HomeMy WebLinkAbout0050 CROCKER LANE - Health 50 Cracker Lark.
Barnstable
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COMMONWEALTH OF MMSACHUSETTS
ED EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 50 Crocker Lane . .
Barnstable. %
Owner's Name: David Van KleeckE �" 3
3laLn
Owner's Address: PO Box 252 - , 4
Date of Inspection: -�-dL5 `^ d
Name of Inspector:(please print) Wi 11 i am _ • Robinson- Sr. c
Company Name: William .E: Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776 .R
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 the inspection.The inspection was performed based on my
training and,experience in the proper function �d maintenance of on site sewage disposal systems.1 am a DEP
approved system inspector pursuant to Se ton I5.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes `
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: t, Date: 7 "-6
Y •
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth•or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority. a ,
Notes and Comments-
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different.
conditions of use.
ti..f
Title 5 Inspection Form 6/15/2000 page I
o . 0
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)...
Property Address: 50 Crocker Lane
Barnstable
Owner. David Van Kleeck
Dateorluspection: f ''
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syste Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One o more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The s stem,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no o not determined(Y,N,ND)in the for the following statements.if"not determined"please
explain.
The septic is me
tal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits s bstantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is repl ced with a complying septic tank as approved by the Board of Health.
•A metal septic will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the L nk is less than 20 years old is available.
ND explain:
Observatio of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) r due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of Board f Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The stem required um q pumping more than 4 tunes a year due to broken or obstrtKtcd pipe(s).The system will
pass inspe ion if(with approval of the Board of Health):
broken pipe(s)are replaced
obswction is nnioved -
ND explain
?, Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 50 Crocker Lane
Barnstable
Owner: David Van Kleeck
Date of Inspection:/
G Further Ev luation is Required by the Board of Health:
Condition exist which require further evaluation by the Board of Health in order to determine if the system
is failing to prote public health,safety or the environment. ,
1. System wi 1 pass unless Board of Health'determines in accordance with 310 CMR 15.303(1)(b)that the
system is i of functioning in a manner which will protect public health,safe[Y and the environment:
Cess o]or privy is within 50 feet of a surface water
)myn
ool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. ll fail unless the Board of Health(and Public Water Supplier,if any)determines that the
systioning ina manner that protects the public health,safety and environment:
ystem has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of ater supply or tributary to a surface water supply.
ystem has a septic.tank and SAS and the SAS is within a Zone I of a public water supply.',
The system has a septic tank and'SAS and the SAS is within 50 feet of a private water supply.well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
priv to water supply well— Method used to.determine distance
•'Th s system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacte is and volatile organic compounds indicates that the well is free from pollution from that facility and
the pr sence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failur criteria are triggered.A copy of the analysis-must be attached to this form. 4
3. Othe
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Page 4 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 50 Crocker Lane
Barnstable
Owner: David Van Kleec]
Date of Inspection:
D. System Fail the Criteria applicable to all systems:
You must indica a`'yes"or"no"to each of the following for all inspections:
Yes No .
Backup f sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharg or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged AS or cesspool
_ Static liq id level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid do th in cesspool is less than 6"below invert or available volume is less than day flow
Required iumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times I Limped
Any porn n of the SAS,cesspool or privy is below high ground water elevation.
Any porn n of cesspool or privy is within I00,feet of a surface water supply or tributary to a surface
water su ly.
Any porti n of a cesspool or privy is within a Zone 1 of a.public well.
_ .Any port n of a cesspool or privy is within 50 feet of a private water supply well.
Any port on of a cesspool or privy is less than 100 feet but greater than 50 feet from a private xater
supply ell with no acceptable water quality analysis.]This system passes if the well water analysis,
perfor ed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
indica s that the well is free.from pollution from that facility and (lie presence of ammonia
nitro n and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are( iggered.A copy of the analysis must be attached to (his form.]
(Yes/N The system fails. I have determined that one or more of the above failure criteria exist as
de cribed in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
alth to determine what will be necessary to correct the failure.
E. Lar Systems:
To be c sidered a large system the system must serve a faci!ity with a design flow of 10,000 gpd to 15,000
gpd-
You us(indicate either"yes"or"no"to each of the following:
(Tlue llowing criteria apply to large systems in addition to the criteria above)
yes no
e 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 s stem is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have ans Bred"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Sectio D above the large system has faikd.The U-Amcr or operator of arty large system considered a
significant thre t under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The sy tem o+,,-ner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST `
Property Address: 50 Crocker Lane
Barnstable °
Owner: navi d van K1 eecc
Date of Inspection:- J✓� o.�
Check if the following have been done.You must indicate`yes"or"no"as to•each of the following:
Yes
_ _ Pumping information was provided by the o occupant,or Board of Health
✓Were any of the system components pumped out in the previous two weeks?
,/ Has the system received normal flows in the previous two week period?
1/ Have large volumes of water been introduced to the system recently or as part of this inspectionT.
Were as built plans of the system obtained and examined?(If they were not-available note as NIA)
Was the facility or dwelling inspected for signs of sewage back up
i
— Was the site inspected for signs of break out.? r
Were all system components,excluding the SAS,located on site?
v _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
P ,
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location.of the Soil Absorption System(SAS)on the site has been determined based on: ..
Yes no
/J Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
• ,l a
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 50 Crocker Lane
Barnstable
Owner:_David Van KleeS,,k
Date of Inspection: L—
FLOW CONDITIONS
RESIDENTIAL.
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):.3
Number of current residents:
Does residence have a garbage grinder(yes or no): V
Is laundry on a separate sewage system(yes or no)* [if yes separate inspection required]
Laundry system inspected(yes or no):&O
Seasonal use:(yes or no): ,tL!�
Water meter readings,if available(last 2 years usage(gpd)): 0 3 10 4 — 68 , 000
Sump pump(yes or no): j� 0 4/0 5 — 75, 000
Last date of occupancy: 9-16
COMMERCIAL/I USTRIAL
Type of cstablishme t:
Design flow(base on 310 CMR 15.203): gpd
Basis of design fl w(seatslpersons/sgft,etc.):
Grease trap pres nt(yes or no):_
Industrial wastf holding tank present(yes or no):_
Non-sanitary aste discharged to the Title 5 system(yes or no):_
Water meter eadings,if available:
Last date 01
occupancy/use:
OTHER(describe):
GENERAL INFORMATION e
Pumping Records f �j' �e,Q 6
Source of information: G T C 9 el 7 ,5 7 � a� 6 � / � �G
Was system pumped as part of the inspection(yes or no):,&p
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TY�F SYSTEM
eptic_ tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)/L�
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]'age 7 of
OFFICIAL INSPECTION 1'OI04-NOT FOIL VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r
Property Address: 50 Crocker Lane
Barnstable
Owner: David Van Kleeck
Date or Inspec(lon:
BUILDING SEWER ate on site plan)
Dcpol below gra
Materials of nstruc(ion:—cast iron 40 PVC other(explain):
Distance nt private water supply well or suction Wie:
Comm is(on condition of jouits,ven(ing,cvidcncc of leakage,etc.):
SEPTIC TANK: locate on site plan).
- m
_ p )
rr
Depth below grade:
Material of construction:�ncrete_metal_fiber of lass yell Ienc '
_oUtcr(explam)
— g —P Y
If tank is metal list age:+ Is age confirmed°by a Ccnificate of Contpliarice(yes or no):_(attach a copy of
certificate)
Dimensions:_ (D ?( (o y �Q
Sludge depth: ( ._Z ;
Distancefrom to of to bottom Pof oullct Icc ror ba(11c:
Scut thickness:—�_
Distance from top of scum to top of outlet(cc or baffle: $
Distance from bottom of scum to bottom of outlet lee or baffle: ( ell
Ilo%v were dimensions determined: n C-CAl C.Uf/LT9
Comments(on pumping recommendations,inlet and outicl lee or bank condition, structural inic0ty, liquid Icvcls
as related tooullei invert cvidcncc of leakage,etc.):
r!5
GREASE TRAP:•_(locate on plan)
Depth below grade:—
pMaterial o(eonstruetior: concrete —metal_fibcrgla�ss 1�olyctltylcnc _other
(explain):
Dimensions:
Scum lhickncs .
Distance Go top of scum to top of outlet(cc or baffle:
Distance oil bottom of scu m to bottom of oullct ice or baffle:
Date of ast pumping: ,
Con cnts(on pumping rccontnrcndatious,uticl and outlet ice or baffle cotiditiun;structural integrity,liquid levels
as elated to outlet ins'cri,es•idcncc of leakage,etc.): w
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACESEWACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORIIIATION(continued)
Property Address: 50 Crocker Lane
Rarn�taYsl P
Owner: David Van Kltzeck
Date of Inspection: -7 Y-0jr—
TIGHT or HOLDING (twik must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construcete_metal_fiberglass___pulydhylene other(explaut):
Din ensions:
Capacity: gallons
Design Flow: gallons/day
Alann prescn (ycs or no):
Alarm lc ce Alarm in working order(yes or no):
Date of la pumping:
Conunen s(condition of alanu and float switches,etc.):
DISTIUBUTION BOX: (if present must be o rcncJ locate on site Ian
I )( plan)
Depth of liquid level above outlet invert:
Conunents(note if box is level and distribution to outlets equal,an)-evidence of solids carryover, any evidence of
leakage into or out of box,ctc.):
PUMP CHAMBER: (locatc'on site plan)
Pumps in working order cs or no):
Alarms in working o cr(yes or no):
Conunents(note edition of pump chamber,condition of pumps and appurtenances, etc.):
Page9of11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 50 Crocker Lane
Barnstable
Owner: David Van Kleeek
Date of Inspection: —G
SOIL ABSORPTION SYSTEM(SAS): (/ (locate on site plan,eicavation not required)
If SAS not located explain why:
Type
aching pits,number:_
aching chambers,number. 3
leaching galleries,number.
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
5hL
, �H L � .at
CESSPOOLS: esspool must be pumped as part of inspection)(locate on site plan)
Number and config ation:
Depth—top of liq d to inlet invert:
Depth of solids 1 er:
Depth of scum yer:
Dimensions of/cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (lV.site plan)
Materials of cons :
Dimensions:
Depth of solids
Comments to condition of soil,signs of hydraulic failure,level,of ponding,condition of vegetation,etc.):
9
Page 10 of 1 l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 50 Cro _ker Lant,
Barnstable
Owner: David VAn Kleeck
Date of Inspection: —
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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PSge l l of l l
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 50 Crocker Lane
Barnstable
Owner. David Van Kleeck
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
�hecked with local excavators,installers-(attach documentation)
VAccessed USGS database-explain:
You must describe how you established the high ground water elevation:
w
4
11 ,
IV
TOWN OF BARNSTABLE
e i
I.UCA'fION � �'
VILLAGE 2 - ASSESSOR'S MAP St LOT \
/
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 157 j / (size) ,3 FI-C)
NO. OF BEDROOMS PRIVATE.WELL OR., PUBLIC WATER r -
BUILDER OR OWNER P/ VIP V'A IV
DATE PERMIT ISSUED: J,
DATE COMPLIANCE I SUED: Lla
VARIANCE GRANTED: Yes No L,,
37� 3L
�'��� .3b
E COMMONWEALTH OF MASSACHUSETTS Fu . .....
BOAR® OF HEALTH
OF.. (d� C ............................
Appliratiun for 3liipu i al Wurkg Tunitrnrtion Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.....Rll�x,�.ocation-A d ess / or Lot N
/� gyp` ` �).s� ..'/.�(.��
....................�-'�""'l. :a .j./......................................... ......'-= --'•-'-- "C'?GL�£ :---f± �'_•__Sn.!'`�Isa ��
__.._
Owner Address
W
Installer Address
D�O
� Type of Building � Size Lot...__.��_______________Sq. feet
Dwelling No. of Bedroo s___>__.____ ________________________Expansion Attic ( ) Garbage Grinder ( )
._._._._ Showers — Cafeteria
p, Other—Type of Building No. of persons______ O ( )
A4 Other fixtures .........................................I
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity!$!®__gallons Length. /.......... Width___, ........ Diameter________________ Depth__ _______--
Disposal Trench—No_ ____________________ Width____ �_._.____ Total Length___'5_:�__._.__-__ Total leaching area_...._._____.___....sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.........................'..............
,4 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___________________.____
•-------•----------- - -
0 Description of Soil.....
1,
-L -- •"----•--•••----••--.....--•----•-------------------••-•---•------------•-------•---•-------------
x
W ---------------------------------------------------------------------------------------•----------------•=---------- ---- ----_
U Nature of Repairs o Alteratior}s—Aryer when a plicat�le.___ d
1- - -�----- -- ` : `a g O
as
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I ^ 5 of the State Sanitary Code—The undersigned further agrees`iot to place the system in
operation until a Certificate of Compliance has b issue y t-e ADoar health.
Application Approved By----------- 7 �' -
Dat
Application Disapproved for the following reasons:-------•---------------------------------•--'---------••------------------------------------------.._...-•---•--
....................•----.....-•-••---------•-•---------------------------'-----.._...--•------...-••-••-••---------------------------------•----•-----------------------•--•-••-------------•---•'-"-'
Date
PermitNo............................... .....'-•-'-------. Issued.......................................................
- D�tz
No
-------THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ ----------- t............0 F..L7— �.........................................................................
Appliration for Disposal Works Tonstrurtion Pumit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
r ... .. ....
................................................ .......I............. ............ ..........
.......... ............
C1 .d Lo i n .,kddress 0. VtA
. .... ........................................... ........ ...... ..........KIfL..4 .....Z4�...
Owner Address
........ .........
Installer Address
Type of Building Size ...Sq. feet
Dwelling—No. of Bedrooms_._:,_______________3.... ...Expansion Attic Garbage Grinder
... ------------------
S
Other—Type of Building '�... No. of persons.......:. .................. Showers :k) — Cafeteria
P4Other fixtures ......................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow...................__..;..................dons.
capacity./ .gallons9. Septic Tank—Liquid capacity./ .gallons Length ...... Width ;V..... Diameter-_-____--__---- Depth. -------
Disposal Trench—NTo..................... Width.j..0........... Total Length.....VZ...... Total leaching area................1...sq.,ft.
Seepage Pit No--------------------- Diameter....._....__.__..._. Depth below inlet................._.. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank_( )
04 Percolation Test Results Per-formed by........................................................................... Date........................................
1.4
Test Pit No. I................minutes per inch Depth of Test Pit._____.__..__......_ Depth to ground water------------------------
Test Pit No. 2................minutes per inch Depth of Test Pit___............._... Depth to ground water----__-_________---.__-_
..........................................................................................I
----------- .......
6&1............................................................................................................................
0 Description of Soil_._
------------
W
....................................................................................................................... -------------
Nature ofRe airs- r k 9�1 71
U Aterations—Answer when applk�PLble`-/.--./.--— —-- ---S-7................ ... - -----
r
................. ....
..........t..... ----------------------I------------------- ,------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'T'IE 5 of the State Sanitary Code—The undersigned further agrees"not to place the system in
operation until a Certificate of Compliance has b issue y t'lZeA')oar4 4 health.
j
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7
. ..... ........
14
d ..... V------------ ---------
Date
C— ... . .... �f
Application Approved By.............. ........................ ........ t
Application Disapproved for the following reasons:.............................................................................................................
........................................................................................................................................................................................................
c Date
PermitNo.--------............................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........0 F....-- .......... .......................
Trdifirate of Toutpliattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------L-----------------
Installer
at.....................................................................................................................................................................................................
has been installed in accordance with the provisions of TITIE 5 or The State Sanitary Code as described 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 WILL FUNCTION SATISFACTORY.
DATE......_____-"----------... _.-. ............................... Inspector.................. ................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PiF HEALTH
.....................................OF........... .......................................................
FEE.Vf..... .(D.........
Disposal Works 01.111nstrudion Virrmit
Permission is hereby granted....... ................. ............................................................................
to Construct-f or RLpair an I i idual Sewage Disposal System
I liz 7
at No......... .............................1Z'r 2��
......................................................... ------------- ............................................I..................
Street
as shown on the application for Disposal Works Construction Permit —...................
........................................................................................................
Board of Health
DATE. ....
/- -t5-� �
'/�:-- -----------*........... ....... ......FORM 1255 HOBB19 WARREN, INC., PUBLISHERS
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