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0054 ANGUS WAY - Health
54 Angus Way Centerville A =, 251 054 I� Omrford, NO. 152.1/3 ORA �:..2 TTI I 1 10% :� 1 } C) r r ^ ;i �! I .� 'i (;ls(- osy' Commonwealth of Massachusetts �r Title 5 Official Inspection Form �T Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Angus Way Property Address 4 Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. City/Town - State Zip Code Date of Inspection 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. Important:When filling out forms A. Inspector Information SI SH 16 on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road r� Company Address Teaticket Ma. 02536 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 05/27/2021 nspector'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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way v� Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This 3 bedroom home has an H-10 1500 gallon septic tank with an H-10 D-Box feeding (2) 500 gallon leaching chambers. At the time of the inspection no visible failure criteria was found. 2) 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): I t5insp.doc•.rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form ±= i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments « � 54 Angus Way V Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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 ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): distribution box is leveled r replaced ❑ o ep aced ❑ Y ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 i c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way V� Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. CityrFown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 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 must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No I ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form rT Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. CityrTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 '/2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts +ry Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �n 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.-The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for an inspections: Yes No ® ❑ 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? ❑ ® 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 (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 f c � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus GPD Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d town water I 9 ( Y 9 (gP ))� Detail: In 2020- 140,000 gallons were used and in 2019 - 127,000 gallons were used. Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way v� Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: based Design flow on 310 CMR 15.203 9 ( ) Gallons per day d P Y(gP ) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No I If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No ' Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Per owner 2 years ago Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 c � Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way u Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): Water was flushed and came freely. t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ 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 Dimensions: H-10 1500 gallon Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 32" Scum thickness 3„ Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 13" How were dimensions determined? sludge judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form t� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way v Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2 -500 gallon ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 I c Commonwealth of Massachusetts - Title 5 Official Inspection Form +' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection no visible failure criteria was found. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 cN Commonwealth of Massachusetts 16— Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is Centerville MA 02632 05/27/2021 required for every -.__ page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 f i3wJ< I � ae. i.8 3• l I i I l I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 r c Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `F L 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 plus feet 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: 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: I augered a hole at a lower elevation and shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts - Title 5 Official Inspection Form += / Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Angus Way Property Address Scott and Linda Thomas Owner Owner's Name information is required for every Centerville MA 02632 05/27/2021 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 ' , r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityrrown State Zip Code Date of Inspection 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. Important:When filling out forms A. General Information on the computer, �� j 7O use only the tab 1. Inspector: 4 / key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name � 74 Beldan Ln. aw I Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmai►.com SI4522 Telephone Number License Number 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 ���6/25/2016 Inspector's Signature Date The system inspector shall submit a co of this ins ectiort report to the Approving Authority Board Y P PY P P PP 9 tY ( 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cost.) 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 j indicated below. Comments: The dwelling located at 54 Angus Way Centerville is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 precast leaching chambers with 4'stone surrounding. The system was found to be in proper working condition at the time of inspection. 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 54 Angus Way Property Address Eric& Denise Barsness Owner Owners Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ 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 ❑ Y ❑ N ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Citylrown State Zip Code Date of Inspection 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 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 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 ❑ ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 11 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. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 54 Angus Way M Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® 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? ❑ ® 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 (if 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): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 353 gpd provided t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 54 Angus Way Property Address Eric& Denise Barsness Owner Owners Name information is required for every Centerville Ma 02632 6/25/2016 page. CityrFown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail Property has a large irrigation system Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 316 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons 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) (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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: system installed 2002 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): 101. Depth below grade: feet Material of construction: ® concrete ❑ 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 Dimensions: 1500 gallons Sludge depth: 6" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityfrown 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 3.5 Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was recently cleaned and should be done again within 2 years and again every 2 years for proper maintenance. Inlet and outlet tees intact, water level was even with outlet invert, tank was structurally sound. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. City/Town 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: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date I!, Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4M at 54 Angus Way Property Address Eric& Denise Barsness Owner owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): Distribution box was video inspected and found in good condition, no rot, water level was even with outlet invert with no high stain lines. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): "If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2x500 gals ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): s.a.s. consists of 2 500 gallon leaching chambers in a 25'x13'x2'trench with 4'stone surrounding. stone was probed and found to be dry with of sign of past saturation. 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityrrown State Zip Code Date of Inspection 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 54 Angus Way Property Address Eric& Denise Barsness Owner Owners Name information is required for every Centerville Ma 02632 6/25/2016 page. City/Town State Zip Code Date 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 . f �- 13 f Z f ,-./ 23 9--r 3(b'3 8 G -2 31 (3-3 / ,3-Y 23`6 t5ins-3/13 Title 5 Official Inspection 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 M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Citylrown 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: 12'+ 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: 9/10/2002Date ❑ 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: Design plan dated 9/10/02 indicates that no groundwater was encountered at 120"and system is designed to have 5'+seperation between bottom of s.a.s. and adjusted high water elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 54 Angus Way Property Address Eric& Denise Barsness Owner Owner's Name information is required for every Centerville Ma 02632 6/25/2016 page. Cityrrown State Zip Code Date of Inspection 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: APPLICANT'S YOUR NAME/S: k=1PA,41 6�— WAS Js—n.11� BUSINESS YOUR HOME ADDRESS: p+Q60,; -,A-�Av �t� *�� �1�I.14,1•ri�I�5� �D.l'T!E12V 4 l�t�' XYl� ,�`?�f D TELEPHONE # Home Telephone Number lui NAME OF,CORP MtllON w ti k NAME OF NEW BUSINESS t NE i 7 I L it'�r� S C t:�` :' ? GY. .<TYPE:OF BUSINESS l.E...C�CZCit? i IS THIS A HOME OCCUPATION' YF YES r� > =lei` n a-6 ADDRESS OF BUSINESS 7. k.al. ,c <,�=clad � , iyit.t: ty►F .( 's.�o3 MAP/PARCEL N[JMB�R� .(Assessng) w ` When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd.&Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has bee ormed of the r it r rements that pertain to this type of business. orized Signature COMMENTS: 3. CONSUMER AFFAIRS [LICENSING A ORITY) This individual has been in !med f h c using requirements that pertain to this type of business. Authorized Signature* COMMENTS: Date: (0 1 f h TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: U tarshas5 4-6 .Tnc, BUSINESS LOCATION: "` n ery►Rt., MAILINGADDRESS: Mail To: TELEPHONE NUMBER: Board of Health � � $" ����- �� Town of Barnstable CONTACT PERSON: Er 8& rsn ess P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: ,_U6- '75-9 1157 Hyannis, MA 02601 TYPEOFBUSINESS: Ca h k f UA)0-4 Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES NO _ This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ADDRESS: TELEPHONE: LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(forgasoline orcoolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants -- Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) Battery acid (electrolyte) Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, NEW USED (inc. carbon tetrachloride) Paint & varnish removers, deglossers Any other products with "poison" labels Paint brush cleaners (including chloroform, formaldehyde, Floor& furniture strippers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS r Book.: 16398 Page: 87 Inst#: 16466 C.tl#: 1043 Rec:2-14-2003 ® 11:13:59a BARN 54 ANGUS WAY DOC DESCRIPTION TRANS AMT 1 BARSNESS, ERIC A RESTRICTION 10.00 DEED RESTRICTION 10.00 rec fee Surcharge CPA $20.00 20.00 Total fees: 30.00 WHEREAS, Eric A. Barsness and Denise M. Barsness, of 47 Rebecca Lane, Osterville, Massachusetts, are the owners of 54 Angus Way, Centerville, Massachusetts, . and being shown on a plan entitled"Plan of Wequaquet Pine Needles owned by Mary A. Tobin, dated 1927, drawn by Nelson Bearse, Surveyor",which said plan is duly recorded in the Barnstable County Registry of Deeds in Book 47, Page 119; WHEREAS, Eric A. Barsness and Denise M. Barsness as'the owners of said lot have agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre- condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code,Title V,Minimum Requirements fat the:Subsurface Disposal of Sanitary Sewage; WHEREAS,the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compliance with 310 CMR 15.200, State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building . permit for the construction of a single family home on this property, is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document; NOW, THEREFORE,Eric A. Barsness and Denise M. Barsness do hereby place the following restriction on their above-referenced land in accordance with their agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. 54 Angus Way, Centerville, Barnstable'County, Massachusetts, may have constructed upon the lot a house containing no more than three(3)bedrooms. Eric A. Barsness_and Denise M. Barsness agree that this shall be a permanent deed restriction' affecting land located on 54 Angus Way, Centerville,.-Massachusetts,-and being sh-ow-n oii the plan recorded in Plan Book 47,Page 119. For title of Eric A. Barsness and Denise M. Barsness see following deed: Book 15803 Page 19. EXECUTED as a sealed instrument this day of Ft'6 r-ua.N 2003. Er A Barsness V�a i0lAA 1/l 0yi De 'se M. Barsness COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. C� , f 3 , 2003 Then personally appeared the above-named Eric A. Barsness and acknowledged the foregoing instrument to be-his free act and deed,before me, Notary Public My commission expires: COMMONWEALTH OF MASSACHUSETTS Barnstable, ss. Fe` , / 3 , 2003 Then personally appeared the above-named Denise M. Barsness and acknowledged the foregoing instrument to b r free act and deed, before me, G Notary Public P,/Uj .7' �-- My commission expires: qa31-�007 . r (� TOWN OF BARNSTABLE LOCATION SEWAGE # .2&Q!0- G VILLAGE �rl�J�P_=rZZ— /e ASSESSOR'S MAP & LOT ZS INSTALLER'S NAME&PHONE NO. _S,9? VZO 973S��esclai 0,1 000410-r r „ SEPTIC TANK CAPACITY /fD0 LEACHING FACILITY: (type) 2^SDo 410,3/.101y (size) NO.OF BEDROOMS 3 BUILDER OR OWNER iPERMIT DATE: { d" O COMPLIANCE DATE: /O Separation Distance Between the: Maximum Adjusted droundwater Table to.the Bottom of Leaching Facility Feet Private Water Supply:We1I and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist • within 300 feet of leachin facili ) Feet Furnished by Cj< ' V./ No. Fee a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(p plication for &gaal *pztem Con!aruction Permit Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ,Complete System El Individual Components Location Address or Lot No.s,f 4Pig f,,j to 0-A Owner's Name,Address_and Tel.No. Assessor'sMap/Parcel —L r-V � q7'-9®76 Installer's Name,Ad ress,and Tel.No. Designer's Name,Address and Tel.No. l - �lfdM LC,l '� °� rlSt / �•S, s-6 3 roc Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(�✓� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow S3 gallons. Plan Date ,.® , Zp©Z Number of sheets—T Revision Date Title Size of Septic Tank Zs0 Type of S.A.S. 'L— �3 %i 660t," Description of Soil Nature of Re airs or Alterations(Answer when applicable) �C�4f�©d �.// /j3J0� �f Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi Board f Hegjth. Signe \Z�- Date Application Approved by O Date Application Disapproved for the following real s Permit No. )®0Z Date Issued d' o. No. Fee THE COMMONWEALTH OF'MASSACHUSETTS r Entered in computer: ✓�� PUBLIC_HEALTH,DIVISION -TOWN-OF BARNSTABLE, MASSACHUSETTS Yes � rication for Mizpozar *pgtem Congt'ruction Permit '0_ r Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. �-q 4 hg v3 ��//�_ / Owner's Name,Address and Tel.No. Assessor'sMap/ParcelosUV'�K 1997 Installer's Name,Address,and Tel.No. 7 Designer's Name,Address and Tel.No. Ck t t",j/. r1, V' VGA Type of Building: Dwelling No.of Bedrooms J Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow .��3 gallons. Plan Date S&I" IS &W Z Number of sheets � Revision Date Title Size of Septic Tank Type of S.A.S. 2 iuy! Description of Soil j Natu a of Re airs orttAlterations(Answer when applicable) AAAct .114 46 wj/ro Date last inspected: Agreement: g 'The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi Boar of He th. Signe Date Application Approved byer t e/�� P� //.!/ I Date Application Disapproved fohe following reas ns Y L Permit No. )p©k-y X Date Issued a d 2- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at S KJ rit/ 111 en constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this dermit shall not be construed as a guarantee that the system., tll fu tion as/Design"ed. C Date 0 Inspector�,tp4/. ✓_ ! , ----�-�� ----------------------------- NO. Fee 50* 1 THE COMMONWEALTH OF MASSACHUSETTS Z r/-�'y PUBLIC HEALTH DIVISION-.BARNSTABLE, MASSACHUSETTS Mwioozat 6potem Con5truction Permit Permission is hereby granted to C nstruct( ° )Repair( )Up rade( Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con ttruction , ust be completed within three years of the date of this prriRit. Date: 1� Approved b �• pp y 6 4.A ` TOWN OF BARNSTABLE Ec.. LOCAVON 641 0!e SEWAGE } VILLAGE �F_l9fl=�'1// : ASSESSOR'S MAP & LOT s.INSTALLER'S NAME&PHONE NO. S09 5�2�- g738✓escl�i d �se�'o� SEPTIC TANK CAPACITY /,ADO LEACHING FACILITY: (type) 2^SOD C10, 1 .try (size) XS'XA 3 NO. OF BEDROOMS *'BUILDER OR OWNER PERM TTDATE: '� ;3�— COMPLIANCE DATE: /0 —3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 'r on site or within 200 feet of leaching facility) Feet Edge of Wetland and-Leaching Facility (If any wetlands exist within 300 feet of le'khin facili )_ y Feet Furnished by A. lrjevt/tr��►✓ A ����� ,_ "� � DFcic Al� - - -�Q,`22.� g . . r�� .., ,TOWN OF BARNSTABLE ,LOCATION /�ti�y-s G�9 y SEWAGE # VILLAGE 24-LAIrZA;� ASSESSOR'S MAP & LOT,`S/— 'o S� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER OR OWNER, 1471 Ae5kw-&-/2 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No r t i i � +� \. �" �� � � i�� 5/25/01 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM hereby certify that the engineered plan signed by me dated 21A ©7— , concerning the property located at ��Y ��y�J �✓ i�,'��� meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct preliminary tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +adjustment for high G.W. _ DIFFERENCE BETWEEN A and B SIGNED . DATE: 9 NOTICE Based upon the above information, a repair permit will be issued for —3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. M q:health folder:perc6kmp SOT 7 �#22 CENTER LANE Design Calculations IN 00 (�O Number of Bedrooms: 3 C�'�� a ce — Garbage Grinder: Na 99 69' X 0 Leaching Capacity Required: 330 Gal./Day We uaq uet Leaching Area Required: 330 Gal./(0.74 Gal./Sq.Ft.)=446 Sq.Ft. X Proposed Leaching Structure: 1-25'L X 13'W X 2'D Leaching Trench Lake Q / Leaching Area Provided: 477 Sq.Ff. he X 98.86' Proposed Leaching Capacity: 353 gpd > 330 gpd. req'd. SITE j X 99.89' X: 99.47' 4' 5' 4' 2 98 6' X 8 - 2" OF 1/8" TO 1/4" R0 PEASTONE (WASHED) y 10I T.H. #1 �' — 1 2 5 T X 9 VVJ s T® �7 ® ® 24" MIN. d X 2 .0 D Street 9887 leaching trench us;ng 2 H-10 500 gal. chambers ° U 2, H-- 10 5 0 0 gal. chambers \/�/I t�} 3/4" TO 1 1/2" WASHED CRUSHED STONE u 4 of stone on sides ends. TRENCH CROSS—SECTION LOCUS 4 ' 000 �, � r f (� NO SCALE O 0 NO SCALE D I �99,57' Crawl i o GENERAL NOTES l 3-20"DIAM.ACCESS MANHIXFS Z Q conc. soace deck �9 11, w D -0 1. ADDRESS: 54 ANGUS WAY 0 2. ASSESSORS NUMBER: MAP 251 PARCEL 054 Q C patio Z f 3• DEVELOPER'S LOT: LOT 52 ••1 r r-f- to � 9 9.7 4' X 9 9,91' X ------------------- 9 7,96' X 4. TOPOGRAPHIC INFORMATION WAS COMPLIED FORM AN� � , -_., " 1'. ON THE GROUND INSTRUMENT SURVEY. i \1 I NLEr 5. TOWN WATER IS PROVIDED TO SITE AND In Her 0- S 4 , I; SURROUNDING PROPERTIES. DWELLING !-T, --- -.- _--;_.___- 6. REFERENCE PLAN: PLAN BOOK 47 PAGE 1 19 '• 7. NO WETLANDS ARE LOCATED WITHIN 100 FEET OF SAS. STEEL REINFORCED PRECAST CONCRETE 8. NO POTABLE WELLS ARE LOCATED WITHIN 150 FEET OF SAS. OE elev.= 100.68 Z PLAN VIEW `JSmt. fl. elev.=93.93' w CONSTRUCTION NOTES slab -3-20'REMOVABLE COVERS �7)) Cellar Wall y -- 1. Contractor is responsible for Digsofe notification r min deor°n«' 4 i and protection of all underground utilities and pipes. n. 13• fINUET'T"• u/ "LEr 8'm' 2•m'n.Inlet outlet e•„� Wr E __ 2. The septic„tank and distribution box shall be set �Y 5 -0 3. Backfill should be clean sand or gravel with no � ,a•min. { E 9u;- -_----- stonesleve overHover 3 of �n 4sfze.l 2' stone, a3'-8' min. T�Q`0) Ln� cns BArrLE : Liw'd eeofh4. This system is subject to inspection during installation 0 �` Th Glen r Harrington, R.S. � L 0 `�1/ •' � 5. The contractor shall instaN this s stem in accordpnce� '_0 5 -o with Title V of the Massachusetts Environmental Code AREA = I J,0O0± gQ. FT• CROSS SECTION END-SECTION g > and the Regulations of the Town of Barnstable. -H-10 1500 GALLON SEPTIC TANK 6. Provide an Acme Precast 1,500 gal. H-10 septic tank, 5-Hole H-10 d-'box with 2 H-10 500 gal. chambers or equal. NOT TO SCALE 7. No vehicle or heavy machinery shall drive over the septic system unless noted as H-20 septic components. Q) USE ACME PRECAST OR EQUAL > 8. Install gas baffle or equal on septic tank outlet tee end. Q , 9. All existing inverts and site conditions shall be verified by contractor. 00.00 10. Existing cesspool to be pumped and bockfilled. ________________- ' '_—___-__-___-__._-_—_-_.-_____-_______--_-.____--_________.___-___---___-_--____-______._____________-______—___-____-______._-_-______-_____-______ 1-20"DIAM. ACCESS MANHOLE I, JJ `t�J approx. edge of pavement e_ " 5' SOIL EVALUATION ANGUS WAY Date of Soil Evol.: July 12, 2002 SITE PLAN _ Test Performed By. GLEN E. HARRINGTON, R.S., CSE I, Excavator: Joe's Septic Service SCALE: 1 "=20' I• ® ® 4 4 2 " Test Hole BENCH MARKON CORNER OF CONC. PATIO ELEV.=100.00' (ASSUMED) No, 1 STEEL REINFORCED PRECAST CONCRETE 2 H—1 0 500 gal. chambers DEPTH SOILS ELEV. PLAN VIEW END-SECTION 0 98.87 A H-1 0 500 GALLON CHAMBER f. IDYRY413 98.29• NOT TO SCALE Sw 28" t ovR s m 96,54 USE ACME PRECAST OR EQUAL c1 j m-es sand 15-25%f-m - — gravd L20 7.5YR5/fi 2.45• �,��QF,�q PROPOSED SEPTIC SYSTEM UPGRADE i C 2 PREPARED FOR co ll ed. sand 2.5Y7f4 LEGEND N BAKER REALTY TRUST 8,87' NO GROUNDWATER ENCOUNTERED co � T co AT I /O`j EXISTING CESSPOOL TO BE 1U70 54 ANGUS WAY PUMPED & BACKFILLED *NOTE: ALL PPES ARE TO BE 4" DIA. SCHEDULE 40 P.V.C. PROPOSED 1500 GAL. �� /$(rGP BARNSTABLE CENTERVILLE MA 10' in. from NOTE: INSTALL GAS BAFF_E OR EQUAL OV SEPTIC TANK OUTLET TEE. 0 o O H-10 SEPTIC TANK ��_]• P ( ) .use to septic tank - - Septic tank cavefs must be Finished grade over system=2% slope owoy Existing House : ihir 6" of finished grads 5 HOLE X 104.46 DENOTES EXISTING PREPARED BY: D-Box cover must be DtST. BOX one chamber cover must be SPOT GRADE within 6" cf finished grode within 6"of fi,ished Tade R.C EXIST!DE DE 9 Existing Grade Elev.=99't 95 T R t S. . .. . . .. ... __........-. EXISTING coNTou GLEN E H A R R I N G T O N full lin. 2--1/8"-1/2" 12" min 9 LEDA ROSE LANE 02' Hashed stone 36" max. ------ S=. 1 Level for 2' / cellar 2a' o 1a s=01 - Too Elev.=97.0' DEEP TEST HOLE MARSTONS MILLS, MA 02648 12' nv rt = 6.52'SENK/AFFLE o aa m o C C7 O o 24"MIN.I' aJAL 'o - B horn f Leach TEL: 5Q8-428-3862 t n N 25• Trench Elev.= 94,52' FAX: 508-428-3862 v : LEACH TRENCH self I a c 6" OF 3/4"-11/2"STONE i c' v - = it WBottom of T.H. #1 Elev.=88.87' W SCALE: 1 "=20' DRAWN BY: GEH SEPT. 10, 2002 SY51EM PROFILE. 6" OF 3/4"-11/2" STONE Not to Scale DATUM: ASSUMED FILE: BAKER.DWG SHEET 1 OF 1 j LU oC � � J � z 0 � 24'-0" a L L 00 O ,-q CD9'-O 3/4" 1 3'-0" 1'-1 1 1/ ' U (V Ln z u) LU cl LU 3'-9 3/4" 7'-4" 4'-5" 4'-5" 4'- 1/4" p 0 O L 14 ce W xLLJ _ z O D15L 5T POCKET (A � m LLu LU LU . 0C 2'G"xG'G" C] a. m o v DN O TITLE: 14R SECOND NEW FLOOR PLAN M MASTER BEDROOM REVISIONS ( CARPET ) 1- 01/29/03 3'-9" T-7 1/2" Fl 1 16'-7 1/2" 2- 02/02/03 PERMIT SET NEW 3- EX15T. HALL 4- ATTIC ( CARPET ) ( UNFIN. ) CU5T0 T-9" 9'-21/2" 4'-51/2" 6'-7" SO N ffvv— A5 NEW . I .C. I � +' I _ I N W. I .C. ( C RPET ) 2'G"x 'G" 2'G"xG' ( CARPET ) I �i U N ao �� 0 - 2'-91/2" 10'-11" 10'-31/2" 0"1QI co > 1 NEW NEW A z I BEDROOM N M. BATHUj I I� _ { CARPET ) ( TILE ) 5HLV. z - - - -� >h WI° 1 O Q zu I O OHO o � SCALE 4'-1 0 3/4" 7'-I 114" 7'-I 1/4" 4'-10 3/4" As Noted 24'-0"± GO'-1 1 1/4"{ ( EXISTING) W N (n tO b� �O Z 0 cn .. EXIST. � � 00 U_ +I Z SUNROOM O N00 n ( Ln CARPET ) . . Z m C7 Z (n IL p w o Z L 0 0 z � LU ot; EXIST. EXIST. U W m W Lu O W a m TITLE: DIN 3 R FIRST Ln FLOOR PLAN EXIST. EXIST. EXIST. I EXIST. OFFICE DINING KITCHEN I BEDROOM REVISIONS ( OAK ) ( TILE ) T-5 1/4" ( CARPET ) 1- 01/29/03 ( CARPET ) I 2- 02/02/03 PERMIT SET EXISTING INTERIOR WALLS I 3- TO BE REMOVED II /ST - ``���L-- I I I I Ln (1) vz I I U I I '� I - F rvT 11 ---J -- ------- m L W ------- �AN-D------- Z EXIST. s BATH LIVING / TLF ' w w ROOM NEW 5' CASED OPN'G. < — — — L 0 EXIST. ( OAK ) I � I I � U II Z GARAGE �6� wI° -- �� O ZIU ;r ii ,� REMOVE EXIST. DOOR tL-� FRAME DRYWALL TO MATCH Q W 1 L---- > STUDY c— OaK ) I Z V1 --- ----- ------------------- _________ ,�I--- REMOVE EXIST. WALL EXIST. i i PATCH FLOORING 0 REMOVE EXIST. BRICK VENEER, CHECwo FOR ROT AND REPLACE AS NEEDED Q EXIST. EXIST. 22'-8 1/4"± 7k 24.-Q"± SCALE ( EXISTING) ( EXISTING) ( EXISTING) As Noted EXISTING FIRST FLOOR = 1953 S.F. fI RST FLOOR SECOND FLOOR ADDITION = 838 5.F. SCALE: 114" = P-0" EXISTING GARAGE = 298 S.F. TOTAL = 3089 S.F.