Loading...
HomeMy WebLinkAbout0029 KEHTEAN DRIVE - Health 29 KEHTEAN DRIVE, BARNSTABLE A= II i No. ® Fee 75 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplitation for Disposal *pBtem Construction Permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. oL9 �G( �l�N IZ o Owner's Name,Address,and Tel.No. . �A ROSqu C F1-MC-::kACZ Assessor's Map/Parcel aq g / In I KEf4TC 1J bR 0AWStq66S Installer's Name,Address,and Tel.40. 5 6-2 477— $r7 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H al Signed Date 9_�L9^ n Application Approved by Date Application Disapproved by — Date for the following reasons Permit No. Date Issued No. � "'� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS fltlfltatiott for Disposal *pstelll Construction 30erttlit Application for a Permit to Construct( ) Repair(K) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. A9 Kr-_j -TEAtW dIZ,' Owner's Name,Address,and Tel.No. Assessor's Map/Parcelf aZ9� 4 gR+ /• act <05HT 04 ��� Installer's Name,Address,and Tel.140. j Q's--477-g$77 Designer's N e,Address,and Tel.No. CyE®�Jtr(ac t�JZ'c9t'Pt �'j pi Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria.( Other Fixtures - Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date �? Title Size of Septic Tank Type of S.A.S. 1 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of H alth. °w Signed q Date �� `-9-g (7 Application Approved by \ w Date Application Disapproved by �`` Date j for the following reasons Permit No. ,-- Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CCERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(A Upgraded( ) Abandoned( )by C,Af,6 W t(7 C Em-r�P4-tcG ; u at y -I<r-- 7-6(' �JM� AAbVUSW6(]9*has been constructed in accordance - ' r .. C'•y �I f with the prroyvisions of.,Title 5 and the for Disposal SysteempConstruction Permit No�-/i' TW d dated Installer N—,TV 1 n �r(�I rCR��S�.] Designer y S is #bedrooms Approved design flow and The issuance of this permit�shaalll not be construed as a guarantee that the system will:fi ction ass designed. Date d`1 Inspector - ,_ r _ No. / ,.�`.�... � Fee _. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction j3ermit Permission is hereby,granted to Construct(, ) Repair( Upgrade( ) Abandon( ) System located at 49 K9K'T4AJ f3r4WS7', cc- and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be!completed within three years of the date of this°permit. Date . Approved by__ ' r WILLIAM W. STUBBLEFIELD CERTIFIED TITLE 5 INSPECTOR Commonwealth of Massachusetts 545 W. Fal. Hwy. • PO. Box 460 Executive Office of Environmental Affairs West Falmouth, MA 02574-0460 (508) 540-6171 Department of . I . Environmental Protection William F.Weld TrudGovernm y'Coxe Lt. maul Celluccl Rr ✓� cf� B.s uha 0 1996 SUBSURFACE SEWAGE DISPOSAL SYSTEM IN9PECTIONORM ^ PART A _ / CERTIFICATION d* d Property Address /G /-/TCId!✓ Uri v,—= 18A�'lt/ �•�• s �4 Address of Owner. Date of Inspection: /is/ 9 (If different) Name of Inspector. Ad ' elep one um rCompany Name, dress 641 re CERTIFICATION STATEMENT &Ve2, lv,4• ®ZO3® 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 sews disposal systems. The system: V Passes Conditionally Passes — Needs Further Evaluation By the Local Approving Authority Fails �.. Iespector's Signature: Date: 4101/-11Z The System Inspector shall submit a copy of this inspection re rt 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: CheckZj C,or D: A] SYSPASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 16.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to beXthexisting The system,upon completion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N, or ND). Dmination in all instances. If"not determined",explain why not) The septic tank is metal, cracked, , shows substantial infiltration or exriltration, or tank failure is imminent. The system will pass iing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a T01e134110ne(617)292-5500 0 A Printed on Recycled Paper ' Y1 t' • + ;(' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A O /1 CERTIFICATION(oontinjued) Property Address: (ve Owner. SlucF Date of Ieupeetion: B)SYSTEM CONDITIONALLY PASSES (continued) I)\ 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 m will pass inspection if(with approval of the Board of Health): broken pipe(@)are replaced obstruction is removed distribution box is levell or replaced The system required pumping m than four tim a year due to broken or obstructed pipe(@). The system will pass inspection if(with approval of the card of Healt ): broken ipe(s)are placed obstructi is re oved C) FURTHER EVALUATION IS REQUIRED BY BO OF HEALTH: Conditions exist which require further eval tion by the B f Health in order to determine if the-system is failing to protect the public health,safety and the environmen 1) SYSTEM WILL PASS UNLESS BO D OF HEALTH DETERMI T THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PRO THE PUBLIC HEALTH AND 9 AND THE ENVIRONMENT. Cesspool or privy is wit 50 t of a surface water Cesspool or privy is ' hin 50 feet a bordering vegetated land or a t marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD HEALTH ( D PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTI ING I A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorptio syste and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil abso tion system an ' within a Zone I of a public water supply well. The system has a septic tank and soil a orption system and is 'thin 50 feet of a private water supply well. The system has a septic tank and soil. rption system and is 1 than 100 feet but 50 feet or more from a private water supply well,unless a well water is for coliform bacteria and vo a organic compounds indicates that the well is free from pollution from that facility d the presence of ammonia nitrogen d nitrate nitrogen is equal to or less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 29 I-IZW7-EA N _,Ur1 VE 4'el m , Owner. ,s-LL E '6-- J Oe)C Date of Inspection: / 9 ` / DI SYSTEM FAILS: I have determined that the system violates one or more of the following failure teria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be coats to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an loaded or clogged SAS or cesspool. Discharge or ponding of efiluen to the surface of the ground surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution above outlet in due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" low invert o available volume is less than 1/2 day flow. Required pumping more than 4 times in a last NOT due to clogged or obstructed pipe(#). Number of times pumped Any portion of the Soil Absorption System, pool or privy in below the high groundwater elevation. An portion of a cesspool or privy is wit ' 100 t of a surface water supply or tributary to a surface water supply. _ Y Po P� P "Y PP Y �9 Any portion of a cesspool or privy is thin a Zone f a public well. Any portion of a cesspool or privy ' within 50 feet of a rivate water supply well. F! Any portion of a cesspool or pri is less than 100 feet but ter than 50 feet from a private water supply well with no acceptable water quality anal is. If the well has been anal to be acceptable, attach copy of well water analysis for coliform bacteria,volatile o c compounds,ammonia nitroge and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to ins in addition to the criteria above: The system serves a facility with a design w of 10,000 gpd or greater( System)and the system is a significant threat to public health and safety and the environment beca one or more of the folio conditions exist: _ the system in within 400 feet of a atirfa drinking water cup the system is within 200 feet of a tributary a surface water supply the system is located in a nitrogen sensitive area Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system d facili to full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the 1 regional ofi'i of the Department for further information._ (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �,� .�/TEA/A/ Owner. .1.3,-Oce Soo Date of Inspection: / Check if the fo wing have been done: ping information wes requested of the owner,occupant, and Board of Health. No a of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As it plans have been obtained and examined. Note if they are not available with N/A. facility or dwelling was inspected for signs of sewage back-up. e system does not receive non-sanitary or industrial waste flow e site was inspected for signs of breakout. m components, excluding the Soil Absorption System, have been located on the site. Th septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. _The ize and location of the Soil Absorption System on the site has been determined based on ezisting information or ap ted by non-intrusive methods. _The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C //�� SYSTEM INFORMATION Property Address �9 ��/�.�T N Orl VE 49-10'AIV 4.d , -00�' Owner. rU Sc�©� Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: &3 sallons + Number of bedrooms: Number of current residents: Garbage grinder(yes or no):-6W Laundry connected to system(yes or no): Seasonal use(yes or no):A/D Water meter readings, if available: 9V o?3 GYJD 6�G• C7/' } s M 1991 npon /7,u. zeaw 6ga Last date of occupancy: �G h r COMMERCIALANDUSTRIAL• Type of establishment: Design flow:_.gallons/day Grease trap present: (yea or no)_ Industrial Waste Bolding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING�)ttEF,CcORDS and source of information: System pumped as part of mspection: (yea or no)_/P If yea, volume pumped: gallons Reason for pumping: TYP2pseepy�t:tank)distribution STEM boyJsoil absorption system Single cesspool Overflow cesspool Privy Shand system(yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information:a y"rS a �/n ��/ •ny'IrJ/o��MS Sewage odors detected when arriving at the site: (yes or no)_ (revised 11/03/95) ES SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Z�4;rAlrZ�.4N Arf ve, �Ig7'�/s1igOJCr IJ'I�, Owner. 46r&Z E I—X-• S049Y Date of Inspection: SEPTIC TANK:_" (locate on site plan) Depth below grade;��2T/7" Material of construction: ncrets_metal_FRP—other(explain) DimensionsW 6 17 if X I f{'6 ' xfO�' SAG Sludge depth: /-7 " _ Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: AIAAle Distance from top of scum to top of outlet tee or baffle: r,2 kt wyh-.E v&.&r' Distance from bottom of scum to bottom of outlet tee or baffler►,✓-44v-k✓C.4 9"' 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.) /YD t6kaoM .4r &z. GREASE TRAP:_ (locate on site plan) , Depth below grade: Material of construction:_concrete_metal_F other(ezp ) 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 e: Comments: (recommendation for pumping,condition of inlet an outlet tees or baffles, depth o ' uid level in relation to outlet invert,structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 s- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) q t Property Address:Z9 ,L/FfsT��N �r 1 ve (�.�/!✓Sf���c/rn�, Owner. B�'�j�� �• 04�,/ Date of Inspection: / TIGHT OR HOLDING TANK_ (Locate on site plan) Depth below grade: Material of construction:�ooncrete_ _FP'P yotliei(eiplaia) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float awl es,etc.), 14 DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_ Comments: ll' (n if level and distribution ' equal, evidence of solids carryover,evidence of 1`eakage into or out of box,etc.) AAA di�iNS D� PUMP CHAMBER_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and app nan ,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Addross: Z� �E.�TE/�.t/��-�v� �.�Jr✓Srr.4 <�/�.Q. Owner. d'UL1 E. sC7Cx/ Date of Iaspee on: Gly�4� 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: leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool,number: ,, (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.)A& &zWe l/y tor/1�,1,r�tsLir A'V—/ 01. Ar L/P OW- CESSPOOLS:_ (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 fail , level of ponding,condition of ve tion,etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions Depth of solids: Comments: (note condition of soil,signs of hydraulic failure, level of pon oa tion of vegetation,etc.) (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address �����iSl T ,�/C� UJ'/Ye �i�/'s7.s/�•q.6�� Owner. R//'UL e r Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' �DC>SE' ZS' Zd'= 21, . I 47'3 L OGAT/CAN `rorn .�s 6ul�T lAN //V /legGrl� OGFiC� DEPTH TO GROUNDWATER Depth to groundwater _feet l / method of determination or approximation: yJ �,4, C.! V141VN/S DA! LG i v .g&OW eA5e;eE. (revised 11/03/95) 9 - j L O CATION S� �)G E PE hMIT UO. 2-7 VILLAGE INSTA LLER'S q-AIRE 8 ADDRESS W U I-L D-E R OR OWNER ER G� u-!� T 'DATE PERMIT ISS-uE D 000, MAT E COMPLIANCE ISSUED �'! � � �' Q �' �� �� � 4� --- m� �� � � No....z."?.. -----. F�s.�3.s................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............ ........--------•---......OF.......................................................................................... Appliration for Bilipm al Workg Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Ar , 101,.,ives Via" ................__ •----.....`.......-----------------•••.--•-- ....................... ----------------------- --------•------ ---- -•-------------------------------------------- Location-AddrPCa or Lot No. 0 ................................... r ._ '! J ��?.S✓!4 ...--------•--- Owner Add r ss a11 j_.._<4V ------------------------------------------- ............ ........... . ,c •------------•---•-----------..---------- Installer Address d Type of Building Size LotJ_t,�/ -----ar....Sq. feet aDwelling—No. of Bedrooms............0 _.....................Expansion Attic ( ) Garbage Grinder ( ) p., Other—Type of Building ............................ No. of persons................._---------- Showers ( ) — Cafeteria ( ) Q' Other fixtures .................................. W Design Flow.....i3JO.........................gallons per person per day. Total daily flow..............................................gallons. WSeptic Tank—Liquid capacitAw..gallons 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..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date......................_................. 04 Test Pit,No. 146 5 .. _minutes per inch Depth of Test Pit-/3.r h..... Depth to ground water__,Vke':0------- 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 0 - 1�,�'. Ca ------ 0 Description of Soil.... V ....•••••••-••--••---•-••--•-••--•••.......-•---•--•--•-•-••-••--•----•••-•-•--••-•---•-----••••-•••---•••-•-•------•--••....._...---•----•--•------••--•-=•••--•-•••••...............••-•-•----------••. W ----••••-----------------------------------------•-•----------•••-•-•-••••-••-...-•-••-•••----•----------------•-•-•-------•-••------•----- •••••••-•---•-••-•-......................................... 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 TITL- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been sued'by the boar ' f health. ed_ - Application Approved BLIZ, •• // / Y --------------•--•. . .................... Date Application Disap ov f or he following reasons---------------------------------------------------------------------------------------------------------------- -----------------------•-•--•---• -•-•... .__...---------•-----•••-•-•-----------•-•-•-----••-••-•-••-•--••••••••••-••----•---•---------•-----•••----•............-••----••••••--- ---•------------ Date PermitNo......................................................... Issued-....................................................... Date 6. . THE COMMONWEALTH OF MASSACHUSETTS ................. BOAR® OF HEALTH ..........................................O F...........................--•--.........----------...................................... ApplirFa#iou for DhipwiFal Works Towitrurtiou Errant I Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ,V ................__......_..................------•----------..._....V------------------------ ---------------------___�`-'-----------Z--------------------------•----.----------- oc tion-Add r or Lot No. . ✓ ..... :. 1�x rG ------------------------------- lJ�l .,�C� ... -s rT.f�?Bl ....... �Q�►�Owner AJddr ........................... ___ -_____Sf e s ... _ . ..... ...............a filer Address Q Type of Building Size Lot_,1r,,.A5.<....Sq. feet U Dwelling—No. of Bedrooms............ ... ....._. _Expansion Attic ( ) Garbage Grinder ( ) —Type g ....__..... No. of persons............................ Showers ( ) — Cafeteria ( ) Other—T e of Building _________________ a' Other fixtures ................................. ----------------- ........._............_-------- W Design Flow.....CJd........................gallons per person per day. Total daily flow........ ...__ga.............................. 11ons. WSeptic Tank—Liquid capacit3pLba0l.gallons 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..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 14& .Z.minutes per inch Depth of Test Pit.A9.V......... Depth to ground water..s9fl,�v!�...._.. Test Pit No. 2................minutes per inch Depth of Test, Pit...................: Depth to ground water........................ --------------------------------••••••----------------...;----- ----------------•---......__.._..... ......:....... --------------------------------- Descry tion of Soil I �{` 'r'`� � .._. V ----------- •................. .--------------- ------------------------------------------- -................................................................................................. W --•--------•...........................................•-•-•----------------•-------•......•-•-•-•-----••------•----•-..........---•••..........__...-----•------•••-•....._------------------......... 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued'by the boar f health. to Application Approved . - a'" = - f� '�' -----._---.-•--- r f Date Application Disapprb_.�f orlihe following reasons--------------------------------------------------------------------------------------------•••-----•-........._ 11, 7� Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARIF HE d 3a....................OF...... ^ ...... ...f... . ................................................ Trrtifirtttr of TompliFaurr y TvIS S TO CE- IFY, That the Individual Sewage Disposal System constructed ( Vf"or Repaired ( ) b ..... .... ------------••--•-•.................................................•--•--•----•------- Installer at =-------• --.---•-------------•---•--•--•--•--•-------•------••---•-•--•-•---•--------•-------•-••••---•--------------- has been installed in accordance with the provisions of TI,TLE of T e State Sanitar Code s d. ribed in the r application for Disposal Works Construction Permit No.. •"".'... Q ..._._..... dated-_ l� Z''................ THE ISSUYF ! OF THIS CERTIFICATE SHALL NOT BE CONSTRU A ARANTEE THAT THE SYSTEM 1A/ITION SATISFACTORY. DATE..... .... ... ••-•--•••-•-•---•••-- Inspector....=---- ........ .........................•- THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HE .� 1 ,Ctrc ........................OF....:�..- •--.......,..!r ,�- No.. ....". ...�!.. FEE.1?.j................ "" _. Permissioni eby granted! - --• ......................---•-••••-•----------••-•-----------........................................................ 'to ConstLu�t r epa' ) Individual Sewage Disposal System atNo....... •----- ----=----------...... ''�....--............................................................... Street as shown on the a/Ilication for Disposal Works Construction Permit No._ ___,__ ___ D ed_._ __ �. j l BoaDATE.._/ -/�f t FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS