I am a DEP a�.p7�proved/system inspector pursuant to Section 15.[340 of Title 5(310 CMR 15.00
Company Name: �7tl,,,.�f r C ��(1^r�rLr/n- a.a r' l++u.
Mailing Address:-� &,o I Z-7. heNear 1YAt, 02_C4- 7
Telephone Number: 4!0:922-. /�• Zo_
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
n
Inspector's Signature: T Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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 ttre
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page IofII
`i Printed on Recycled Paper
s
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continuedl
'roperty Address: S() 't
Jwner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I.have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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 approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
_ The 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 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 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).
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 pipets). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page.2of1.1
f �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determ' a if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WI H 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH A D SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated w/e'tlando, t marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH ND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system'( AS)and 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 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 syste�j and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption sys=and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysi for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the resence of ammonia nitrogen and nitrate nitrogen is,equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
r �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist a described in 310 CMR 15.303. The basis.for this
determination is identified below. The Board of Health should be contacted o determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to a overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the groun or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet inv rt 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 1l2 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, cess ool or privy is below the high groundwater elevation.
Any port ion of a cesspool privy is within 1 feet of a surface water supply or tributary to a surface water supply.
p or P Y
Any portion of a cesspool or privy is within 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 lesfthan 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If t7e well has been analyzed to be acceptable, attach copy of well water analysis for
'coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of th'�following:
The following criteria apply to large systems m addition to the criteria above:
The system serves a facility with a desi n flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment ecause 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 2 0 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area•IWPA)or a mapped Zone II of a public
water supply well ,,
The owner or operator of any such 7ystem shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
i
revised 9/2/98 Page 4of11
r �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: N'I`IA CQis
Owner:
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 NIA.
i
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.
�' _ 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:
Existing information. For example, 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)1
The facility owner (and occupants,if different from owner) were provided with information on the proper maintanaws of
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DI
SPOSAL SYSTEM INSPECTION FORM.PART C
SYSTEM INFORMATION
'roperty Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 0 g.P•d./bedroom.
Number of bedrooms (design):C)Z� Number of bedrooms (actua1):0
Total DESIGN flow 12—0
Number of current residents: C
Garbage grinder(yes or no): KU //���
Laundry(separate system) ( s orQ.._; If yes, separate inspection required
Laundry system inspected or no)
Seasonal use (yes or no): ti
Water meter readings, if available (last two year's usage (gpd): .
Sump Pump(yes or no):ti
Last date of occupancy: �54�j
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: 9Pd ( Based on 15.203)
Basis of design flow
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 source of information:
ti�A
System pumped as part of inspection: (yes or no) ki--
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
X 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 Tank Copy of DEP Approval
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) IUD_1 ,
revised 9/2/98 Page 6(if II
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(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.)
SEPTIC TANK:_
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_Fiberglass _Polyethylene_other(explai
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_.lYes/Nol
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How dimensions were determined:
;omments:
(recommendation for pumping, condition of inlet and outlet.tees or baffles, de th of liquid level in relation to outlet invert; structural integrity,
evidence of leakage, etc.)
GREASE TRAP: -
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _Pol thylene_other(explain)
Dimensions:
Scum thickness: e
Distance from top of scum to top of outlet tee or baffle: - r
Distance from bottom of scum to bottom of outlet tee or ba e:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and ou at tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 ` Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Iroperty Address:
Owner: /
Date of Inspection:
i
TIGHT OR 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 _other(expl i�/
f
Dimensions: /
Capacity: gallons
Design flow: gallons/day
Alarm present
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:_
(locate on site plan)
Depth of liquid level above outlet invert:
Com
ments: / c. -
(note if level and distribution is equal, evidence of solids carry%ver, evidence of leakage into or out of box, et
PUMP CHAMBER:_
(locate on site plan)
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.)
/
revised 9/2/98 / page sorll
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
6� SYSTEM INFORMATION (continued)
,ropem Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): V
(locate on site plan, if possible; excav von not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_aoXS
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of pornding, damp soil, �onditiorrof vegetation, etc.) '
``'' �l.►�)..i � Yl\+ry c. ���,p
CESSPOOLS: 5
(locate on site plan)
Number and configuration: ` UUt
Depth-top of liquid to inlet invert: r�
Depth of solids layer: l' U
)epth of scum layer: O u
Dimensions of cesspool: SbiR•l (�,
Materials of construction: C'csryca?_q
Indication of groundwater: N
inflow (cesspool must be pumped as part of inspection) •�%�
Comments:
(note condition of soil, signs of hydraulic failure, level of pondin conditi n 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 ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
n
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION (continued)
'roperty Address: SG 6(,INNtn
)wner: 1
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
S c�
AL
. A
L
f �1
k3— �;S`
revised 9/2/98 Page 10of11
�I .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
;operty Address: -11S8
Owner:
Date of Inspection:
NRCS Report name ---
Soil Type_ — -- --
Typical depth to groundwater_ _
USGS Date website visited 0-0
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope kL�
Surface water rs0
Check Cellar 4yQ
Shallow wellsja
fi
Estimated Depth to Groundwater'Zli Feet
Please indicate all the methods used to determine High-Groundwater Elevation:.
Obtained from Design Plans on record '
Observed Site(Abutting property, observation hole. basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps r
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groun
dwater Elevation. (Must be completed)
Uti ).��,C..��e �� c•v�v�. � V\Gc" 1�.—I��r•I,-S`,l 0(,��i o
}
3
revised 9/2/98 Page ttof11
"w TOWN OF BARNSTABLE
LOCATION 50 j SEWAGE # 7- 6f. D.,
VILLAGE L
�.. `. ��- ASSESSOR'S AP O
INSTALLER'S NAME & PHONE NO.--i�o x' V
SEPTIC TANK CAPACITY
LEACHING.FACILITY:(type) (size) q;
!i NO. OF BEDROOMS" PRIVATE WELLC3RUBLIC WA r
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �-�
1 l6
' W
I
�I rr
y 1
i
Pell)
h
NO.U.... - !/ Flcs....... .�
THE'COMMONWEALTH OF MASSACHUSETTS
' BOARD OF HEALTH
'n-.:...........OF..�� '�`2r�.s:✓�1v��------.._......_..._._.....__... ...............-.
Appl ration for flisposal Works Toust.rur#inn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage,Disposal
System at:
...........� _....1�i.�2.Y.�:!::��. ::�!! �---•-•-----•....._. .............. ...--•......................................
,^n Location-Address or Lot No.
............................... .........•--•---......sS ✓Y�L:Q... ........ ......................
�-� Owner. Address
..............Z....:..........:C :.- -----•-•- _ t �f..14..Lt 1:�_5 ...............................................
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms___..�J.........................:........Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building
a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( �)
W
Design Flow-Othe�x�tures .........- -.._gallons per person per day. Total daily flow___a._3_0.........................gallons. 9
WSeptic Tank—Liquid capacity___..._.____gallons Length................ Width................ Diameter............... Depth................
Disposal Trench—No_____________________ Width..................... Total Length._:.................. Total leaching area....................sq. ft.
3 Seepage Pit No........I........... Diameter......1.c_�:_....... Depth below inlet.... ............ Total leaching area...................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.......................
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a,
0 Description of Soil...........................................................................................................................................................................
W ------------
-----•---•-----•----•-•-•-•--•-•• . -.......--•-•--•-----------------•--------------.._......._.._•-----•----•-;--..::...._._..----•-----................................................
.._---------••---:.--•-••••-•-------••----•••-•-•••:..:---••---•-•---•--•---•_..._•-••....._...-••------•••--•-------••--•------...•-•-•-•••-•-••-•-...-•--••-•--•.....................................
U Nature of Repairs or Alterations—Answer when applicable._.:__.: T ��___:____{�w e..:_.._ ..x.. ........................6ST
---•----•-P-.--�---- -�..? ...__mac =f�� 'e......�.'r.F-------2-c. . T
Agreement: ,
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of IITLL 5 of the State Sanitary Code= The undersigned further agrees not to place the system in.
' operation until a Certificate of Compliance has been issued by the board�hli.eall.thh.Signed---------
Date
Q
Application Approved BY--. v_ . _........-• ........................................
Date
Application Disapproved for the following reasons_................................_..............................................................................
..
....................:.............
.......
...........
...•-•---_....__..__.............................................................................................................
..._••-•
.....
..........
Date
PermitNo..0...I..._•....4.'..---•-----------•--------------- Issued........................................................
�- ----- -- — — - '— --�--_� Date — --� -----�
+ ...., � � �.._. rW �.... 1. \.�-v��.✓•.a^^.•- - ., � .. i, -�..�,-'4.-..r. . .. _ .•,'!' ..,a ... _ .. ... -._.. ,w+... -._ .x_ r � `r
No.U... ....11l Fss......
THE.-COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH t
...._.~T.v.. ..'... ..............0F...�'.�.'�:!'.�'5'.±4 ..................................................... ' d
Appliration for Disposal Works Tonstrur#inn "rrmi#
Application is hereby made for a Permit to Construct ( ) or Repair (—)-"a*n Individual Sewage Disposal
System at:
-•-•-•-•--:.....___.._ �.?...... .................................. -- ........_..... ............................................
Location-Address or Lot No.
.......... ___..ate.\ .................................... . ........... ...............................
rr-- Owner Address
W ..�.._..:.. ............................................. ................ ....................................................
Installer Address
Type of Building Size Lot:........................i Sq. feet
U Dwelling—No. of Bedrooms.....�-•�....................................Expansion Attic ( ) Garbage Grinder ( )
a'4 e of Building ..
Other—T yp g •--------------------------- No. of persons---•--------------...-_-_-.. Showers (• ) — Cafeteria ( )
Otherfixtures ............... ...•••••--•----•-..................••--•••-•---•-------.......---•-----------••••--•-•.... .............................
' WW Design Flow..............'.._......................gallons per person per day. Total daily flow...��...-3.d.........................gallons.
WSeptic Tank—Liquid ca.pacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No...................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........)........... Diameter.....1.c_�.(....... Depth Uelow inlet___.Y.'......... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
,.� Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�f Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' ------------------------------
----••---......._ .......--•-•-•......................._......-•-.........................................................
ODescription of Soil........................................•----•-•-............i..........................................................................................................
W ---- --------------------------•--•--------•---•-•--._...------•--.......-----............._...........------•.
•----...---•-----------------------•-------•-------------•------------------------------------------...--------------------------------•----------------------•--•----------------.....-•--•---..._..---
U Nature of Repairs or Alterations—Answer
......whenapplicable...... .........'�ec't5a ... 5__�C?On L-.....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
I- f
�Signed t.. �. --..---- I� ���`
�l Date .. .
Application Approved By . _A..- . -• -- ......... . -• ..........................................
Date
Application Disapproved for the following reasons:..............4............................'___.:.._____._......._.._.................... ......._._.__
nn
PermitNo.-.O.�.----7 .-..---....••.....-•----••---.. Issued...........................................
Date
.......
Date
I
—_-------------�------- -------_.-----_----- --------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Oww
Trri fira#r of Tomplittnrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by-------------------.........� .C:cN.0 !i:......--....AC C2 via\ . •. ..._
.taller
at........................I ..............., e�l'�'v�`'� i1 t_'-[•` t_)t v-- ...............
............................................
been installed in accordance with the provisions of TITLE 5 o h State Sanitary Code As de in the
kl
application for Disposal Works Construction Permit No._?..7'-1l��.t_.._.-. dated_...�Q�p�- ............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................./. ..................... Inspector............. �
-------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS sM�
BOARD OF HEALTH t
e. nn�i fiQ.4 a.Var.............OF....... �.y.r�c c1 ? ................._...................
NO - •• """` FEE.......... ........^_
r Disposal Works Tun#rnr#ion frrmit
Permission is hereby granted.. . _ .p:.. _....0 ._ c�. � �.......•.
to Construct ( ) or Repair ( c)_an Ind victual Sewage Disposal System ( q
tat No.:.......... '� !A4l,a'-� :.............. ,t c ' "' -'P --------------•- ........
7._...._.__�, Street �]� 1
as shown on the application for Disposal Works Constructio rmit o.'_._J01 Da ed-_ o_a�.8. ........
- -m .............................
/� Board of Healt
DATE. �{f ;