HomeMy WebLinkAbout0286 MIDPINE RD - Health (2) 2nA MIDPINE RD., BARNSTABLE .
9 I
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508)"385-1300
19 Hummel Drive
South Dennis, MA 02660 t,
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIf, �`NA
DEPARTMENT OF ENVIRONMENTAL PROTECTIO
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
p CERTIFICATION
Property Address: "8 6 M ��( �r N� �� Name of Owner W;�l i c1w, of„dt ��r Z�.�c�A co re
C 6" �C^ I,) ; ct Address of Owner: -2pa h /t4;d 'Pi h, Rd• y
Date of Inspection: 8 42 S 19 9 ��✓w o v+ti po yr�- , /4 a. 0 2 6 7,f
Name of Inspector:(Please Print) Troy Williams
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Troy William§ Se tic Inspections
Maaing Address: 19 Hummel Drive, So. Dennis, MA 02660
Telephone Number: (508) 385-1300
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 Inspector's Signature: A✓.4JC�°(i�t w1 Date: 8 /J
'Z 3
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 ttte
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.
nevi .qPr3 q /;) /c�p k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner: 286 Midpine Road,Cummaquid, MA
Date of Inspection: William T. &Elizabeth M. Corey
August 23, 1999
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
Healthl.
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 Page2ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Prop"Address: 286 Midpine Road, Cummaquid, MA
Owner: William T. &Elizabeth M. Corey f
Date of Inspection: August 23, 1999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:A/ll,�
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
._ - Pekr l of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contirxied)
286 Midpine Road, Cummaquid, MA
Property Address: William T.&Elizabeth M. Corey
Owner: August 23, 1999
Date of Inspection:
D. SYSTEM FAILS: A/M
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 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 portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: A/
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'II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 p,ped of „
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 286 Midpine Road,Cummaquid, MA
.Owner: William T. &Elizabeth M. Corey
Date of Inspection: August 23, 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.
_ None of the system components have been pumped-for-art 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.
_ NI9 As built plans have been obtained and examined. Note if they are not available with NIA.
_ 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 const(uction, 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:
N/19 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)1
The facility owner (and occupants,if different from owner) were.provided with information on tha.propermaintanance of
Subsurface Disposal Systems.
revi.sed Page SofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: 286 Midpine Road,Cummaquid, MA
Date of Inspection: William T. &Elizabeth M. Corey
August 23, 1999 `
FLOW CONDITIONSRESIDENTIAL:
Design flow: //u g.p.d./bedroom.
Number of bedrooms(design):-1L Number of bedrooms(actu ): y
Total DESIGN flow yyo �+,S�» a. No P(K h o H 70i/e
Number of current residents:3
Garbage grinder(yes or no):-A�Ij5
Laundry(separate system) (yes or no):1L/0_; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):_JVO
Water meter readings,if available(last two year's usage(gpd): 95�99 = 5-2 000 //60 s p7� _ I 000y 0,/104, r
Sump Pump(yes or no): VO 1
Last date of occupancy: CxwP IL N .
COMMERCIAL/INDUSTRIAI
Type of establishment:
Design flow:_ opd (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: /� 1 PV�Y�c/i 9y e-✓ r O L,l,, "a_� u,+, -/bL�:1, c try [gaN%,e OWhw
System pumped s�f inspec ion: (yes or no) /1!0
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
_Z Septic tank/disicir .haui/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components,date installed Of known) and source of information: 0✓ �,�.h w
i
Sewage odors detected when arriving at the site:,(yes or no) NO
revised 9/2/98 1'e�e6of II
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corrtirxied)
Property Address:
Owner: 286 Mjdpine Road, Cummaquid, MA
Date of hspection: William T. &Elizabeth M. Corey
A
BUILDING SEWER: August 23, 1999
(Locate on site plan)
Depth below grade: / --
Material of construction: cast iron-/40 PVC y other(explain)
rG.^r �'Jr u .
Distance from private tit,e, supply �„ �, suction aria /V/19
Diameter y,"
Comments: (condition of joints, venting, evidence of leakage,etc.) /f
rw.+- Nnt
� t t Y"na-)- 4✓D uJ�Fy 7 C- �✓...�H c � �, r-c
�O CTwN
.. .. .r..n._,e b t o f C c1 h C.c {.� I h �� —!�._�X" Nt`'�`J U✓ Hf ca y �t o
(locate on site plan)
/
Depth below grader
Material of construction:Zconcrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age )s.age confirmed by Certificate of Compliance—(Yes/No)
Dimensions: 7 IS 0 0�4//a H .
Sludge depth: ' '/
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: /&p/1!4,-"
Distance from top of scum to top of outlet tee or baffle: IVO $ C--:-)A-
Distance from bottom of scum to bottom of outlet tee or baffle: Ly S L;lvy
How dimensions were determined: Prt�
Comments:
(recommendation for pump in , condition of inlet and outlet to s or baffles depth of liquid level in relation to outi t invert,structura 4ntegrity,
evi nce of leakage,etc.) nr, refit ->Re t ✓ ny f �c. CA,^.Jl
I �Nit t c r
GREASE TRAP:_IV
(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 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Ote A ` ' 286 Midpine Road, Cummaquid, MA
Date of Inspection: William T. &Elizabeth M. Corey
August 23, 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:1V///,
(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.) h../,r`� /•`I,,�
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
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(corr6nued)
Owner:Property
Y A ss 286 Midpine Road, Cummaquid, MA
Date of kupection: William T. &Elizabeth M. Corey
August 23, 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: //
leaching pits, number: b x- / G/;, ? ; k
leaching chambers,number:_
leaching galleries,number:_
leaching trenches,number, length:
leaching fields, number,dimensions:
overflow cesspool,number:_
Alternative system:
Name of Technology:
Comments:
(no a condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc
mod`
W e v 1—L S t:n Ih !> JC All J t Hl i C r^
cr •
On
' t.� o-ti � .G✓t O j �
iJ C I"G Y o a�.� K,s e h
(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)
a
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: J� +
(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 Pige9ofII
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: 286 Midpine Road,Cummaquid, MA
Date of I—pection: William T. &Elizabeth M. Corey
August 23, 1999
r
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)
I•ht
3y'
1$0o ywri�h
�s I 7S
revised 9/2/98 Page 10of II -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(con6rxmd)
Property Address.owner: 286 Midpine Road,Cummaquid, MA
Date of Inspection: William T. &Elizabeth M. Corey
August 23, 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 Y
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 154 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site JAbutting 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) L
!TG►1 Gi v j le-' ho /c 6►► J-1G, 111jor i h 9 ova "�Sj 75
C., GtIC�o / o �y is a c./"J yr 4 w /J'cr /.�
9
C'h A w A, C—
revised 9/2/98 Page „ urtll
-
No.....J E7 Fz�s... ................
\� THE COMMONWEALTH OF MASSACHUSETTS pp
�✓ \\� BOARD F HEALTH
C� .........of ............. �..- -- -- --._.-..................----
Appliratilin -fur Dig niittl Work C�iat �trurtion muff
Application is hereby made for a Permit to Construct l� or Repair an Individual Sewage Disposal
PP Y ( ) P ( ) a P
SC71
at:
.ocation_Address
Y - _ _ or
.N - b_... -- 1 �Ntoa.
hner
_1 � C e �o dress ��e
� adl � -G^ C �
.--------- -------
Installer Address
d Type of Building Size Lot...L(_(Qc0.... ...Sq. feet
U Dwelling—No. of Bedrooms----------- -__-Expansion Attic ( ) Garbage Grinder (
Other—Type of Building ----- No. of persons---__--------------------- Showers Cafeteria ( )
Other fixtures ----------------------
W Design Flow--------------------- b._...._... ll�ts.P�s person per day. Total daily flow_-__-_-_____ --------------gallons.
Ix Septic Tank-V Liquid capacity.kdegailons Length................ Width------.......... Diameter_----- Depth----.-__.-.--.
x Disposal Trench—No. .................... Width.................... Total Length---------- #00 "� ingarea---..--.----...___-_sq. ft.
Seepage Pit No_________ _______ Diameter______-�v__ , Depth below inlet------- --------. eeachtng area------------------sq, ft.
z Other Distribution box Dosing tank ( )
~" Percolatign Test Results Performed b ..__._-:=L___.__.___M:�RI?—A _
Y .......... Date........................................
W
a Test Pit No. I...... _ ._minutes per inch Depth of "lest Pit____________________ Depth to ground water------------------------
G% Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
a,
kY------------
0 Description of Soil------� lAuZ----•-------------•L+-��- --------------:----------------------------------------------------------------------
W
U Nature of Repairs or Alterations—Answer when applicable..----------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedes ' idual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Co e The undersig ed further agrees not to place the system in
operation until a Certificate of Compliance has been su by t e board o healt .
1 13Y...
_ D e
Application Approved B / .. ?
Date
Application Disapproved for the following reasons---------------------------------------------------------------------------------------------•-------------------
•---•--•--••-•---•------------------------------------------ •--------...-----•---•••-•-------•---•-----------•-----------------------------------------------•--........_...-------------------••-----
�/ Date
Permit No......................................................... Issued----- �L•1a7/'------------------ ----
No...- .................. Fiz$...�iV...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ADF HEALTH
---- -------OF..... ....! -"
�r
AppliratinU -fur Diiipaoat Quark Clumi#rurtion ` &u i#
Application is hereby made for a Permit to Construct V or a air an Individual Sewage Disposal
PP y ( ) P ( ) 5 b posal
stem at:
ocation ddress -------------•................ . --------------.._..._..-----------
WY - bLt�p1� : G1.�LS ,tk.�soU.�
or No
---------- -$` �c �.u - - 4
O ner ress
w t. Q
----------- -----------------
Installer Address
Q Type of Building Size Lot...L(1,606.."`�C"...Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder (tom)
KJ per, Other—Type of Building -_.__ .0_(,__�P--- No. of persons____________________________ Showers Cafeteria ( )
Q' Other fixtures --•---------•----------------- --
w Design Flow _______________-7 ......_..._.____gallons per person per day. Total daily flow----------------- O_ .............gallons.
W Septic Tank _ __Liquid capacity_,_440 0-gallons Length---------------- Width.........------- Diameter__: - - ----
Depth......----------
x Disposal Trench—*No_ ___________________ Width-------------------- Total Length.............. o area--------------.-----sq. ft.
Seepage Pit No.......... .',___ Diameter____.__l W. t Depth below inlet........ o al eaching area____-______..._.sq. ft.
17
z Other Distribution box ( . .;; -,Dr*ing tank*(_.,)
aPercolation Test Results - Performedb% .; __.__: `t'_ ._i _ Date__________________________________ _----- ___
Test Pit No. 1-----*S----___min,utess per inch Depth.,of. lest Pit __________________ Depth to ground water------------------------
t=, Test Pit No. 2__________------minutes per`arch P�,pt(t�o est Pit_______________._.._ Depth-to ground water
a =-•-•------------------ •---- ke
,es O ____ ...._..• ____
Description of Soil------ L�i� _ `---- � lU�.l»: -
.�
/ \ .___________________________________________ _____14 .
n�.
.Uw _______________________ ..__..__._.-. -_.-_-__-__________________________________________.._____________._ ___ _______________________ __ _______________________ _
Nature of Repairs or Alterations'—Answer when applicable...._.._: ______________________________ ________________________ _ t
________________________________________________________________________________________ ____ 4�.�^A 'F _ _
Agreement:
+a. i -
The undersigned agrees to install the aforedes dual Sewage Disposal System in accordance wifil '?k
the provisions of Article XI of the State Sanitary& e The ut4dersig_hed further'agrees not to place the system in
operation until a Certificate of Compliance has been su b e board o healt
Signe
-----
W 9S t D e a
Application,Approved By------ - -- _ S --- -- ...... .. 7 /.•.---.
Date%m,- ..
Application Disapproved for the following reasons_____________ ... {
................••--• Date
�..>.: .Permit No................................................... Issued.-----...------.....
••---•--- ....-•---••---•--
Date
r ^
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH���
x
OF..
V rrifirc'Yfl� uaf not i�tnrr
oe
S IS _ E- RTIFY, Th the ividual - stem construhed t , : ��air
ed
b { - - •----- -- ................... . --- - )
,�-- '.�!!'!"'""'•'�• .......................................--•---••--------
has been installed in accordance withreprovisions of Article XI of The State Sanitary Code as des ribed_ in the
application for Disposal Works Construction Permit No-----------------l. --------- dated..__ " ...76;.--.-------.--
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 F H ALTH
No... Jt ,�_.-�..
VVIFEE--f-�_....N.�...
i� ua ua k1i QTilni# rtivall M1
Y g - t` _ /lJ. `
Permission •s hereby ranted__ ______.. .........__._._
to Construct R .pair ( )f Individual Sewage-Di o tem
at No.!!%.,.... r------- ....
Street
as shown on the a lication for Disposal Works Construction t No. .. .... . __ Dated____ ____ ______ 7 -----------
.PP P ��� --- ----�
._...
- Board of ealth '
DATE............................... .................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
_e _..na�xaee�c�.ss�mea :emz,. .avF.:aa� •;.en- i
�� �` j r�'tom• � i. +,� r. �v' �` ,k�"'