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91 Title 5 Application/Permits 1962, Inspection 2009 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name information is required for every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. page. City/Town State Zip Code Date of Inspection Important:When filling out forms on the computer, use only the tab key to move your cursor-do not use the return key. LK Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: DOMINIC TORRETTI Name of Inspector CLEAN SEPTICS P 0 BOX 394 Company Name 252 WEST STREET Company Address LUDLOW MASS. City/Town State 413 583 2138 SI4025 Telephone Number license Number 01069 Zip Code B. Certification 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 the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority SEPTEMBER 1, 2009 Ir�pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ulna•09108 Tee 5 Official Inspection Form Subsurface Sewage Disposal System.Page 1 W 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name Iequirei o is every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 p agge.e. d tor page. City/Town State Zip Code Date of Inspection thins•09109 B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: PUMP SEPTIC TANK EVERY ONE TO THREE YEARS, ADD CCLS BACTERIA ONCE A MONTH 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. Check the box for"yes", "no" or not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Title S Official Inspection Form Subsurface Savage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name required tD is every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page- page. City/Town State Zip Code Date of Inspection tsms•ow08 B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y E N E ND (Explain below): ❑ obstruction is removed E V E N S ND (Explain below): ❑ distribution box is leveled or replaced E V E N ❑ ND (Explain below): ❑ The system required pumping more than 4 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 E V E N S ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 public health, safety or 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 public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form subsurface Sewage Disposal System.Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name information is required for every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 __--- page. City/Town State Zip Code Date of Inspection o'ins-tyros B. Certification (cont.) 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, safety and 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 SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: .' This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to 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 El ® 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 %day flow Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Page 4 N 17 Owner information is required for every page. isms.09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owners Name NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Z ❑ Z ❑ Z ❑ Z ❑ Z ❑ Z ❑ Z ❑ Z 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 SAS, cesspool or privy is below high ground water elevation. Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or no to each of the following, in addition to the questions in Section D. 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 I I of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form.Subsurface Sewage Disposal System.Pages or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owners Name information is NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. for every page. City/Town State Zip Code Date of Inspection is woe C. Checklist Check if the following have been done. You must indicate yes" or"no" as to each of the following: Yes No ® IN Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? IN ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? • ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field Of any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design). 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3 330GPD Tina 5 Official Inspecton Form.subsurface Sewage Disposal System•Page 6 of 11 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name required for is NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. for every page. City/Town State Zip Code Date of Inspection mns•09/08 D. System Information Description: Number of current residents: Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes Z No Water meter readings, if available (last 2 years usage (gpd)): N NI/A A WATER Detail: N/A 2 Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non-sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes Z No PRESENT Date Gallons per day(gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No Tdle 5 Official In Yon Form Subsurface Sew age Disposal Syslem Page]an Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owners Name information is required for every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Other(describe below): Date Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) Of yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract General Information PUMPED OCTOBER 10, 2007 gallons ❑ Tight tank. Attach a copy of the DEP approval. Other(describe): SEPTIC TANK, LEACHING PIT thins•OWN Tills 5 Official Inspection roam:Subsurface Sewage Disposal System.Page a of n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owners Name information is required quired for every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. City/Town State Zip Code Date of Inspection thins•09/08 D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: APPROXIMATELY 45 YEARS OLD, INSTALLED IN AUGUST 1962 Were sewage odors detected when arriving at the site? Building Sewer(locate on site plan): Depth below grade: Material of construction: ® cast iron ❑ 40 PVC El other(explain): Distance from private water supply well or suction line: ❑ Yes ® No feet feet Comments(on condition of joints, venting, evidence of leakage, etc.): JOINTS AND VENTING OK, NO LEAKAGE Septic Tank(locate on site plan): Depth below grade: Material of construction: ®concrete feet ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No L 9'X W 5'X H 5' Dimensions: Sludge depth: Title S Official Inspection Fanm.Subsurface Sewage Disposal System.Page 9 m 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name information is reequired quired for every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? 1" MEASURED Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): PUMP TANK EVERY ONE -THREE YEARS. INLET AND OUTLET BAFFLE OK. TANK IS STRUCTURALLY SOUND, LIQUID LEVELS ARE AT OUTLET INVERT, NO LEAKAGE Grease Trap(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal feet ❑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: Date tslns.09108 age 5°Metal Inspection Form:Subsurface Sewage olspoeal System•Page 10 or 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner's Name NORTHHAMPTON City/Town MASS. 01060 SEPTEMBER 1, 2009 State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: Date of last pumping: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No thins.0&09 Tills 5 Official Inspection Form Subsurface Sewage Disposal System .Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owners Name NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 City/Town State Zip Code Date of Inspection D. System Information (coot.) Distribution Box(if present must be opened) (locate on site plan): NO D-BOX Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: Alarms in working order: ❑ Yes ❑ No ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: I5IM•09/00 Title 5 Official mspediw Form.Subsurface Sewage Disposal System.Page 12 of 17 Owner information is required for every page. 1sns.09/08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner's Name NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ❑ leaching fields ❑ overflow cesspool ❑ innovative/alternative system number: number: number: number, length: number, dimensions: number: Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SOIL AND VEGETATION ARE OK, NO SIGNS OF HYDRAULIC FAILURE, NO PONDING Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No Tile 5 Official Inspectpon Form Subsurface Sewage Disposal System.Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name Iequiredifn is for every NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. page. City/Town State Zip Code Date of Inspection um,•psme D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(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.): Mlle 5 Difnal Inspection Form Subsurface Sewage Disposal Syslem•Pape 1a of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Awner Owners Name nformation is required for every MASS. SEPTEMBER, 2009 page. City/Town State Zip Code Cate of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 7240,4 bn N Lco,cin P, F(mr„a c‘ctr a ls.ns.09108 In k+ \\bFL\\ c, C' yy Nlrrrn(on.cr'(C'S ( .) CLrr,infer Tile s omuai Inspection Form Subsurface Sewage Disposal System•Page 15 o.17 xI Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name required fo information is NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: NONE @ 6' feet Please indicate all methods used to determine the high ground water elevation: • Obtained from system design plans on record If checked, date of design plan reviewed: AUGUST 1962 Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health- explain ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Before filing this Inspection Report, please see Report Completeness Checklist on next page. sins.WIW title 5 Official Inspechon Form.Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 91 MOUNTAIN RD Property Address NORMAN ROBERTS Owner Owner's Name information is NORTHHAMPTON MASS. 01060 SEPTEMBER 1, 2009 page. for every page. City/Town State Zip Code Date of Inspection Isms•09108 E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked • Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form Subsurface Sewepe Disposal System•Page 17 of 17 x4 a Installer Address Type of Building Size Lot . C d G Sq. feet Dwelling—No. of Bedrooms `3 Expansion Attic ( ) Garbage Grinder ( ) 1, Other—Type of Building No. of persons Showers ( ) — Cafeteria ( ) t' Other fixtures 2 Design Flow ,T._. -gallons per person per day. Total daily flow gallons. X Septic Tank—Liquid capacity gallons Length Width Diameter Depth Z Disposal Trench—Np. Width Total Length Total leaching arm. sq. ft. Seepage Pit No F Diameter Depth below inlet Total leaching area sq. ft. ti Other Distribution box ( ) Dosing 44.4.4. }f Percolation Test Results Performed by d✓1 Date. tiTest Pit No. 1 minutes per inch Depth of Test Pit Depth to ground water A Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water D Description of Soil 4 4 Z Nature of Repairs or Alterations—Answer when applicable No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF 4 Application for 1@ispooal 1;1 arks kionotrttttiori Pantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: la nnmieaders Ci . or Lee No. Omer ♦ Address 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 has been issued by the board of health. Signed Application Approved By Application Disapproved for 11w following reasons. Permit No Dale Issued Date by at has been installed in accordance with the provisions of Article X1 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 WILS FUNCTIQN SATISFACTORY. DATE • '" Inspector m�� - 'r ? /% X-!i * is s-dr/ No THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1.,. E. Mertifirate at CninpHanre THIS IS TO CERTIFY, That:the Ipdiv4ual Sewage Disposal System constructed e) or Repaired ( ) 1 ; Installer ;3 THE COMMONWEALTH OF MASSACHUSETTS 4 BOARR OF }-IEALT}}H- e i OF r. d. Disposal i:i nrk.ij-(tonptrnrtinn Devout FHE Permissio9A(hereby granted ` to Construe ) or'Ittre stir j ap,Indlvidual Sewage Disposal System at No / street / /as shown on the application for Disposal Works Construction Pernik No / 3 .... Dated ? 71 t DATE t . FORM 1255 HOBBS & WARREN INC.. PUBLISHERS Hoard of Health C