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505 Title 5 Aplications/Permits 1966, 2010 Inspection Reports 2010, Conservation Commission Permit Important:When filling out forms on the computer, use only the tab key to move your cursor-do not use the retum key. Commonwealth of Massachusetts City/Town of Percolation Test Form 12 Percolation test results must be submitted with the Soil Suitability Assessment for On-site Sewage Disposal. DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with the local Board of Health to determine the form they use. A. Site Information Owner Name Street Address or Lot# City/Town State Zip Code Contact Person Of different from Owner) Telephone Number B. Test Results Observation Hole# Depth of Perc Start Pre-Soak End Pre-Soak Time at 12" Time at 9" Time at 6" Time(9"-6") Rate(Min./Inch) Test Performed By: Witnessed By: Comments: t5fomi12.doc•06/03 Date Time Date Time 4 SS _sa Si 0 I0 ' 9 el I D D fin., Test Passed: ( Test Passed: ❑ Test Failed: ❑ Test Failed: ❑ fin :- rip l Perc Test•Page 1 of 1 Commonwealth of Massachusetts vLti,. City/Town of Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (continued) Deep Observation Hole Number: — I - -Z -- - Redoximorphic Features Coarse Fragments Soil Horizon/Soil Matrix:Color- (mottles) Soil Texture %by Volume Soil Soil Depth(in.) Layer Moist(Munsell) (USDA) Cobbles& Structure Consistence Other Depth Color Percent Gravel (Moist) Stones — 1 9,9 (,o9 � '� v- \-;0 ) 7y LS -3\ I Lo dov e,77 vRoi) curd @ Stp Additional Notes: QQr C CS'1 , yct,u1_ �6 1 . (>\ ).D 6C i\j\1A1Lr " Ir r. DEP form 11 •rev. 1/10 Form 11 -Soil Suitability Assessment for On-Site Sewage Disposal •Page 3 of 8 i 10 t5: FORM 3A - CERTIFICATE OF COMPLIANCE Fee COMMONWEALTH OF MASSACHUSETTS Board of Health, Nor-I-Innke.-. , MA. CERTIFICATE OF COMPLIANCE Description of Work: Sindividual Component(s) ❑ Complete System The undersigned hereby certify That Pie Sewage Disposal System, ct Construed O, Repaired / ), Upgraded /Abandoned ( ) by: Clod/Acts EkCagvq vlq at: 505 Nor+L i0.rocks Rocket has been installed in accordance with the provisions of 310 CAR 15.00 (Tide 5) and the approved design plans/as-built plans relating to application No. dated II 10 Zo 0 Approved Design FIowS7$ (gpd) Installer Designer Date 0/!9/2oli The issuance of this p c rntit shall not be construed as a guarantee that the system will function as designed. inspector — Firl is11E4 3r4eiiin9 ✓lo*f Crimple-kJ 4+ Afvne_ oC inspec.-Hog■ Sep iC_JFe tk Shoulcl be puo"reci every +krce, years an r1er 5�tou11,1 be elleanee, Avnvoetl1y L Avoid -TlasNin9 po cler efe-Ter,en•45 and. 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Y 1 " ` A i k y4 ,d ° -'" '.fir 0 1 v 3-05 /(/o(tJ %� T S ,COJ Commonwealth of Massachusetts U fi City/Town of Septic System Installation Checklist B. Application Checklist (cont.) 2. Construction Inspection a) Building Sewer(310 CMR 15.222) Approved N/A Problem All waste pipes tied into building sewer Basement check li ❑ ❑ Schedule 40 PVC 4" or cast iron Verify by reading pipe 07 ❑ ❑ Minimum slope of 0.01-0.02 Visual [- ❑ ❑ Pipe laid in continuous straight line Visual Lr ❑ ❑ Pipe laid on compact, firm base Visual [� ❑ ❑ Cleanouts precede all changes in alignment/grade Verify by visual/tape ❑ ❑ ❑ Cleanout provided every 100 ft. Verify by visual/tape ❑ ❑ ❑ Backfill material clean Viisual J [/ ❑ ill b) Septic Tank(310 CMR 15 223) (e)„„4.-7 h.-If Approved N/A Problem Tank is set level with 6°stone under (15.228) Check with level ❑ ❑ ❑ Tank is required size/loading per plan Verify with plan ❑ ❑ ❑ Inlet and outlet are at proper location (15.227) Verify with plan ❑ ❑ ❑ Tank is water tight(15.226) Test ❑/ ❑ ❑ Outlet tees extend 6°above flow line Verify by visual/tape [�" ❑ ❑ Approved filter device placed at outlet DEP list ❑ ❑ Gas baffle installed at outlet tee Visual ❑ ❑ Inlet and outlet tees on center line Visual ❑ ❑ Tank is backfilled with acceptable material Visual ❑ ❑ ❑ Notes: / /- / /'es Septic System Installation Checklist 11-09.doc•date Form Name•Page 2 of 6 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cont.) c) Distribution Box(310 CMR 15.232) Approved N/A Problem All outlet pipes at same elevation Check by adding water �y [11 ❑ Number of outlets , / Number of laterals Z per plan per plan Inlet tee min. 1"over outlet Visual and w/tape Er ❑ ❑ D box set on level base Visual [�/ ❑ ❑ Top of D box 36°max depth Visual and w/tape �y'/ ❑ ❑ D box is water-tight Add water ky' ❑ ❑ 0 box has a minimum of 2°thick wall and ,--,/ ❑ ❑ 12°inside dimension 4� d) Pump Chamber(310 CMR 15.231) vf/A Approved N/A Problem Tank is set level Visual and w/level ❑ ❑ Proper volume is provided Check plan and tank ❑ ❑ Float elevations set per plan Measure w/tape ❑ ❑ Min. 2°delivery line to D box Visual ❑ ❑ Number of pumps: ❑ ❑ Specified pump provided or designers ❑ ❑ approval for equal pump Correct pump sequence ❑ ❑ Covers set to grade ❑ ❑ ❑ Electrical permit provided ❑ ❑ ❑ 6°of stone beneath chamber Visual ❑ ❑ ❑ Chamber is water-tight Test ❑ ❑ ❑ Min. 9°cover provided Visual ❑ ,❑0 ❑ / Correct loading provided per plan Visual on tank ❑ t� ❑ Notes: Septic System Installation Checklist 11-09.doc•date Form Name•Page 3 of 6 A Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist (cont.) GO-F/0 $'5�� e) Leaching Facility(310 CMR 15.240) (� (/-- Approved N/A Problem No frozen material used including back fill Visual ❑ ❑ No clay,tailings or stones larger than 6'for . ❑ ❑ cover material Soil at bottom/sides of excavation matches ❑ ❑ info on deep holes —/ All impervious layers removed Visual ❑ ❑ No remaining NB horizons Visual Er- ❑ ❑ Groundwater conditions match plan and Visual/check plan ❑ ❑ deep holes Vented if under impervious cover per plan ❑ ❑ (15.241) Vent is protected from precipitation ❑ ❑ and animal entry Cover of a minimum of 9"over leach area Et ❑ ❑ Pipe slope equal to 0.005. Check wltransit 8' ❑ ❑ Leach area per design(15.241) [a- ❑ ❑ Excavation is level and at required depth Visual/check plan ❑ ❑ Removal of 5 ft material and replacement (if in fill) Visual/check plan [} ❑ ❑ Back fill material is acceptable Visual ,[-�/ ❑ ❑ Final contours correct per plan Check with plan ❑ ❑ Surface/subsurface drainage away from EV. ❑ ❑ leach area Final grade and side slopes are stable [T� ❑ ❑ Distribution lines are capped, vented, or ❑ ❑ connected together � / Impermeable barrier(15.255[2]) t��/ ❑ ❑ Retaining wall inspected by PE ,,1444,,, ❑ ❑ Retaining wall is water-proofed ❑ ❑ Retaining wall/barrier is at correct ❑ ❑ depth/height Septic System Installation Checklist 11-09.doc•date Form Name•Page 4 of 6 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist(cont) f) Leaching trenches(310 CMR 15.251) Approved N/A Problem Number of trenches: ❑ ❑ ❑ Depth of trenches: ❑ ❑ ❑ Wdth of trenches: ❑ ❑ ❑ Trench spacing per plan ❑ ❑ ❑ Stone is double-washed[3/4"to 1 W] (15.247) ❑ ❑ ❑ g) Leaching fields (310 CMR 15.242) Length of field: V2 / ,U ❑ ❑ Width of field: 25.- Ly' ❑ ❑ Min. of 2 distribution lines ❑ ❑ Separation distance conforms to plan (�/ ❑ ❑ Stone is double-washed[3/4"to 11S] (15.247) EK ❑ ❑ F6 Leaching Pits(310 CMR 15.253) Number of pits: ❑ ❑ ❑ Depth of pits: ❑ ❑ ❑ Stone is double-washed[3/4"to 1'/a"](15.247) ❑ ❑ ❑ Each pit has min. 1 20"access cover ❑ ❑ ❑ Piping network and configuration of ❑ ❑ ❑ pits/chambers per plan i) Tight Tank(310 CMR 15.260) Tank is set level with 6"stone under Visual and with level ❑ ❑ ❑ Tank is proper size per plan Visual with plan ❑ ❑ ❑ Pumping contract has been provided ❑ ❑ ❑ Covers to grade Visual ❑ ❑ ❑ AN alarm set at 3/5 tank capacity Check floats by raising ❑ ❑ ❑ AN alarm test on separate circuit Set off alarm ❑ ❑ ❑ Septic System Installation Checklist 11-09.doc•date Form Name•Page 5 of 6 Commonwealth of Massachusetts City/Town of Septic System Installation Checklist B. Application Checklist(cont.) j) Certificate of Compliance(310 CMR 15.021) As Built Plan Submitted Signed by Installer Signed by Designer Certificate of Compliance Issued Notes: AT A IoM nr,y&sor ' Date Date X. /A ?/,✓ Septic System Installation Chen 1-09.doc•date Form Name•Page 6 of 6 Ben Wood From: Sarah LaValley Sent: Wednesday, June 08, 2011 10:11 AM To: Ben Wood Subject: RE: 505 N. Farms Road Hi Ben- No additional Conservation Commission review required. Thanks! -Sarah From. Ben Wood Sent: Wednesday, June 08, 2011 9:32 PM To: Sarah LaValley Subject: FW: 505 N. Farms Road Septic plan to sign off on..... Thanks. Ben _'O 6g gia$E23i[ic"a"sg !' 1 1`i� iii E,4 EI aPPEi Iaii 11E E pga 4• 944 p fiia;�P11 p I a�E i P ea E eP E,on1 I I E a9e 1. F€11111 E azs E4•-iIES ° ^E ° ��vN iwi gilin E R¢?sE � 6 I1'ph idl Ed3�-Ri§ P 1 1 g�pa E lagla.E °-D a ! as a 1 q sgg 5 E E4 Ea R .� - 11' i Cof dP •E ^A did F• 3 g4 `d$a: w. 6. `E 8E a ' FFCC e a PPE Ik A 6g 2 g ��41 e 191 c i 1111 iE R °a ac s1 `@ ` 5E a P % g I1ai1i IIl ill i*P EE e2 i 4 4 R d E• g ai3ib tt N E 9 ocl P' $ :Ia afi11 a '/h gi li I. L_ EE1i ip E; o lx ` g" a€ ! s3 " �i °a• E a` j P twit 1~ a s g .¢ p di g ."E E i } ghtir i 1 1s 1 a laliI4g -11i 1 E' 111 111M 1 1' lit E 111[.., 1 1 i?11' ! i __ii_ II _ __i8E __II 1 e a. �EEEE1E i I ;' :ii1P1ii r / I P g I I 113 �'s ' �/,4 1 •a,1 P3M' E69 /1 if / ' rl ' ' "11 E 1 s 1 �' /I lin E 1 Pi I• E ,' BOARD OF HEALTH DONNA C.SALLOOM,CHAIR SUZANNE SMITH,M.D. JOANNE LEVIN,M.D. Benjamin Wood,MPH,Director Javeria Mir,MPH,Health Inspector Patrida Abbott RN,Public Health Nurse Heather McBride,Clerk CITY OF NORTHAMPTON MASSACHUSETTS 01060 OFFICE OF THE BOARD OF HEALTH (413)587-1214 FAX(413)587-1221 212 MAIN STREET NORTHAMPTON,MA 01060 Onsite Septic System Construction Permit: Conservation Commission Review NOTE: As of 1/1/11, Septic System Permits will not be issued by the Northampton Board of Health until we receive this form signed by the Northampton Conservation Commission Staff Member. The Conservation Commission can be reached by contacting: 0 Sarah LaValley, Conservation, Preservation and Land Use Planner SLaValley@northamptonma.gov Office of Planning& Development 210 Main Street, Rm. 11,City Hall Northampton, MA 01060 Property Owner: W Act,— (totik Address: -9 6C N. Engineer: V"\ckt--k Conservation Commission Conservation, Preservation and Land Use Planner Date: c//' (erne": / k 1l, /Li) Massachusetts Department of Environmental Protection �— //�� ` , �/ Bureau of Resource Protection —Wastewater Permitting Program 4�S / dress o Fn+,rs pc,,, , N,,,Aci "ip(rr Form 11 - Soil Suitability Assessment for On-Site Sewage oDisposal D. Determination of High Groundwater Elevation _L 1. Method used: ❑ Depth observed standing water in observation hole A. B. C D ❑ Depth weeping from side of observation hole A. B. C D. Depth to soil redoximorphic features (mottles) A. SO rl B 74' c. D. ❑ Groundwater adjustment(USGS methodology) A B C D. 2. Index Well Number Reading Date Index Well Level Adjustment Factor Adjusted Groundwater Level E. Depth of Pervious Material 1. Depth of Naturally Occurring Pervious Material a Does at least four feet of naturallyAccurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? Yes g No❑ b. If yes. at what depth was it observed? Upper boundary. Lower boundary: F. Certification I certify that I have passed the soil evaluator examination* approved by the Department of Environmental Protection and that the above analysis was pe rmed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. J t, iy 7 Lo to HILLTOWN ENVIRONMENTAL CONSULTING 1 �,Signa ` P.O. BOX MA 'Signs re of 5011 Eva uator Date CHESTERFIELD. MA 01012 Mar Thompson (413)296-4499 Typed or Printed Name of Soil Evaluator ate of oil 1997 /� 5� 'Date of Soil Evaluator Ezam/ /-VImee. YeCI0 LV -rq frd- - Alorga1M1hi, Name of Board of Health Witnest Boaki of Health Note: This form must be submitted to the approving authority with Percolation Test Form 12 DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal• Page4of 4 I I Massachusetts Department of Environmental Protection SOS / ior-{f f �r rrn5 °°� I\/°r-/Aa ill Y9?c1n Bureau of Resource Protection—Wastewater Permitting Program Site Address or Map/Lot Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole: Date: 717/10 Time: /3 S I Weather: Shin ny 1. Deep Hole Number 2- Location (Identify on Plan )- 2. Land Use. Lot tri In Surface Stones. — Slope (%). 5 Vegetation. JCr^» to g.woodland, agricultural field.vacant lot,etc Landform. +r 1 I n iy e Position on landscape. 3 Distances from: Open Water Body /DD-f ft. Drainage Way /6075 ft_ Possible Wet Area /6&" ft. Property Line 2D ft Drinking Water Well /bp- - ft. Other ft. 4 Parent Material i ac■0A 4,i k Unsuitable Materials Present Yes 2/NoE If Yes- Disturbed SoiID Fill Material/Impervious Layer(s)❑ Weathered/Fractured Rock D Bedrock D 5 Groundwater Observed. Yes fl No L✓ If Yes'. Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater �4 ° I RedoKlmorphlc Features I Coarse Fragments Soil Soil Matrix- (nottles) %h) Volume Den Y S(USDA)re I Color-Moist( i Depth Color Percent i Gravel 1 Cobbles — Soil Consistence p Horizon/ r SoA Structure So' ( Layer Monsell) &Stones (Moist) - Other L LC' -601 I l _ 06 --741 13W SL 2 i 5/5/¢ v>1a551ve X, iciLle 7413o G 5 ._ 5VS/3 74" 5 ,54 > sr S% { 2,5/472r _ 1 iD% massive- Piaole Additional Notes HILLTOWN ENVIRONMENTAL CONSULTING ,t P.O. BOX 314 DEP Form 11 Soil Suitability Assessment for On-Site Sewage Disposal • Page3 of4 CUES TERFIELO, MA 01012 (413) 296-4499 Massachusetts Department of Environmental Protection 5 0 Nom{t, IU,.,,,5 Resa 4 No.--T1,0 4-0 r•,F Bureau of Resource Protection —Wastewater Permitting Program Site adores or rmap��m Number Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal C. On-Site Review (minimum of two holes required at every proposed disposal area) Deep Observation Hole: Date. 7, 1/0 Time 9'0o Weather c/oucly 1 Deep Hole Number / Location (Identify on Plan ): 2. Land Use. Lai wPN Surface Stones. — Slope (%): a Vegetation- 3 ram (e g woodland, agricultural f ield,vacant lot,etc Landform 118 t retie- Position on landscape. 3 Distances from Open Water Body 2.00 1`ft. Drainage Way — ft. Possible Wet Area IDD 1- ft Property Line SD ft. Drinking Water Well 175 ft. Other ft. 4 Parent Material q/4c/4/ 71/11 Unsuitable Materials Present Yes VNo El If Yes: Disturbed Soil❑ Fill Materially Impervious Layer(s)El Weathered/Fractured Rock El Bedrock ❑ 5 Groundwater Observed. Yes ❑ No L�' If Yes'. Depth Weeping from Pit Depth Standing Water in Hole Estimated Depth to High Groundwater: 50 ft Redoximorphic Features Coarse Fragments _. Depth Soil Soil Matrix_ (mottles) ".6 by Volume Horizon/ Soil Texture Color-Moist - (l0'7 Layer Depth Color Percent Gravel Cobbles Soil Structure Soil Consistence Y (USDA) (Munsell) _ ( &Stones (Moist) Other 0 -25 Ft I i — — Z8-31 A SL z,5Y4/3 - f. igLie 31-40! Bw 5L- Z,5YSA- l:0749-5/1l:0749-5/1/61 —I;la 6� r 40-ill C 5L— IsYs13 Co z s1414 >s% /ox, r gg5Nt 1%-;, � 1t 1 L H Additional Notes HILL TOWN ENVIRONMENTAL CONSULTING P.O. BOX 314 CHESTERFIELD, MA 01012 DEP Forth 11 Soil Suitability Assessment for On-Site Sewage Disposal ••Pagel 2 4 (413) 296-4499 I Massachusetts Department of Environmental Protection 605 Ner}L arms Road1 Noef tier+ p*n Bureau of Resource Protection —Wastewater Permitting Program Sue Address or Map/Lot Number ,\ Form 11 - Soil Suitability Assessment for On-Site Sewage Disposal A. Facility Information Assessment Performed By: Owner Name. Yl////74/+l 14/r7y e el< HILLTOWN ENVIRONMENTAL CONSULTING P.O. BOX 314 Street Address. _5054#e , 1 Frrnj /yokc+f Map/Lot CHESTERFIELD, MA 01012 (413) 296 -4499 ray Florence Stale. /t•i Zip code 0/062- B. Site Information / 1_ (Check one) New Construction ❑ Upgrade t� Repair ❑ � '7 2. Published Soil Surrey available? Yes I/ No ❑ If yes. /9e/ /51 ;I' `j�cnY aa Oe4rcrck_ Year Published Publmalion Scale Sol MapUnit Sbi Name Soil Imitations /Dc,-es 5701,1 , 1.41441055 3- SuncCial Geologic al'Report available? Yes ❑ No ❑ If yes. Year Published Publication Scale Map Unit Geologic Material Landform 4. Flood Rate Insurance Map Above the 500 year flood boundary? Yes a No ❑ Within the 100 year flood boundary? Yes ❑ No L✓ Within the 500 year flood boundary? Yes ❑ No ❑ Within a Velocity Zone? Yes ❑ No ❑ 5. Wetland Area. National Wetland Inventory Map Map Unit Name Wetlands Conservancy Program Map Map Unit Name 1 6. Current Water Resource Conditions (USGS) -7/It) Range. Above Normal ❑ Normal ❑ Below Normal u Mohnear 7. Other references reviewed_ DEP Fonn 11 Soil Suitability Assessment for On Sile Sewage Disposal • Page / of if Massachusetts Department of Environmental Protection Alor-fAq/np-fo•k 1di Bureau of Resource Protection —Wastewater Permitting Program Site Address or Map/Lot Number Form 12 - Percolation Test A. Facility Information HILLTOWN ENVIRONMENTAL CONSULTING 1. Faculty Information P.O. BOX 314 CHESTERFIELD, MA 01012 (413)296-4499// // arer frnP(^ / /qrK Owner Name 605 Na(-t11 i y /c( , Map/Lot Street ddress // � ,/ lore gel(' c /-lA Olo6 Z. Glly State Zip Code Percolation Test Date: 7 /7 Po Observation Hole p-r Depth Of Pere __ Start Pre-soak 9: 53 End Pre-soak /0 ;09 Time at 12" /0 ' 0- Time at 9" /0 'r 29 Time at 6" l / 100 Time (9"-6' 1 A4IM Rate — Min/Inch / l M.N///.I 1. Minimum of 1 Percolation test must be performed In both the primary area AND reserve area. Site Passed ® Site Failed ❑ Performed By: Mark Thompson Witnessed By: A•lmet Pet ✓05k�/ Comments: DEP Form 12 Percolation Test• Page 1 of 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Proper/. Address S/-)" N- ri Dane, Itr) : L i -riL :. Date of Inspection. ) T S V B] SYSTEM CONDITIONALLY PASSES )continuedi Sewage backup or breakout or high static water level observed In the distribution box is due to broken o' obstructed pipes, or due to a broken, settled or uneven distribution box. The system will pass Inspection d Iwith apprmai or the Board of Healtb). Describe observations broken pl9efv are replaced obstruction is removed distribution box Is levelled or replaced The system required pumping more than four rimes a year due to broken or obstruned p'pe)5) The system w.II pass msbenion if {with approval of the Board of Health, broken pipets: are eplacee oOst•jNOn i5 removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: /6 // Concu ons exist when require further evaluation by the Board of Health in order to determine it the system fading :o pm:ect me public health saten and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or pr'' is within 50 feet of a surface water Cesspool or prr.v- 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 APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 3) OTHER [revised Oc] `he system has a septic tank and soil absorption system (SAS) and the SAS Is within 100 feet to a surface water supply or tr ibutan to a surface water supply Tne system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water sup: well Tne system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water suppts well Tne 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 web is free irom pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is eq..ai. to or Tess than 5 ppm method used to determine distance (approximation not valid) Page 2 of 10 tiiLL:As'. ` HELD Go.cmo ARGEO PAL L CELLCCCI G ■cmo. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL_ AFFAIRS Lf DEPARTMENT OF ENVIRONMENTAL PROTECTI N ONE N INTER STREET. BOSTON. MA C2128 6'P-292-£50'. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 21968 XORTHAmproN qDA R OF HEALni '1 TRUDY COXE Scare DAN'IDB STRI HS Commssionc Property Address Sig; A -024in `�{ }''°a"" Address of Owner. Date of Inspection: ° S -ti-` %fr (II diHerentt Name of Inspector'. L' ,//,.ihl L ( ir:S I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 1310 CMR 13.0001 Company Name'. B L L Ce ,2 Ida Mailing Address. , Sa /.14,5" wa'I C HC$/C'f/•CCD xs'I t] L' C ! e Telephone Number 4/3 —' SF,- Y CERTIFICATION STATEMENT cents Ina! I have persona y mspeclee the sewage disposal system at this address and tha! Cne iatormaeon reooned below a true. accara:e and compete as of the t i m e of inspect on The i n specllon was performed based or m, Iran ing and experience in the o•oper 'unerion and my n.essence of on-s le sewage dispose' s stems The system: sL asses _ Eonde tonally Passes _ Neeos sane Es aI.aI'o- By the vocal Approving Authority Faia Inspector's Signature: LL 1/ Date- . "�'c,_ 'Id she Sr stem 'mspenor shall Suomr, a copy of this Inspection report to the Approving Author's, athin thin 130! days of comp'et,no thins inspect on ',' the system is shared system or has a design flow of 10.000 god or greater Inc ,nspemr and the system owner sna,, submit tPe report to the appropriate regional oeice of the Department CO Encirpnme ta'. Protection T. e ong nay snould De sent tot e /-.em owner a-d copies sent to the omed ,t apohcaole, and me approving authonn. INSPECTION SLMMARt Check (4,: B, C, or D. Aj SYSTEM PASSES: cm' • have not found any information which indicates that the system violates any of the failure criteria as defined ,n 310 CMR 15.303 Any fa.lure cnterla not evaluated are indicated below COMMENTS eI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass' section need to t>e replaced or repaired The s,stem noon completion of the replacement or repay, as approved by the Board of Health, vita pass. no.cate ses, no. or not determined IY, N, or ND; Describe basis of determtnation to apt instances If not de!e m,ned". explain wos not _ The sept c ank is metal, unless the owner or operator has provided the system inspector to a copy ot a C nAcate of Compliance tanachedl indicating that the tank was Installed within twenty (20) years prior to the date of the ins ion. or the septic tank, whether or not metal, is cracked, structurally unsound, shows suostantial mbltation or execration or Lank La lyre ,.s imminent The system will pass inspection if me existing septic tank is reptaced with a conforming septic Lank as approved by the Board of Mealm. tr.....d G4/7579'I) Page 1 of 10 DEP on the veona Wee Wee egg/mrw magnet stare ma waits ICJ Pr.ete on RecyUM Pace' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Proper Address. he"- N' EC Oti Onner 'N L e LjL•C_M irs"- rV Date ot Inspect lore. 5 3 _ ri4 Check if the following have been done. You must Indicate either "Yes" or No as to each of the following. yes No Pump.ng information was provided by the owner, occupant, or Board of Health. None oi the system components have been pumped for at least two weeks and the system has been receiving norma flow rates during that period. Large volumes of water have not been Introduced into the system receniw or as oa of th is !napes-Mon As b.: 1: plans have been obtained and examined. Note if tney are not avarlabie with NIA Tne tatelm or dwelling was inspected for signs or sewage back-up. Tne scslem does not receive non-sanitary or Industrial waste flow. 'ne see was rspecied tin signs ot breacoul . __ ems co^'ocneres ewe acting the So ' Aosorpt'un System, have been locates on the site _ Tne septic tank mar holes svere uncovered. opened. and the interior of we septic tank was-rspeoed im :ono The o _a Les or tees. material ot construction. dimensions, depth of liquid, depth of sludge, depict of scum T�e s.ae and local on of the Sod Absorption System on the site has been determined based on _ Tne Lacks.. owner rano occupants. If different from owners were provided with information on the proper maintenance ca Sub-Surface Disposal System. Easing mformabon Ex. Plan at 6 0 H Deteo tied in Tne field ',taw of the failure criteria related to Part C Is at issue, approxima.or 0, d.stance s anacceotao'el I'5 302811b% :r.vv.d 04/25,97, page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued( Property Address. X0'1 ' t-.1k'st S Owner_ jp-1, L -t AL ,c6 /GC Lce Date es n 3TT-N5« %r' DI SYSTEM FAILS. 11/27:6 sou must indicate e 1es" o' \p as 10 each of the follow.ng. I have oete'mmed that the system nolates one or more of the following la IlUre criteria as defined ir. 310 CMR 13 303 The ras,s for this determination is identified below. The Board of Health should be contacted to determine what will be necessary m correct the failure Yes No Backup o'sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS of cesspool S.a:.c _ou 0 level in the d'strioueon box above outlet invert due to an overloaded or ctoggeo SAS or cesspoo. L,cc c dept^ in cesspool 15 less Iran 6" below mven or available volume is less than 1;2 day now Required pumping more than 4 times in the last year NOT due to clogged or oostructed pipets;. Numper of ones pumped _. An oorton o' Inc Son Aosorpoon System, cesspool or privy is below the high groundwater elevation Art, port or or a cesspool or pnv■ is within 100 feet of a surface water supply or trioutary to a surface water suppll Any portion 01 a cesspool or privy is within a Zone I of a public well Ars pom.or of a cesspool or privy is within 50 feet of a private water supply well An■ pomon 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 qua(iry analysis If the well has been analyzed to be acceptable, attach copy or well water analysis for conform. oactera volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: / 4 ,o. muss indicate PP.ne"Yes' or No as to each of the following. Tne 'b..owing :mend apply to large systems in addaion w he criteria above The system serves a taNle,, with a design flow of IQ000 gpd or greater (Large Syveml and me system Is a sigro(icant threat to pubic Health and safety and the environment because one or more of the following conditions exist Yes No Me 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 bring the system and facility into full compliance with the groundwater treatment program requsements of 3't4 CMR 5.00 and 6.00 Please consult the local regional office of the Department tor further mformauon. ■r.v,ued 04/15/9', p.go s of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propern, Aodress •x 9 -s - N' Fa FatM S' Qd ITC c kten a' Owner 'hNlc , flc , c.G Km( cC , Dale of Inspection g T., eL 5 e BUILDING SEWER- ..orate on sle mar Dep;n be,oss grace .11 va.ea, o' consvamron cast iron 1/0 PVC _ other lexplalnl D Sarre nom •,.a.e »ate, s..pply well or summa I, r ▪ a tie ter Comments ,conomen of Joints, venting, evidence of leakage, etc.f SEPTIC TANK. a Dca:e tins era^ 9 p:^ De o» grace f 2_ a er a d conr.n,a or /concrete _metal _Fiberglass _Polyethylene _othertexplaml ' :a-, s ne.a s'. age _ is age conf• med by Cenj,cate of Consonance _(Yes/NoI • —ens J 2-1 1 K b= L' A b'1 `H _...cge see:r Rs1a°ce nom roc a s_ege to 0070e-10r oudet tee or baffle 0 scvm mess f. J stance 'r Ors" top of scum to top of outlet lee or baffle C% 2. stance nom bonom o1 sc..m to bonom of outlet tee or ba111e. O . .,.tie' .cos ^ere set ern nec [•..L4' T ?Mac tc 1.- 5Ir nu. jnnert 'ecommenoa:ron fur pumping condmmn of inlet and outlet tees or baffles, depth of liquid level in relation to Dune' Inver, stmmara. n.teger e.roence of learage. etc l TN / S rS &At_ c.:.., rrra GC .Tr c. rry,u r_ w4' zits, 4r1amp GREASE TRAP- /%j) x2:e De Sire pant yea ^ De ow grace rere _metal _Fiberglass _Polyethylene _otnerlexpla'n • -ters,ons Scum Ih,ckness D-Lance from top of scum to top of outlet tee or baffle_ D stance from boatels of scum to bonom of outlet lee or baffle Date of last parep.ee 1-mmens es.ess.eArnencai On NCrr porno ng, condition of inlet and outlet tees or baffles, depth of I,gmd level in relation ID pull el nven struceral -'sgr Nr e. tie^ce o' easage etc Pape 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION P r opera Aodress. CVO'" N. IAA 2M rta tia O»nen Pr rL -t AL c_6 KccLES. Date of Inspection . cc,: NE ri 5. RESIDENTIAL Des gcr On 440 R 0 d"bedroom for 5 A5 Numper of De rooms NLmpe' 0• cure- residents Caoage g' der ',ves or no' TA .a.:nah c0-re ted t0 System Ives or not LOOTS seasonal ..se .ves of no'. a;;r v;a•.e' meter read!.gs. a vaable tlas•. two (L year usage (gpol) fS rt C_ sump lm0 'ye5 or rQ; d!il rut r FLOW CONDITIONS ,au sale c• 0ccsoarc- LUFF(2 En/1-L7/ COMMERCI AL INDUSTRIAL'. N/ A -,>e o •.abtr.sn,menl Des gr. tics, _ galions/dav Crease trap present ves Or n iroes(r.a' Waste Holding Tank present Ives or not Non-samtan .+asle discharged to the Llle 5 system. lyes or not na'e' meter reap ngs. it ava.aole T OTHER. Decade Las. Ca.e Co occoanC, GENERAL INFORMATION PLMPINC RECORDS ano source of information N E-L.1 6P F/C. TA 5) K Svs:em pumped as pan of mvpectlon ryes or not_ if ves volume pumped gallons Reason fa pumping TYPE Of SYSTEM ✓ Septic tan Sid upi bua,on box/soil absorption system Sngle cesspool Ovedlow cesspool Prn1 Shared system (yes Or no) (if yes, attach previous inspection records, if any) LA Tecnno-.ogy etc Copy of up to date contract Omer APPROXIMATE AGE of all components, dale Installed (if known) and source of Information. .56e) n(. TA/dr, eu_ [ ccg Lc CE`,C,4< N .ci ccn Senage odors detected when arriving at the site (yes or no) . 2 > r.v_..e Clam'. Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address. SL' N r A.odS Sid. FLor_c'-.ec Owner. )7ri , e + qc 'c - KE LL Date of Inspection. F5 Ty;G r($ SOIL ABSORPTION SYSTEM (SAS) !ooze on she plan it posslbfe. excava ion not required but may be approximated by non-mtrusrve methods. Id not aetermmed to be present explain 4Cfl»t/ ma VcO f? M U -3e* L it 5 4 ) :;<&-re voe leach mg pits. number leach,ng chambers. nurnber_ leacnmg gal'enes. number each'rg trenches. no mcer length. leach mg Irelos number d'menssons lfegcr,,, n5 % 3`; oven on cesspool. number_ AIerra: re s,gem Name or Tenon cgs nnents none 0000 Ion of soy' Fw (- .'a ns of hvdraubc failure, level of ponding condition of vegetation, etc.) Ado f•6-du OF fittp [;c- F4'4 -« oe ?a t. Dr ti6_ CESSPOOLS. ocace on s.Ie plan N.nDer and cony gaga! or Depth-lop o' updio to inlet inver Depth of solids lare� Deptn of scan layer Dimensions of cesspoo Materials of construction and,cation of grourd..ater m0ow .cesspool null oe pamped as pan of inspection! Comments :note condition of soil signs of hydraulic )allure, level of pondrng, condition of vegetation, etc/ PRIVY: /j4.4 .locale on she p■an. Malenab of cons! ect'or Dimensions Depth ofsoids Comments role coney on C. so s grs of hvdrautic failure. level of ponding, condnron of vegetation, etc.: p.ps 0 of If Prrepe^,s Add'ess Ov.ner. 1I-$ L Date of Inspection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued/ o ti. r4jrn C R,1 'h t CE /CE( Lc- 5-.c TIGHT OR HOLDING TANK.etils4 'Tank muss be pumped prior to or at time, of inspection` soca',e oc. site n';an Depth oelow grape _ Mater.a'. of construct.on concrete metal Fiberglass Polyethylene otherlexplamt mensioes Caodciry gancns Design non ga.,onsda. A.aim r s.0TA mg order Yes, No Da.e orec s o,.s oamomg Co m Tens cord,;ror or 'et cood0101 c• alarm and float switches. etc.` DISTRIBLTION BOA. Y CC orproPes Dec n c cu m e.e a0ose o..'.lei mxei u" h t --?cc p LEVELFIRs mole ie.e a°s d s.rmst o^. is equal evidence of soli0s Parryover evidence of leakage into or out of box. etc.'. FF' Cr v_Lti h...FC: OF.N/ c Lc—Ar_gL c CN,rc �.of s. , 4r PUMP CHAMBER: /�/; 'loca e o-. sole p a P„mos .n Working omen 'Yes or Noi Alarms A:arms in work ng order (Yes or N0`_ Comments `note condoler. of pump chamber, condrt ion of pumps and appunenances, etc.) Fag. 7 of 10 Properts Address'. 7C'' tv O.ner Nri, c 'J. Date co Inspection Y IJ, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,r- • iCA S &c J: c.. Dept' to Groundwaer?/D Feet Please mdicate a the me:hoc s used to determine High Groundwater Elevation o Oo;a nerd ao°t Design Plans on record art Ooser.anon o' Ate IAbumng property, observation hole, basement sump etc Date-- re t nom local condn.ons _'ec. .,,tn ical Soaro of nealm Cnecn EE.AtA maps Ceec. poTmng 'eco'os j_ necr. ;oca e.Ca.atcrs nstallers v$e _SCS Data , c'c s no sin, estab 'shed me High Groundwater Elevation. (Must be completed ATt v. A'. Ve=I Eto'rva 1) FS''T `6. X Ce1,' ; Ci_. /welt f Wt (L 17tC I Ach r.:4 `_ ( Ch t. CC EfJ Page 10 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Proper.. Aocress' OMn e P,1!L yqc, E ICc ! L� Dale or )nspemorr. Tor N SKETCH OF SEWAGE DISPOSAL SYSTEM: incluce ties tc a'. '.east two permanent references landmarks or benchmarks !acre all wel,s wi',mr 100 (Locate where puDlic water supply comes Into house) ti r! .4 T) R'CN C.c° O A ,ALL AIL AS✓i—'£MN`TS r9::meC _4 9: 9' ABC ,AG)0aor, M4Tc No `:CALF_ cfp• f of :0 I. ._ c \fN , pry ' , � A N 'I I f -1" NI C , C. ) 1.1 .. - 1 ' / < ' �1 AI — A/) „ d (-2 Y e1 r17 d —J7 -_ /—/-1.11 ti 4 t, CHECK OR FILL IN No 11 THE COMMONWEALTH OF MASSACHUSETTS • BOARD OF HEALTH CL-4, OF PO4-eiT-firer FEE Appliratiun fur flispnattl ri,nrizn (1[nttntrurtinn ljrrmit Application is hereby made for a Permit to Construct ( ) or Repair (1/1-in Individual Sewage Disposal System at: �I✓ 1G/'.!�(q� ';�fN-NSA∎}� 1e ddiw • ,,owner G p yl J t �(� Y filer Type of Building Dwelling—No. of Bedrooms Other—Type of Building Other fixtures Design Flow Septic Tank—Liquid capacijy Disposal Trench—No / or Lot No. Address Address Size Lot Sq. feet Expansion Attic ( ) Garbage Grinder ( ) No. of persons Showers ( ) — Cafeteria ( ) gallons per person per day. Total daily flow gallons gallons Length Width Diameter Depth Width Q/d ' Total Length 4 7' Total leaching area 7#/ 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 IZepairs or Alterations—Answer ?then applieabl�..�� e � L a * u ' Xc,:i0 ' L .Li. tt Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article RI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beep issued by the boaldof hea ` � , Du 1 Application Approved 13y '�-�'rV G ii Pee"�' 4 "'E 'x/ )�•i r Date Date ,)2.rtt ;7 j L Application Disapproved for the following reasons Permit No -� Issued Date by THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..';.' q OF i/ .L gonY -+I atertifiratr of Gtthnpliaurr THIS IS TO CFR 'FY, That the Individual Sewage Disposal System constructed ( ) or Repaired (, ) Installer at _, has been installed in accordance with the provisions of Article XI of The State Sanitary Code as dese.5ibediin Jhe application for Disposal Works Construction Permit No i / f dated }'"4"4 ' / t THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ---- Vt,f 5( f , i P • Inspector t ) r I fn DATE c THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (; ( y OF.. -?°'1w..nystTj No 1 1 / Pinpuzal Ifork,n QRwtntrurtinu itirrtnit Permission is hereby granted _`.rL-.v -1�'^�1� L 'k to Construct ( ) or Repair (K an Individual Se ale Disposal System at No -417.11244 ws....j 20 c( No. d o _ I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH C'd y OF Atioriligmeltin oC1udL<� APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT no -1 Application for a Permit to Construct ( ) Repair (/:pgrade (di Abandon ( 1 - ❑Complete System 24dividual Components S05 /vorr1i Finns Road 14,/I/ 4 .417,14 `/vrk do� sosN � F W.a rm3 I %of eitC¢ 10 C/O(x-' MapiPa IR C1gr�ktmcr4vq T� %8OY' T'� wrl1;AMT Address 4//3 586 s8ol Hi/1)54•161 Tre1Plt vironrvyerfr{a/ OlD h ILi7r -__tm - .r'�..W n .i . : et- �X.3/�} C�i¢J7teg old /'!/� /D/L 4/3-226 449/ Ade,c,s vclephonc r Z63-7%8 .a Type of Building: Sin/e 7an,j/ dtQeffIH4 Dwelling—No.of Bedrooms 4 J Other—Type of Building No.of persons Other fixtures Lot Size Sq. feet Garbage Grinder (,Vo) Showers ( ), Cafeteria ( ) Design Flow(min. re uired) 44I' gpd Calculated deli n flow 770 gpd Design flow provided 440 gpd Plan: Date I it: 2ot0 ur ber of sheets Revision Date Title 5et>Ja-y2 15 se 5 w. Description of Soil(s) arras 11 Soil Evaluator Form No. Name of Soil Evaluator_acnrmp(ors Date of Evaluation 7/7/Zat 0 DESCRIPTION OF REPAIRS OR ALTERATIONS replaceexrs-h)i, S,A,S,as per " roved ceJyr. The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TRU 5 and forth- agrees not to a system in operation until a Certificate of Compliance has been issued by the Board of Heolth. Signed Date at/c9011 i Vc. Inspections le It FORM t - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 '- THE COMMONWEALTH OF MASSACHUSETTS BOARD /OF HEALTH :71 OF t‘k,'7 F ✓t(FRi APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT Application for a Permit to Construct ( ) Repair (/Upgrade (0 Abandon ( ) - ❑Complete System ]Individual Components FEE %--' ' /: S 5 rw r*i ,i,n !>oa.4 y'i/,/jk./v( !b1 el i Li �9yK L:xuno¢ SNpwt f'S/l'-i�(i nl ✓. </.:rnc. id4 n%vim Map riri If)∎ 2L4 rl �- Aae.c.. tm / pp d -c�V r! �� lc y,F� ' t( rinh71? .-1 j ` rrr v/^r nC�-�fql — .., 3 + CieJ--eru're er4lfi J10/Z. fryu�.F""�4r y /'�T��t- ,,{�t� ti4:7' ''-'71.{-?' irr-f7-,16-1 ,....a...e._.o"474- •<C-Z. Address �: _-1y -:-5 - �)cF Address =*1j 2�6 -4419 T Izpnon,: LIcpno'c Type of Building: - r...7/. /Pp. /P -y Dwelling—No.of Bedrooms j Other—Type of Building No.of persons / 4 Lot Size Sq. feet Garbage Grinder (.Vo) Showers ( ). Cafeteria Other fixtures Design Flow(min.required) 440 gpd Calculated design flow 146 gpd Design flow provided dr4/.,' gpd Plan: Date i 17!o 4 v t Number of sheets Revision Date Title c - t �,_ ■7 - r.. ( � , r,d c Description of Soil(s) - t Soil Evaluator Form No. Name of Soil Evaluator �') r.:p r Date of Evaluation i/7,/_0(0 DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TIRE 5 and further agrees not to plans the system in operation until a Certificate of Campl'an e ha been ed by the Board of Health. Signed �- r� Date "c+- Inspections r/ rJ �W AL 21 FORM 1 - APPLICATION FOR DSCP DEP APPROVED FORM 5/96 No. - THE COMMONWEALTH OF MASSACHUSETTS Fri.' /4/ 4Fl.:try;Dt-• BOARD OF HEALTH CERTIFICATE OF COMPLIANCE Description of Pork: []' Individual Component(s) El Complete System The undersigned hereby certify that the Sewage Disposal System:Constructed( ).Repaired( ).Upgraded(4,Abandoned 1 1 by:_, ) /� „ / i 1 I at _ - !v'----bk hi v, -,S IA uGC4 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 ,/gfi) (gpd) I j.Installer / /' ten , / Designer //vY �w�j� InspectoP—' �- _' Date %f%/'^�// The issuanke of this sertifisatdshall not be construed as a guarantee that the system will function as designed. FORM 3 - CERTIFICATE OF COMPLIANCE DEP APPROVED FORM 5/96 No THE COMMONWEALTH OF MASSACHUSETTS /L.)/1),Uu ii yr BOARD OF HEALTH DISPOSAL SYSTEM CONSTRUCTION PERMIT Permission is hereby grant dto Consewct ( ) Repair ( ) Upgrade ( „-) Abandon ( ) an individual sewage disposal system at '-'i FE; ILI: lc9.696) as described in the application for Disposal System Construction Permit No. ,. . dated _i, .., . . . iC.�� Provided; Construction shall be completed within three years of the date of this permit. All local conditions must be met. Date ,)- Board of Health w FORM 2 - DSCP DEP APPROVED FORM 5/96 FORM 1255 [REV S/96) (-1184W1 HOBBB&WAPPEN'° PUBLISHERS- BOSTON