5 Title 5 Applications/Permits 1968, 2014, Inspection 2014 COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 5 North Farms Road
Florence MA
Owner's Name: Estate of Leona Day c/o Bob Day
Owner's Address: : 528 Florence Road
Florence,MA 01062
Date of Inspection: October 9,2014
Name of Inspector:(please print) Michael Lavigne
Company Name: Environmental Design,Inc.
Mailing Address: 477 River Road
Deerfield,MA 01342
Telephone Number: 413-539-1179
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector'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.
Notes and Comments
****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.
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5 North Farms Road
Florence.MA
Owner's Name: Dav Estate of Leona do Bob Day
Date of Inspection: October 9,2014
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the thilure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
exhibits 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
indieating that the tack is less than 20 years old is available.
ND explain:
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):
ND explain
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_ 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):
ND explain:
broken pipe(s)are replaced
obstruction is removed
Page 3 of It
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: S North Farms Road
Florence MA
Owner's Name: Day Estate of Leona c/o Bob Day
Date of Inspection: October 9.2014
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Bored 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)(6)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
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 t00 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the MS 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 conform
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,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 5 North Farms Road
Florence,MA
Owner's Name: Day Estate of Leona do Bob Day
Date of Inspection: October 9.2014
I). System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
N/A Static liquid level In the distribution box above outlet invert due wan overloaded or clogged SAS or
cesspool
N/A Liquid depth in cesspool is less than 6"below invert or available volume is less than X day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped—
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well.
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/A 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 aeceptable water quality analysis.(Tills system passes If the well water analysis,
performed at a DEP certified laboratory,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,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.(
No (Yes/No)The system Igjjg.1 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
BPd
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems te addition to the criteria above)
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
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.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 5 North Farms Road
Florence.MA
Owner's Name: Day Estate of Leona do Bob Day
Date of inspection: October 9,2014
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks ?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X 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? TANK IS BEING REPLACED. SEE ACCOMPANYING PHOTOS.
X 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 our
Yes No
X Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3Xb)]
Page 6 of 1I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: S North Farms Road
Florence.MA
Owner's Name: Day Estate of Leona c/o Bob Day
Date of Inspection: October 9.2014
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): unknown Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd
Number of current residents: None_
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required)
Laundry system inspected(yes or no): Yes
Seasonal use:(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no): No
Last date of occupancy: Apnroximately one Year ago
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):______gpd
Basis of design flow(seats/persons/sgft,etcj:
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): No—Tank Replaced._
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,soil absorption system
_Single cesspool
_Overflow cesspool
Prit'y
_Shared system(yes or no)(if 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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date Stalled(if(mown)and source of information:
S.A.S— 10 years_Inspector's estimate based on components/piping. Septic Tank replaced after Inspection.
Were sewage odors detected when arriving at the site(yes or no): No
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner's Name:
Date of Inspection:
5 North Farms Road
Florence,MA
Day Estate of Leona c/o Bob Day
October 9,2014
BUILDING SEWER(locate on site plan)
Depth below grade: — 12"
Materials of construction: X cast iron _40 PVC other(explain):
Distadce from private Water supply Well or suction line: TdWn Water
Comments(on condition of joints,venting,evidence of leakage,etc.): No problems noted.
SEPTIC TANK: X (locate on site plan)
Depth below grade: —9"
Material of construction: X concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confined by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10 Y'x 5 Yd x 5'
Sludge depth: none
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: mug
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: Tape
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.): A new 1500 gallon Septic Tank was installed and
inspected. The Tank has a 6"plastic intake riser and an effluent filter. It is a two-compartment model. The Tank
should be Dumped every three to five years.or as needed,and the filter should be cleaned at every vamping as a
minimum and as needed based on usage, See Accompanying Photos.
GREASE TRAP: N/A (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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage, etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner's Name:
Date of Inspection:
5 North Fame Rood
Florence.MA
Dav Estate of Leona c/o Bob Day
October 9 2014
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction:_concrete metal_fiberglass polyethylene_other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):_
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: N/A (if present must be opened)(locate on site plan)
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: N/A (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):
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 North Farms Road
Florence MA
Owner's Name: Day Estate of Leona c/o Bob Day
Date of Inspection: October 9.2014
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why: Via excavation. See Photos
Type Unknown—See Comments
_leaching pits,number:
leaching chambers,number:
leaching galleries,number
leaching trenches,number,length:
leaching fields,noather,dimensions:
overflow cesspool,number:
innovative/alter ative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.); No problems noted. The Owner's Representative recalled that
the Soil Absorption System had been upended about ten to fifteen years aeo and believed that plastic Infiltrators
may have been used As the Inspector I chose to excavate adjacent to the leaching area and reveal the segregate
The attached photos show clean dry stone and no evidence of clogging beneath the system. Like new condition.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on
It 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 or no):_
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: N/A (locate on she plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Properly Address: S North Farms Rend
Florence.MA
Owner's Name Ott Estate of l eons Go Bob Do
Date of Irapeetfoo: October 9.2014
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 Poet.Locate when public water supply eaten the building.
Page 11 of II
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 5 North Farms Road
Florence,MA
Owner's Name: Day Estate of Leona do Bob Day
Date of Inspection: October 9.2014
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water > 10 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
X 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
S.A.S.sits atop hill(ten to twenty feet above a ravine/swak)in dry sandy soils.
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•vCCJ T /%?y
No. THE COMMONWEALTH OF MASSACHUSETTS
� IBOARD OF HEALTH
�`PY OF
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct ( ) Repair i ) Upgrade O Abandon ( ) - -Complete System Jlndividual Components
Type of Building: A\}}a� \ o x_d % POI... P Lot Size Sq.feel
Dwelling—No.of Beth-Cobs- S l Garbage Grinder WO
)ther—Type of Building No.of persons lQ Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required)
Plan: Date
Title
pd Calcula
Nu er of s -ets
design Flow gpd Design flow provided
Desc
nofSoil(s)
valuator Form No.
art
Dale
Na - of Soil Evaluator to of Evaluation
DESCRIPTION OF REPAIRS OR . ITERATIONS CAP • • a
_. _ /nWi nAt
At
The undersi
PITU5and fu
Inspections
a..
agrees to install the above described Individual Sewage Dispos I System in accordance with the provisions of
g not to play�system in operation until a Certificate of Compliance has been issued by the Board of Health.
I,G� j itfre /447/
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
ect
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ep
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r,r�honc<
Type of Building: A\}}a� \ o x_d % POI... P Lot Size Sq.feel
Dwelling—No.of Beth-Cobs- S l Garbage Grinder WO
)ther—Type of Building No.of persons lQ Showers ( ), Cafeteria ( )
Other fixtures
Design Flow(min.required)
Plan: Date
Title
pd Calcula
Nu er of s -ets
design Flow gpd Design flow provided
Desc
nofSoil(s)
valuator Form No.
art
Dale
Na - of Soil Evaluator to of Evaluation
DESCRIPTION OF REPAIRS OR . ITERATIONS CAP • • a
_. _ /nWi nAt
At
The undersi
PITU5and fu
Inspections
a..
agrees to install the above described Individual Sewage Dispos I System in accordance with the provisions of
g not to play�system in operation until a Certificate of Compliance has been issued by the Board of Health.
I,G� j itfre /447/
FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96
ect
No.
THE COMMONWEALTH OF MASSACHUSETTS Fir
BOARD OF HEALTH
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded( ),Abandoned( )
at
has been installed in accordance with the provisions of 310 CMR 15.00 (Title 5) and the approved design plans/as-built
plans relating to application No. dated . Approved Design Flow (gpd)
Installer
Designer:
Inspector Date
The issuance of this certificate shall not be construed as a guarantee that the system will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96
No. . a- � THE COMMONWEALTH OF MASSACHUSETTS FEE
/;,. 17./l' BOARD OF HEALTH
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to Co9struct ) Repair ( ;) Upgrade ( ) Abandon ( ) an individual sewage
disposal system at ;l.C:// n u <: _ as described
in the application for Disposal System Construction Permit No✓ „11 dated
Provided: Constyuctiorhall be completed within three years of the date of this permit.All local conditions must be met.
Date Board of Health
FORM 2 - DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) ()HAW Hoess6 WARREN TM
PUBLISHERS - BOSTON
CHECK OR FILL IN WHERE APPLICABLE
FEE..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Applirttfinn for Dispnsttl nrks fknnsfrnrfinn 1 rrmif
Application is hereby made for a Permit to Construct (Z) or Repair ( ) an Individual Sewage Disposal
System at:
_ Location•Address
Owner
or Let No.
Address
Itetaller Address
Type of Building Size Lot Sq. feet
Dwelling—No. of Bedrooms Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons Showers ( ) — Cafeteria ( )
Other fixtures
Design Flow gallons per person per day. Total daily flow gallons.
Septic Tank—Liquid capacity gallons Length Width Diameter Depth
Disposal Trench—No. Width Total Length Total leaching area sq. ft.
Seepage Pit No Diameter Depth below inlet Total leaching area sq. ft.
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
Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water
Description of Soil
Nature of Repairs or Alterations—Answer when applicable.._
6 r l
r
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 the following reasons
Permit No - t
Issued
Date
nste
Dade
Date
by
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�f I
1' of
O rrtifirate of fQnmplisttrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
(41
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 >J%_E dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. _
DATE f ..,,L x- `' /"/-6.�. Inspector....-..::p e
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF -
Disposal csnrks Qtnnstrixrtinn firrmit
Permission is hereby granted._
to Construct ( ) or Repair (.Ian Individuat,Sewage Disposal System
at No
No
FEE
Street
as shown on the application for Disposal Works Construction Permit No - Dated
Board of Health
DATE
FORM 1255 HOBBS & WARREN. INC_ PUBLISHERS