HomeMy WebLinkAbout0151 MIDPINE RD - Health EE 151 MID PINE RD., BARNSTABLE
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TROY WILLIAMS
SEPTIC INSPECTIONS
Certified *MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PRO CTION
ONE WINTER STREET, BOSTON MA 02108 (617) 292- 40
UV �E�wLo
TRU-D COKE
�pyfN Or MRNSTAM Secretary
HEALTH DEPT.
ARGEO PAUL CELLUCCI s DAVID:B. TRUHS
Governor �Coicunissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ `�
PART A
CERTIFICATION
Property Address: 151 M ' c'f Pi~e Rd.. Name of Owner � L
C/�'11 CJti Vti G.5
-0..n Gl 1.! d Address of Owner: / y 3 (yroal a f f
Date of Inspection: 61Y/� �iz �•^:L.� c �.,, /Zt O, 7 O I
Narne of Inspector:(Please Print) Troy Williams
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
MaTing Address: 19 Hummel*Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
CERTIFICATION STATEMENT
1 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 /
Inspectors Signarture: 1 (�-� 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 the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:owner: 151 Mid Pine Road, a �Cumma ui MA
Date of kuptio,: James Langway
June 4, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. An
criteria not evaluated are indicated below. y failure
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 pipe(s). 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 P.u , 2o( II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Address: 151 Mid Pine Road; Cummaquid,MA
Owner: James Langway
Date of 4upection:June 4, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: V//3 "
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
Public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)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 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,IF ANY)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 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 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
revised 9/2/9P rr,Re3ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
151 Mid Pine Road, Cummaquid,MA
Property Address: James Langway
Owner: June 4, 1999
Date of Inspection:
D. SYSTEM FAILS: N1A
You must indicate either 'Yes" or "No" to each of the following:
have determined that one or more of the following failure conditions exist as described 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 potion 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.
E- LARGE SYSTEM FAILS: M
You must indicate either "Yes" or "No" 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 =IWPA) or a mapped Zone If of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 1 5.304(2). Please consult the local regional
office of the Department for further information.
r. evisd 9/2/98
PeCe 4 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 151 Mid Pine Road, Cummaquid,MA
owner: James Langway
Date of Inspection: June 4, 1999
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.
,(S<< o«�nu��y )
None of the system components have been pumped-forat least two weeks and-the $Ystem has been•receiv►ngmDrmal 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.
lL/ _ The site was inspected for signs of breakout.
Ae/ _ All system components, excluding the Soil Absorption System, have been located on the site.
1L _ 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)
/ [15.302(3)(b)]
The facility owner(and occupants,if different from owner) were.provided with Information on the.propermaintenance of
SubSurface Disposal Systems.
revised 9/2/98
Vag, 5 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 151 Mid Pine Road, Cummaquid,MA
Date of Inspection: James Lang'ay
June 4, 1999
FLOW CONDITIONSRESIDEN71gl:
Design flow: J
.�_g.p.d./bedroom.
Number of bedrooms(design): 3 Number of bedrooms (actual):
Total DESIGN flow —
Number of current rest ents: p
Garbage grinder(yes or no):_AL0
Laundry(separate system) (yes or no):&0; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):_YgS
Water meter readings,if available(last two year's usage(gpd): Z8/q% _ P,c)OO
N �OctUG o a h s Sump Pump(yes or no): o t
Last date of occupancy: • G L.0 S•uhw / U S —4- S wr.c.•
COMMERCIAL/INDUSTRIAL: AIM
Type of establishment:
Design flow: apd (Based on 15.203)
Basis of design flow
Grease trap present:
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-
System pumped as part of inspection: (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
1
TYPF�OF SYSTEM
_ Septic tank/ /soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
1/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 inst$lied W known)and source of^information: (1►. ., ,-� /
Sewage odors detected when arriving at the site: (yes or no) A/0 r
revised 9 /2/98
rwge 6 or i i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(cmd4mied)
Property Address:
owner: 151 Mid Pine Road, Cummaquid,MA
Date of k-pection: James Langway
BUILDING SEWER: June 4, 1999
(Locate on site plan) pp
Depth below grade:
Material of construction:_cast iron V 40 PVC other(explain)
a- L)
Distance from private water s6pply well or suction line IV/�
Diameter y,1,
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(explain)
If tank is metal,list age 1s.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: !
S ��/ X �O V O
Sludge depth: !�
Distance from top of sludge to bottom of outlet tee or baffle: IQ
Scum thickness: Od/1=
Distance from top of scum to top of outlet tee or baffle:A16 S
Distance from bottom of scum to bottom of outlet tee or baffle: /Vo S c- ve
How dimensions were determined:
Comments:
(recommendation for pumping,condition of inlet and outie tees or baffles,depth of liquid level in relation to outlet invert,structuret-integrity,
evi erica of leakage,etc.) (r,on cs c s� '� ct ,� /Ol/ G —Tt ✓ cs�! L� # w<✓,�
c ✓,.mot, w Z.��
v pM CA. • J
i•
GREASE
(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.)
revised 9/2/98 Page 7of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address:
Owner: 151 Mid Pine Road, Cummaquid, MA
Dace of Inspection: James Langway
June 4, 1999
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(explain)
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•_N/R
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note-if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box, etc.)
PUMP CHAMBER:,N//3
(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.)
.. a y,f
- e
revised 9/2/98 P.grBorI I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Prop"Address:owns.: 151 Mid Pine Road, Cummaquid,MA
Date of Inspection: James Langway
June 4, 1999
SOIL ABSORPTION SYSTEM(SAS):-.,,—/
(locate on site plan, if possible;excavation not required, location may be approximated by non-intrusive methods)
If not located,explain:
Type: b// /
leaching pits, number: h Ot. iX b LGctic1,
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, signs of hydraui failure, level of ponding, damp soil, condition of Vegetation, etc.) // )
w e r v�.a�..-� r
�c d
r r
— 92
0. I�i
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 failure, level of ponding, condition of vegetation, etc.)
PRIVY:_,A/l/q
(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.)
re,,-ised 9/2/98
r.R� 9 or i i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 151 Mid Pine Road,Cwnmaquid,MA
Date of Inspection: James Langway
June 4, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks of benchmarks
locate all wells within 100- (Locate where public water supply comes into house)
a
I
3� 25 n/-
r
�ppv�w��n� \
rv, I,—
revised 9/2/98
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contirxue<f)
Property Address: 151 Mid Pine Road, Cummaquid,MA
owner:
Date of inspection: James Lang-way
June 4, 1999
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep ✓
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater /,/+Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design 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
Checked pumping records
Checked local excavators,installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
S
I GK 5 4. I'j 1 . PN C I.j k--�s..� �'✓ti r/� . ��l j. / C._l-�i,CI/H's /3 - .
w w C�`Gar 2� �a V li f'i O
F ,
revised 9/2/98 Page 11 or 11
TOWN OF B.ARNSTABLE
�vuS� .I Ise
LOCATION C T"//�. 0/ &/.Uf'. EWAGE #
E of
VILLAGE g!!!;Zj1iS/,,51�BIG� ASSESSOR'S MAP & LOT//y
r
INSTALLER'S NAME & PHONE NO. _ ®,
SEPTIC TANK CAPACITY lfC)�
LEACHING FACILITY:(type) I DOC, (size)
NO. OF BEDROOMS 3 PRIVATE WELL OR UBLI
BUILDER OR OWNER Z4ti��'��
DATE PERMIT ISSUED:
DATE .COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
S - y
a
N
Vl w
a
v A Oi
a
No......................... Fjcs. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(J� _.. ._ ..... ............._.. OF...............................--.......................................................
Appliratinn for BWVaaat Works Tons .rurtinn Vautit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: ( `
..
ti ress ot No.
........ ..................................... ..... ..bz;�i
Owr �� ress�. .Y.: .........� . c ..... ............._............................._
nstaller dress
UType of Building "� Size Lot.. ��. .....Sq. feet
►� Dwelling—No. of Bedrooms._..,......1............................Expansion Attic ( ) Garbage Grinder (`''T"
of Building persons ----__-•--_
a Other—Type g ............................ No. of p __._ Showers ( ) — Cafeteria ( )
Otherfixtur s ..------•---•...................••-------•---•--•-••-----••--•----•---••---•-•----•--•----------.
W Design Flow........... ......-. _...�.,,�gallons per person per day. Total daily flow......... ��................gallons.
WSeptic Tank—Liquid capacity .✓... allons Length.... Q...... Width..S .... Diameter. ......... Depth................
x Disposal Trench—No idth.................... Total Length.................... Total leaching area.....................sq. ft.
Seepage Pit No/dio. . Diameter.................... 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_____-_____-__--__--_.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
iri
O Description of Soil.........................
!...1 _.__...._...__...._
•• --••• ---------------------------------------- --------- ----------••---•-----------------
W
-------------------------------------------------•-------•--••---•---.._......_...---••-•---•-•-----------•-••------------•...-----•--•--•----••----•----••••--•--•--------•--------------•--•-•---••-
V Nature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance h issue y he rd of health. f
Signe /y( 7 2. .. ...
Date
ApplicationApproved By..................................................................................................
Date
Application Disapproved for the following reasons:..................................................................... ..........................................
.................................•-•---------------------...-------------•• ............................................................. ..........................................................
Date
PermitNo........................................................... Issued........................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
m A
LI
DATA
THE COMMONWEALTH OF MASSACHUSETTS
}
BOARD OF HEALTH
-- ----- ............................OF.........................................._.........._.... ........... ........._.
AVV iration for Uhiposal Warho Qattstrurtion Vantit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
/ //
... .: A�XT�i. le 5�_n,hs... 0 ... ............... ............•........................ .5.. X._.oltiotlddreGs r i> Lo Not ...._.. ...� ..... ............/'� . ..
E l:�y7=+`K:•t;6's !••�'{','�s'94.?j 0
}✓r r Aldressw .. I......�1•� ......................
Installer f Address
UType of Building Size Lot....,}.'4�..O ......Sq. feet
►-� Dwelling—No. of Bedrooms.......•,, ............................Expansion Attic ( ) Garbage Grinder
`j
p•, Other—Type of Building ............................ No. of persons....... e---__--_-••._ Showers ( ) — Cafeteria ( )
w Other fixtures ----------•-... .....-•-•••---• . .
W Design Flow............ 5 ............... .gallons per person per day. Total daily flow......... 3. ..................gallons.
P4 Septic Tank—Liquid capacity/p✓?-allons Length..../d...... Width.:. --�.... Diameter.. _........ Depth................
W Disposal Trench—No.. g a q
x �"""
� 'idth..__•---•_---------. Total Len th.__.__--•-------_--. Total leaching area--------------------s ft.
Seepage Pit No.-J,A. .; '&4. eter.................... Depth below inlet.................... 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........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.............-...... Depth to ground water........................
..................................................r---_....:A...---•-•--•-•-•••--......................_---•-•------...---••-•--......._.........----__-•--
ODescription of Soil ; ?: -Gi4 -i :._....1 !!- .----------------•-•------------•----------------------•-------------------.....-•----
Z --•---•••--•------------------------------------•---••......••....• ••----.....-----•--••-••------•••....•--•--•-•------•--------•-••-•----•--•••••-•-•-•---•--••-••••-••-••-••-•--•-•-•---•----••------
U Nature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance 1* n issued y the drd\ of health.
! \�
Signed: V �> . ,F/ �) Z
;V} Date
ApplicationApproved By.................................................................................................
Date
Application Disapproved for the following reasons:... ...... .....................................................................................................
_........--•--•------•--...-•-----------------------------------•-••-------------....--••-----------•---••----•-•-•-••••-----••-•---••-•--••••-•-•••-••--••-••-•-•••-• .................................
Date
PermitNo......................................................... Issued...--------•-----••.
• ••.............................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF........................... ......................11..............I.,................
Trrttfiratr of Tautphaurr
THIS IS.TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by......................................••-•--....••----•--••------•-•••--......_......•-•-----•-----•---• ---•••••----•-••••-••-•--•--•......................_......••--................__-•--.......
Installer
at................-......................................................................................
has been installed in accordance with the provisions of Article XI of 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 OF HEALTH
41
............. . ........... ...OF....... �!:`? �. ....:.�? .. ./4�................................... r
NO........... ..........
Dispasal 10orkii Tonstrurtiott ranfit
«.
Permission is hereby granted....-'-=- :.................................................:..:__..... ............... .............................................
to Construct O or Repair ( ,) an Individual Sewage Disposal System
Sheet d _
as shown on the application for Disposal Works Construction Permit Dated......
,r.....:' ..... .......:.
............................................ .....................
. , :�„
"x Board of Ilealth
DATE.. �• r
FARM 1255 HOESS & WARREN, INC., PUBLISHERS � �-71_---
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