HomeMy WebLinkAbout0100 WINGFOOT DRIVE - Health 100 WINGFOOT DRIVE, BARNSTABLE
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F�i cutfve Office of Environmental Affairs
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Environmental Protection ' G + �
WHIla F.Weld Trudy
Argoo Paul Cellucci Divid, .a$truuh ,+
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0 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Proportypddre.a: 100 Wingfoot Drive Cummaquid Mass Address of Owner.
Date of Inspootlon:8/3 0/96 (If different)
NarneofInspector, Joseph P.Macomber Jr.
Company Nance,Address and Telephone Number.
J.P.Macomber & Son Inc. Box 66 Centerville,Mass . 02632-0066 508-775-3338
CERTIFICATION STATEMENT
I certify that I have par;c._Il �1.o 44wage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspoction was performed based on nay training and experience in the proper function and
n.aintenalica c:GY'.•'w/ .,..;.;,:. The system:
_ Needs Further Evaluation By the Local Approving Authority
._._ Fails
Inspector's 9lgnature: L ���/�/�2'(� i Data:
The System Inspector&hall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. It the system is a shared system or has a de.Agn 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:
Check A, B, C, or D:
A) SYSTEM PASSES:
I have not found any viw::h iadicntcs that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated wi indicated•below.
II) SYSTEM CONDITIONALLY P,%SSES:
N� One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,pas-en
inspection.
Indicate 780,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,cracked,structurally unsound, shows substantial inilltratioa or"riiltration,-or tank failure is
imminent. The system will pats inspection if the existing septic tank is replaced with a poaforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street 0 Boe!:::,: •r;.soachuse#U 02108 0 FAX(617)556-1049 a Telephone(617)292.SSW
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (oontinued)
Property Address: Lucy McCarthy
Owner. 100 Wingfoot Drive Cummaquid,Mass .
Date of Inspection: $/3 0/9 6
B)SYSTEM CONDITIONALLY PASSES (continued)
A& Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pips(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
Q� The system required pumping more than four tiro^,i a year due to broken or obstructed pipe(a). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
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 enviroturent.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
1L� Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feat of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMEN'C:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water sup
ply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for ooliform 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 6 ppm.
3) OTHER'
(revised 11/03/95) 2
. o
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
PropertyAddresa: 100 Winggfoot Drive Cummaquid,Mass .
Owner. Lucy McCart.Iy
Date of Inspection:8/3 0/9 6
D) SYSTEM FAILS:
e
I have determined that the system violates one or more of the following failure criteria as defined 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. _
Aed Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Q((J Discharge or ponding of effluent to the surface orW ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level ivtha distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in•eesspoolo-U 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
&LO 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 60 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 60 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.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
�d
The system serves a,tacility with a design flow of 10,000 gpd or greater(Large System)and the system is a siguificaat threat to public
health and safety and the environment because one or more of the following conditions exist:
the system is within 400 foot 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 nhrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone 13 of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for Author Information..
(revised.11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 100 Wingfoot Drive Cummaquid,Mass .
Owner. . Lucy McCarthy
Date of IaspeotIon: g/3 0/9 6 •
Check if the following have been done:
,,Pumping information was requested of th owner - pant,and Board of Health.
Y—INone of the system components have been pumped for at least two weeks and the system has been receiving normal now rates
during that period Large volumes of water have not been introduced into the system recently or as part of this inspection.
e, Ao 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.
LThe system does not receive non-sanitary or industrial waste flow
The site was inspected for signs of breakout.
1' All system components, fea�cluding the Soil Absorption System, have been located on the site.
V The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected for condition of banes or
tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.
ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
2The 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 6EWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PropertyAdd,,:6:.: 100 Wingfoot Drive Cummaquid,Mass .
Owner. Lucy McCarthy
Date of IaepocUou: 8/30/96
FLOW CONDITIONS
RESIDENTULI
Design flow:-. i aallona Pere; '
Number of bedrooms: '�✓
Number of current residents: j
Garbage grinder(yes or no): �'S
Laundry connected to system(yes or no):/—
Seeaoaal use(yes or no):
Water meter readings, if available: Iagw!=
Last date of occupancy: � -1-1�6
COMM ERCIAL/INDUSTR�IAL
Type of establishment: A -:
Design flow:-ka-gallons/day ''//��
Grease trap present: (yea or nokao
Industrial Waste Holding Tank present: (yea or.noj)h
Non-sanitary waste discharged to the Title 5 system: tyes or no)�14
Water meter readings, if available: ID A
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy: Iv
GENERAL INFORMATION
PUMPINGf ORDS ac d source of orniation: (�
System pumped as part of inspection: (yes or ro)&P
If yes, volume pumped: -- 6�otts
Reason for puulping
T7EYSTEM '
Septic taulddistribution box/soil abcorp.ion iysteiu
Single
Ovtr2,)w, cvx:.y�l
Privy
)Shared system(yes or no) (if yes, attach previous inspection records, it any)
A2_ Other(explain)
APeR,O�XIM�ATE AGE of all components, date in.:tLLE,,i (if known) and source of information: PiQ�s�
Sewage odors detected when arriving at the site: cyeu or no)
(revised 11/03/95) 6
-CAC% DiSi'OSAL SYSTIM INSPECTION FORM
PART C
(continued)
Property Address: 100 Wingfoot Drive Cummaquid,Mass .
Owner: Lucy McCarthy
Date of Inspection: 8/30/96
SEPTIC TANK-
(locate on site plan)
Depth below grade:
Material of construction: concrete _metal _FRP _ o::.•,:.c..;i ,:i
Dimensions:_. i
Sludge depth: L
Distance from to�gt fludge to bottom of outlet tee or
Scum thickness:_ �Y
Distance from top of scum to top of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baffle._ZZOC�
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffle depth of_liollid
Ted IPvel i nel let i
`� � ��out u r I
s,t
,rity, evidence of leakage, etc.) Pum septic tank every ne
Tisf ; eepplAce;Water lave ou _invert , is an
�atplutilrslll,aniin(3 ;The se�tj t ank sh _w-s no ins of leakaze.—
NQ ,-ap ir-S e needed at. the -prP_s_ent. time, Pump tank annua .
Garbage disposal present.
GREASE TRAP.ti),-jUe
(locate on site pian)
Depth below grade:�j►!
Material of constnjrtion;10/ oncrete _metal _FRP _o[hvf(L:xplain)
Dimensions--
Scum thickness:__ T—
Distance from top Ul scum to top of outlet tee or bafile:._l�r'1i
Distance from bottom ni trom v, honorr of ouiiel lei
Comments:
(recommendation for pumping, condi—ri of inlet and outlet te,2s or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage,
(revised 8115195) U
f .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddresw 100 Wingfoot Drive Cummaquid,Mass .
Owner. Lucy McCarthy
Date of Inspection: g/3 0/9 6
TIGHT OR HOLDING TANkQ"451C
(locate on site plan) •
Depth below grade: 2
Material of oonstructiow: ' ncrete_metal_FRP—other(explain) -
el/�
Dimensions: k//
Capacity: ns
Design IIow: &e aallons/day
Alarm level:_
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX-Je
(locate on site plan)
Depth of liquid level above outlet invert: A0
Comments:
(tc� T ;r � b
o su a offslcsi eve�; oev carryoverNo evidence o
ea age in or out, o e ox, no repairs neeaecL at the present time
PUMP CHAMBER:j/&t,
(locate on site plan)
Pumps in working orden(yes or no) L4,
Comments:
(note condition of pump chamber,condition of pumps and appurtenances, etc.)
. (revised 11/03/95) 7
,.,SUIU'ACE SEWAGE:DISPOSAL SYSTEM INSPECTION i'w%:'A
PART C
SYSTEM INFORMATION (continued)
100 Wingfoot Drive Cummaqu id,Mass .
Owner. Lucy McCarthy
Data of 8/30/96
SOIL ABSORPTION SYSTEM (SAS):ledO l it U61- a e C4 s 7 A�T e k7' ACAS 1,4) s7o, �
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
v
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: �—
overilow oesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level o! nding,condition of vegetation,etc.)
Medium Sand•No signs of Hydraulic failure or ondin vege a io
_is normal, No Repairs needed at the present time.
CESSPOOLS:�'(Ie
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: A214, _
Depth of solids layer:_ A,
Depth of scum layer: A,A
Dimensions of mupool: 0
Materials of construct:on: V4
Indication olgro",dwuur: Ally
inflow(cesspool must be pumped as part of inspection)
Co n : (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.)
PRIVY: �/'L'Q
(locate on site plan)
Materials of construction: ,01 i/9 Dimensions:
Depth of solids:
Ce ts:�" lail condition of soil, signs of hydraulic ure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
8VUSURYACE SEWAGE DISPOSAL SYSTEM INSPECTION ,FORM
PART B
SYSTEM INFORMATION continued
`-' SKETCH OF SEWAGE L'SPOSAL SYSTEM:
include ties to at least two permanent references landmarks. or benchmarks .
loca*te all wells within 100 '
Barnstable Water Company
362-6498 ,
DEPTH TO GROUNDWATER
'16:1 + depth to groundwater
p!:ktbod of. determinq;lon or approxim,atiw;
ZIA- Wet*
_ No water encountered when system installed Plan
-= on .file Barnstable Board Of Health.
,dss 1��C
THE COMMONWEALTH OF MASSACHUSETTS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
BE IT KNOWN THAT
Joseph P. Macomber, Jr.
Has satisfied the Departments qualifications as required and is hereby
authorized to use the title
CERTIFIED TITLE 5 SYSTEM INSPECTOR
as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of tre
General Laws. Issued by The Department of Environmental Protectica.
June 8, 1995
Acting Director of the ion of Water Pollution Cc ntrol
b
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Y•R.t1 TIt�Rt•T'S�TT^1:•R:JST!'RTTTrTT.T'dTT.TT:•.'t!i•T:'TfifT:STlTRT TfT�tTi T'+i YTCT.R:1 •. •��41
'DOWN OF Barnstable BOARD OF HEALTH J
SOBSURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I
F•••ar•t^r••.-:: --.rrr.^.--ri:nrm•n:.snrs+rmsnr�•mrr.�•r-�trs�-s:mrrar'r+t•n*+erar nrmnarsesttrnrs ri<ntn
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 100 Wingfoot Drive Cummaquid,Mass.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME Lucy McCarthy
PART D - CERTIFICATION
NAME OF INSPECTOR Joseph P. Macomber. JR..
COMPANY NAME J.P.Macomber & Svfi'Inc. . . .
COMPANY ADDRESS Box 66 Centerville ,Mass . 02632.
Street Town or City Stat• LIp
COMPANY ELEP110NE ( 50 ) '_725 3338 FAX ( 790 1 1578 508
tria'essnamrtt+rn �9�a� as
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal, system at
this address and that the information reported is true, accurate, and
complete as of the time of -inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
• u i Ur its 1,
Check one: '
'XXXXXXXXX Systeui PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
hea1Lh or tile. environment as defined in 310 CMR 15 , 303 , Any failtire
criteria not evaluated areas stated in the FAILURE CRITERIA section of
this form .
System FAILED*
The inspection w11ic1t I have conducted has found that the system fails to
Protect the public health and the environment in accordance with Title
6 , 310 CMR 15 , 303, and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form .
Inspector Signatur ✓�" - Date 9/3/96
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF I1EAL1'I1.
* If the inspection FAILED, the owner or"" perator shall u d
he
within o'ne year of the date .of the inspection, unless allowed ortrequi,redm
otherwise as provided in 3.10 CMR 16 . 305 .
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TOWN OF BARNSTABLE
LOCATION iC,b` .P/�/�dT •�!^!!%G� SEWAGE#
VILLAGE <j�t�lr4�A�� �✓��� ASSESSOR'S MAP & LOT
'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACEITY: (type) i �'.�} (size) t0on oaf.
NO.OF BEDROOMS
BUILDER OR OWNER J&4t - !
+ DATE: "�� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist r'
within 300 feet of leachin acilyt�) Feet
Furnished by ��
I�, j
\ �.� \ j� I
... . '\ �
\ l
\ ��
No.......Y........ ^ „ FEs...r. ..... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ®E HEALTH
Appfirati n for Disposal Morks Tons union Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Indivviijdual Sewage Disposal
Syst at: _ 1 o
�j ...... _ _......_ .... - ess . .. --•
L cai . ... . �.
t d .. of No.
.. F ....._.... .. ........................ ........................................... ..........................._..._..............
... .... .. __ ..... _ _-.. ........
Jw er Address
W / .._.,................................ ..•............................ ••-•-••-•........_.............._....•---
a
� staller Address
Type of Building/ Size Lot............................Sq. feet
U Dwelling No. of Bedrooms................. ........:................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons......................... Showers Cafeteria
Pa Other fixtures ........................
--------------------------------------------------------------•----- ------•--•-••-•-
_ Design Flow. ............ ��..____-.___ allons per person per day. Total daily flow............ -----_•••-••---•----•-_--gallons.
W' Septic Tank Liquid capacity
v gallons Length Width Diameter Depth
Disposal Trench—N _ ____________________ Wid t ._...___._.._._.___. al 1�(
1 1 Ching area....._..._..___..___sq. ft.
Seepage Pit No. Diameter_ ep 1 b ---•- - leachin ar sq. ft.
ri u ion box Dosin ank — D -
Z Other Dist b t ( ) g ( ) � " *�' y
Percolation Test Results Performed bY.......................................................................... D te_...............---••-•---•-•---....----
aTest Pit No. 1................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.....................
.. . .....•' ./.......L......... '_ ..
i�
O Description of Soil-.-q- ---- -
x
U
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 Article XI of the State Sanitary Code— The undersigned further gees not to place the system in
operation until a Certificate of Compliance has been issued by the boar . f health.
>gned......... ....... ......... .............. ..................
•-••••• ................................
• D to
Application Approved By.......... ..•• ---•••---.... �
Date
Application Disapproved for {ie following reasons:----•-•-----------------------------------•••--- ...........................................................
• ......................•-•----••••-----•••--•-•-•--•-•-•••-•••-••--•••-•••-••••---•-•--•..._......••••--•-•••••-•--••-•-•---•••....---••--------••-•------•......---•-•.................................
Date
PermitNo......................................................... Issued........................................................
Date
1 �h
No..... ......... _............._
THE:COMMONWEALTH OF MASSACHUSETTS
BOARD, 09 HEALTH
- -- ....OF.......... :... :. *-
Avvfir�f vtt for 43hip t ial Works Tomitrurfint rumit
Application is hereby made for a Permi to Construct,,.( ) or Repair (" ), an Individual Sewage Disposal
Syst at
catioµ- ess ,...+ t No. tx._,�.......... ............. .............•... ....................... _......_........... ......_ ........
. w er Address
W
a ......... '
Installer Address
Type of,.Bulldi Size Lot----- feet
}
aDwelling A No. of Bedrooms.......:........: ...............:........Expansion Attic .( ) Garbage Grinder ( )
aOther=Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtu es Y ------------------------------------------------------
77
Design Flow.::....:..... .. . . .. allons per person per day. Total daily flow._.......... ... gallons.
W --•-- - -
WSeptic Tank Liquid capacit __gallons Length............... Width................ Diame r................ Depth................
x. ... P W id ching area---- --.sq. ft.
Disposal Trench-N
{'� To leYte
ar .......s ft.;
Seepage Pit No...... ____...,. Diameter :_ ept b n t. q.
Z Other Distribution box ( ) Dosing ank
Percolation Test Results Performed by: .............................-'------.
Test Pit No. 1................minutes per inch- Depth of Test Pit.................... Depth to ground water..........................
rX, Test Pit No. 2..__.. .minutes per inch Depth of Test Pit .. Depth to ground water ____
f
O Description of Soil.... --. .....e .!! '
U -------- ----------------------- ----'--'---......-•--•----...--•-----•-.---
----------------•--- , , ------------•-----------------.......------------------------------------......----------•-----------------------------------........------
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 4rees not to place the system in
operation until a Certificate of Compliance has been i ued by the.boa f hea th.
igned....... •. ..
�,,r*
Application Approved BY------• ...._-- ---- rQ�! 'Z-= }--1+------ -
Date
Application Disapproved for he following reasons----------------------------------------------•-----•-----------•-------------------.....---....-----------......
.........................••--------------.......---------------------------------........-------•,---------•--•-••----'----'---•----'-------••------.
Date
Permit No. Issued.. f r-'--•...••.....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 09 HEALTH 0
^e
,..°..,. ......:.OF........ ...........
JACIr
wrr#if iratr of Tompliana
TH IS TO CERTIFY . hat the di ual Sewage Di o al Sy constructed ( ) or Repaired ( )
.. '-by >yL' ...ti-.
- r
ry - ! ! Instialler
of - - -----------------•----.. f�.zit
. ....... -- •-•-----•-----------
his been installed in accordance the provisions of Article X of he State Sanitar Code descr ed in the
application for Disposal Works Construction Permit No.............. 7 ._ _ --%
-- --•----------•--- dated---, _..._._.. ----
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY...-,
tt t 1 f t,{ i..i YJ_ 'b'h3 +P•t�rx.t..
♦h. JYrt .
r DATE -� r Inspector ,
y, >i•-v � -�ra ; ° '� :ter •s - t 1�
r :}? F f t w t
THE COMMONWEALTH -OF MASSACHUSETTS
BOARD' OF HEALTH -.'W'
2•., ...........................
f `
OF........... --
No...----'- ,v
Tea sir rrntii
Permission 's hereby granted...:._: ...
.. ..
to Con str ) or Repair ( ) an Ind> dual a Disposal Sy
at No. X, -�.. tom/ 14"� ...G .r ""! #•--
1 Strr
as shown on the application for Disposal Works Construction P it o._-- . _... Dated_...... ...... .... ...
;r
oard of Health
DATE... �...,r.�............................. ..........
FCRM 1255 HOBBS & WARREN.;INC.. PUBLISHERS -
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