Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0978 BUMPS RIVER ROAD - Health
978 Bumps River Road" Centerville P A = 168 096 Oftndefloyr OEM& 1521/3 ORA 10010 P2 ie�edYe6a.:.:.i.a...rYW..vs•...a....c......w.r. ..:-_.W.rdL1i�.-.�<e.,1w:��1.iYY.�.IYL's'rYtr.aY.W.�`-_. - •�t _-.�.^':�u.5xwu�.rvraurwuW�Y� /'w• - ^w^^�^Y^'^".�s.. — �"..... _—_-�-��,,�.u.r�wLr __ .. ..:.... .,iw.,,.mi,:: ..a..,...:.. n.i:�d.�r s.::.d. -._� '�..�..,kLWI� �•.W.iw r , Commonwealth of Massachusetts Title 6 Oficiat Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address u Owner's Name information is CENTERVI LLE required for MA 02632 3/15/10 every page. Cltyrrown . 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. ImpoWhen filling A. General Information When filling out forms the computer, r,use 1. Inspector: only the tab key -to-move-your cursor-do not DOiJG11ASA aRc�VOiG use the return Name of Inspector 'k,y: 'DGUGL•A s-Ac-BRGWN-INC d---h Company Name o' .P-Q--.BOX-1,45 Company Address CENTERVILLE MA City/Town State 02632 Zip Code 508-420-4534 S14297 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' r a C>. ® Passes ❑ Conditionally Passes ❑ Fails y=, ,0 ❑ Needs Further Evaluation by the Local Approving Authority ti mow= 3i 1-5-/10 Inspect Signature Date Q0 The system inspector shall submit a copy of this inspection report to the Approving f uthority( rd sM 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 a.4-copies-sent--to-the-bu"r,-if-applicable;-ar4d-the-approk4ng-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. (Sins•09/08 Title 5 Officml Inspection Form:Subsurface Sewage Ds sal System•P i of rl Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. CrtylTown State Zip Code Date of Inspection .-Ceffift-afi-m(carts j Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in T1UCW 15-- or'in TlU CfVil•t 15-31J4 exist. Any failure criteria not-evaluated-are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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-09/08 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 ' 978 BUMPS RIVER RD Properly Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cltyrrown State Zip Code Date of Inspection -00M M(-c nnnt) 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, �fgt•.and o o kdl�,n�cn+._ ❑ 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 t5lns•09/08 Title 5 Official Inspection Forth:Subsurface Sew age Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. City/Town State Zip Code Date of Inspection a lc rtificabw(MTWY 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 cttrfarp water-%upplyort'ibutaryto-a surfacewater supply- El 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". -Meth od-used-to-determine-dis Lance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. a dither: 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 El ® L'I�IIITJ it`i�esspp�iol I�ie5�fh�r 6'15eISw(TT1% I�aliat dl'�7�VUIUML-1-Imo'& than Y day flow pins-09/U8 t me o(racial inspection Form:SUbsurace Sewage Dsposat System-Page 4 of 11 1- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cityrrown State Zip Code Date of Inspection -CeMft UU (cunt.)- 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.Gbail]_Gf_CL%tfl4--mlist heattaCbed tot j.%f�jXL]_ ❑ ® 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—MPA)-ora-mapped Zone-W-ef-a-public-water-suppyr 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•09M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Iltle 6 Official TnspecUon Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address OwFer Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. City/Town 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) �. f 1. V41 _.ttae.facilityor duvellingsrasp ted_for-sig!4s _of_sewaga hack_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 Mpected fm thre LvrK ticrT-c;fthe--baff1worfieees lrraterial- 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins•091D8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 L i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Cityrrown 0 State Zip Code Date ate of Inspection $. SyStOm Informatkm Description: ACCORDING TO AS-BUILT 1,000 GALLON SEPTIC TANK D-BOX AND 4 INFILTRATORS WITH STONE ALL H-20 Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ❑ No is.laundry--on a-separate seuva9e-system?-[tf yesseparate Inspection equire4_ ❑- Yes ❑. -Na Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: HOUSE VACANT WATER OFF Sump pump? ❑ Yes ❑ No Last date of occupancy: 2008 Date Commercial/Industrial Flow Conditions: TyPeQf Establishrx wt:. Design flow(based on 310 CM 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cityrrown State Zip Code Date of Inspection $: Systerninfo-vrrvation (zurw)- 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•09108 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 't 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cityrrown State Zip Code Date of Inspection D. System!00117 M(cont) Approximate age of all components, date installed(if known) and source of information: ACCORDING TO AS-BUILT SYSTEM INSTALLED IN 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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.): Septic Tank(locate on site plan): Depth below grade: 1.5 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: 1000 GALLON Sludge depth: VARYING AND LIGHT t5ins•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Jr 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cltyrrown State Zip Code Date of Inspection SyStM 1114DUFfIldbUft-(tant)- Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 0 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Cstrrrtit s(�i�u►rfpir� irftet arsd�uYlet „ itizsri;strorWal'irflegrity; liquid levels as related to outlet invert, evidence of leakage, etc.): WOODEN POLE Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El 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•09/08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 10 of 17 1— Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cttyfrown State Zip Code Date of Inspection Dr SyStm informatkm(oanq- 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 LOOKS CLEAN AT THIS TIME 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 Comments(condition of alarm and float switches, etc.): ' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No thins-u9N8 I Itle b OmCial Inspection Form:subsurface Sewage Ulsposal System-Page 11 of 1 t I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cdyfrown State Zip Code Date of Inspection D: SySte�-it�rlfr>iatk �t 00a-f1�)- 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;-e16:):- BOX LEVEL NO LEAKAGE LOOKS LIKE ORIGINAL LEACH PIT IS STILL HOOKED UP TO D-BOX 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: AS-BUILT SHOWS A OBSERVATION PORT BUT IT WAS NOT ABLE TO BE LOCATED t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. Cdyff wn Date/10 State Zip Code Date of Inspection a system urbi ratii`m(-oov) Type: ❑ leaching pits number: ® leaching chambers number: 4 .INEILT-RATORS ❑ 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.;: 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•05/08 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 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. City/Town State Zip Code Date of Inspection a. Systmi 1Ir rrTTathM(M-rt)- 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..): thins-u9/ua I ine o(Ahcial Inspection Form:Subsurtace Sewage ulsposal System-Page 14 of 1 t i` i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. City/Town State Zip Code Date of Inspection D. System!nfo r (cant)- 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- t5ins•osme Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 3/15/10 every page. Cltyrrown State Zip Code Date of Inspection a: SySterfli ill'rfOpll1111ati�rr Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 10 FT++ 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: HOUSE SITS ON A HILL WELL ABOVE ADJACENT POND Before filing this Inspection Report, please see Report Completeness Checklist on next page, t5ins-0908 Title 5 Official Inspection Form:Subsurface Sewage asposal System-Page 16 of 17 l� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 978 BUMPS RIVER RD Property Address Owner Owner's Name information is CENTERVILLE required for MA 02632 every page. 6tyfrown 0 State Zip Code Date ate of Inspection E. RW-poTtCoTnptetenessCheddiSt ® 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 tams-09A)b I Itle b mcial Inspection Form:SUDSURace Sewage uisposal System-Page 1 t of 1 L .�l / � . " -:� -. R t - - - _ _ ` - - .. - - , - - - .. . - ': - .. . T OF BA,RNSTABLE � I LOCATION - '/ f { ViLLAGfi='-- SEWAGE# '{. I _iL P lair 1-11 �Y$�FLSOR� —~� . -----ASSESS R'S MAp&-LOT . NAME.&Pjk im N t SEPTIC TANK CAPACITY f LEACHII�JG FACII.TTy , (t3'pe)j1. . (sate) . -- NO,OF BEDROOMS . . . . B UIi DER OR � i. j....' 1 _ i . PERMTTDATE - COMPLIANCE:DATE: I Stpgrataon Dastance Betweenahe -- - . _ ; ,- . Maximum Adjusted Groundwater Table to the Bottom.of Leaching Fac�latyr 4 Private Water Supply Well and7-9 Leaehua Facila Feet ._ ' ' on sitc ar w�thtn 200 feet of kachang facilityry (If any wells eaast w Edge of W 11 etianil aad feactt;n FA - y wetlaQds rust 8 �> (f a11. Felt watlunr�00 fztt of leacbinng�f acaiaty) ". Furnished by r r. Feet 1 . �_- .. - 7%. . . .-��V���� - . . .,--r.:-r '- .---��1--f�. ...r -.. .9 ��q-":-�'.j-, 'r. � . .ik . � . . ,.- .1. 9 f ... .. - . . .. .. m , p v A . - .. . . . .:.. -. �. r 3_: - _ . - - - _ " - .... i .,. >. - �. RO F . r .. j.9 r.:..,�r- �. f- ��' o _ , . � 1 �. s 1.1. / x I w `,w % � - j t .: ,`err �"'i��.� . `� .. , -- T-a " r -.f "" a . s .,.. g z . +-+ -v- - .�`-�'' i' ry .c' No._.C. V- . Faa_..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE .2 ppliration for Di-nVasal lVorkii Towitrnrtion Pun it Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: r ...�.� ____ ......._ � ...---------••�a�=�� 1. ..--••-•......--••--...._... Location \ddress or Lot No. A 1<ai s.rL j ri°1........... �r)X1�G 1'�................... 5 l. ._..........--------"--•--------••-•--- - _. Owner Address Sc�.1- —---------- -------- t--.--------- ltk- `-^qk --------------t'!�`------------0u_jQ1...........................Installer Address - U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms....S,�..............................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons-------..................... Showers ( ) — Cafeteria ( ) a. Other fixtures ................ -- w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................Width.............---Diameter...--...........Depth................ x Disposal Trench—No.__...............Width....................Total Length....................Total leaching area...................sq.ft. Seepage Pit No..........-._---_- Diameter...................- Depth below inlet....................Total leaching area..................sq.ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....................................••------............................. Date------------..... •-------------------a .`4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ k. Test Pit No. 2...............minutes per inch Depth of Test Pit.-----__--_-.___- Depth to ground water....................._ 0 a -------------------------------------------------------------•-•--••----------••-•------ Description of Soil...................................................................................................................................................................... x w U Nature of Repairs or Alterations—Answer when applicable.. ' ........ ...... �1 _�:Iai!5 ` .........-................. . ..f�_S-T_u a_ -s P. _...54 s �''`? `^�1// �Q 1!�sNt�.-.eFau•z -�`" -'"f _ ? Agreement: The.undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.. ....... .r. .. ................. .... . Application Approved By ..._._...._.. ...... ........ _.......................... _............ ......./,C5- ie-3'-y—4`� Application Disapproved for the following reasons: ..__...................__..._..........--...----.--..--..................._....--.......__......................... ....._........................._........................ - ..__..._......_................ ........ ............._........__. Permit No. ........... � .- �.t�-.. ------------._. Issued ......._... Drc THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ger#ifirate of (gomplianre THIS IS TO CERTIFY,That the Individual Sewage Disposal System constructed( )or Repaired b i �kc'tL•l l Y . .......-- ............................................ ........._...----------_..- - --- ..........._...._...._........_....................... ..............- -.......:.............. t r ��r�QS N -- �_Z......._.........._C N..k _V�\�t. ' has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .....7 y-6-Da-7.._..... dated ........................._...._..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. .. DATE...✓.�i G� 7` .../.../.........._.. Inspectti� 6':.-3 .. �.......... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ���� j"�� 7 TOWN OF BARNSTABLE No... == -• / FEE_/ 06pnoat Zarb Tonitrnrtion Permit Permission is hereby granted... --------2.'g --------------------------------------------------------------------------------------------- to Construct ) or Repair an Individua1 Sewage Disposal System 0 C:1lti at No. cf-� ........ sa ........ /- :tv .... Street / as shown on the application for Disposal Works Construction Permit No... -(:- ._.. Dated........[_':._.4._;•..-------•-•• r � --------------------------------•---- 1�Board of Health DATE-------------L=---------��........... FORM 3E108 HOBBS R WARREN.INC..PUBLISHERS COMMONWEALTH OF MASSACHUSETTS11 r EXECUTIVE OFFICE OF ENVIROIW T� L.fA v DEPARTMENT OF ENVIRONMENTAL PROTECTION 2005 MAR 14 PH 3: 15 D�Y�St(lfi TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: �gGC/I A"� �./�.��TJ 1 ®•� �- Owner's Name: Owner's Address: ko Date of Inspection: G2.t.c��"i. Name of Inspect • (please .rgin p r'+ Company Name Mailing Address: c Telephone Number: / CERTIFICATION STATEMENT / I certify that I have personally inspected the,sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: �1 Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority /1'F ils Inspector's Signature: Date: 2 tc loa The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shard 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-zie buyer,if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection aed 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. i Title 5 Inspection Form 6/15/2000 page 1 Page 2 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: �rti J _ � Owner: Date ofI.nspection: Inspection.Summary: Check A,B,C,D,or E./ALWAYS complete all of Section D A. S stem Passes: I have not found any information which indicates that any of the failure criteria described in.310 CMR 15.303 or in 3.10 CMR 15.304 exist. Any failure criteria.not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section.need to,be replaced or repaired.The system, upon completion of the replacement or repair; as approved by the Board of Health,will pass: Answer yes,no or not determined(Y,N IUD)in the 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. ND explain: Observation of sewage backup or break out or high.static water level in the distribution box due to broken or obstructed.pipe(s)or due to a broken, settled or uneven distribution box. System.will pass inspection if(with approval of Board of Health): brok--n pipe(s)are replaced ob_Gtruction is removed distribution box,is leveled or replaced ND explain: The system required pumping mPxe than'4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with.approval of the Bard of Health): brol-.�pipe(s)are replaced obstrt:ction is removed ND explain: 2 Paee 3 of I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0 p,q � Owner: Date of Inspection: 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 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 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 DAP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is-ree from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attacred to this form. 3. Other: 3 I Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A. CERTIFICATION(continued) Property Address: 'Gt; t;, Date of Inspection: O j 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 facilky 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 lclogged.SAS or cesspool Static liquid level in the dist-ibution box above outlet invert due to an overloaded onclogged SAS or / cesspool Liquid depth in cesspool is less than.6"below invert or available volume is less than%z day flow _ Required pumping more thar_4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped 1/ Any portion of the SAS, ce3Sp00l or privy,is below high ground water elevation. Any portion of cesspool orp-ivy is within 100 feet of a surface water,supply or tributary to a surface water supply. _ I Any portion of a cesspool er.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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the.presence,of ammonia nitrogen.and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No).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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes . no the system is.within 400 feet o 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 nitrngen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a si-nificant threat under.Section E or faded 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. 4 Pase 5 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 6 Owner: Date of Inspection: Check if the following have been done:You must indicate"yes"or"no"as to each of the followinsz: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previcus 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 ? LZ _ 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? V _ Were all system components, excluding the SAS, located on site Were the septic tank manholes uncovered, opened, and the irr_erior of the tank inspected for the condition _ of thhe 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 owne`)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: Yes o Existing information.For example, a plan at the Board of Health. _U_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR l 5.302(3)(b)] b _ 5. Page 6 of I 1 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM-INFORMATION Property Address: it ` c� Owner: ; Date of Inspection: CJ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_L Number of bedrooms.(actual): DESIGN flow based on 3 10,CMR 15.203 (for example: 11:0 gpd x 4 of bedrooms): Number of current residents: oZ Does residence have,a garbage grinderr(yes or no): P Is laundry on a separate sewage system(yes or'no): [if yes separate inspection required] Laundry system inspected(ye or no): Q Seasonal use: (yes or no): .A 0 � L/ � Water meter readings, if av 'lable(last 2 years usage(gpd)):03_ ( ©� o� 'Jf..�©� Sump pump(yes or no): Last date of occupancy: —rut.) 4&ztla 1 Ce�Lt:� COMMERCIAL/INDUSTRIAL/XO Type of establishment: Design. flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgf€,etc.) Grease trap present(yes or no): Industrial.waste holding tank present(yes or no): Non-sanitary waste discharged to the Tate 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER.(describe): GENERAL INFORMATION Pumping Records 1 — Source of information: 111 J R Was system pumped as part of the inspect' (yes or no) _ If yes, volume pumped: gallons -- How was.quantity pumped determined? Reason for pumping: M OF SYSTEM ptic tank, distribution box,soil absorption'system _Single cesspool _Overflow cesspool _Privy _Shared system (yes or no)(if yes,Ettach previous inspection records, if any) _Innovative/Alternative technology_Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy oflhe DEP approval Other(describe): proximate age of all components, date installed(if known,) and source of information: k2 Were sewage,odors detected when arriving at the site(yes or noy-2-D. 6 f Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT_ S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: Owner: Date of Inspection: BUILDING SEWER(locate on site plan) V Depth below grade: Materials of construction:_cast iron _40 PVC other(explain):. Distance from private water supply well or suction line: ` Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below grade: 5!� .Material of construction::L/1C,0ncrete_metal_fiberglass_polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliz-ice (yes or no):_(attach a copy of certificate) DimensionS:0'S X(, ` ks Sludge depth: /q ` �� of Distance from top of sludge to bottom of outlet tee or baffle. Scum thickness: Distance from top of scum to top of outlet tee or baffle: 2 �� Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: ,� X-,on4 Comments(on pumping recommen at� ions,&eet and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert, vidence of lea age, etc): f ii GREASE T"(locate on site plan) a Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page.8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: . CST Owner•d Date of Inspection: TIGHT or HOLDING TANK'",Y stank 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: gal lo-is Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working.order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX:—LZ/(if preser_t must be opened)(locate on site plan) Depth of liquid level above outlet invert: , � �J2 Comments(note if box is level and distribution to outlet'equal, any evidence of solids carryover,.any evidence of .1 kage intq or out of bQx,etc.): n PUMP CHAMBE (locate on site plan). Pumps in working order(yes or no.): Alarms in working order(yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7? G�^ Owner: Date of Inspection:t7 AYr , SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: 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 por_ding, damp soil, condition of vegetation, et ): c � r j A. v c r)tj CESSPOOLSID(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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIV�Y/VA (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.): 9 Pace 10 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: "af L _ (/Jil(/Z JCfG► Owner: r ' Date of Inspection:tea» �� C7S SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposa 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. �1 J ,p � 0' l yi a I 10 Page I I of 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEINJ INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner a. Date of Inspection:V , 0 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet Please indicate(check) all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of cosign plan reviewed: Observed site(abutting property/observation hole within 150 feet o=SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers-(attach documentation) _i/Accessed USGS database-explain: You must describe how you established the high ground water elevation46 11 Permit Plumber: Date: Competed by: ` HIGH GROUND-WATER LEVEL COMPUTAITION Site Location: "� -5 1�� Lot No. Owner: S LI Address: Contractor: /7�Address: J�— d' Notes: STEP 1 Measure depth to water table tonearest 1/10 . ............................................_................................. .Date _ month/dd ay/Year i STEP 2 Using Water-Level Range ?one and Index Well Map locaLB site and determine: OAppropriate index we'l......................... .......... B� Water-level ranae zone ...................................................- STEP 3 Using monthly report "Current Water Resources Conditicns" determine current depth �o water level for index well ........................... �Z 7,�I month/year STEP 4 Using Table of Water-levy Adjustments for index well (STEP 2A), current depth to water level for index v--ell (STEP 3), II and water-level zone (STEP 2B) 7 determine water-level adjustment .......................................................................................... STEP 5 Estimate depth to high w-ater by subtracting the water- level adjustment (STEP Q from measured depth to water level at site (STEP 1) .......................................................... . ................................................ �21 Figure 13.—Reproducible computation firm. 15 i w.......... .�........,>.a...,, ..,I�_•. ..��..--..�.,..._........ .....-,.,,............-....�........, i,.,...,...�.,...... ....... .............:-.J.._..,............._...,...... 1 , j x .. ASSESSORS MAP N0: '� PARCEL N0: 2 ZZ No... Fmc.... .=3.4�a........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Mipasal Workii Tomitrurtiurt ramit Application is hereby made for a Permit to Construct ( ) or Repair 11>6 an Individual Sewage Disposal System at: .......2 - Av PA...... r 'Q.... ..........................- Location-Address or Lot No. .......E:=..------S 1 tv . ...................... ...... e>yks,L-r—Y.,�1�.....-...__......_....... .... ............. ---. ... ----- Owner Address W �eK ..._...lp N -•----•--•----•................................. ....... �3`�` '' ............. :! S................... W Installer Address U Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther Other—Type of Building ............................ No. of persons.....--..............--..... Showers ( ) — Cafeteria fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.........--.gallons Length................ Width--.....----..... Diameter....----........ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.--..........--..... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit......--............ Depth to ground water..---.--................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ Oa --••-•-•----••---------------•--•-------------••••---------•-------••------...-•----..............--......................................................... Description of Soil........................................................................................................................................................................ W U .........................................................•-•----------------••-----•-•-•-------•---•----•------•-••---•-------------•--•----•--------•---------...-•-••••------------------•------------ W x -••--------------------------•-•---------•-•------•----•••-•--•-•---•-----------•-•--------••--------------•----•------------•.....----•---•--•---------•--•------------•-••-•-------•••---------------- U Nature of Repairs or Alterations—Answer when applicable....PQ&-----------4........0! _SVI Tex _._._..i............. r...---•--------•-----------••----•--•----•----•---••-----------------------•------------------•------------...------------......---•--•---•---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com has been issued by the board of health. Signed .- ---- --- I 1 4-\------ ApplicationApproved By ............ ---------�.......----------------------------------------------------------- —_9.2 to Application Disapproved for the following reasons- -------------- -------------------------------- --------------- ------------------- ----------- ---............. -- ------------------------ ------------------------------------------------------------------ ------------ ------------ --------------- --------------- -------------------- ----------------- ........................................ Dare PermitNo. ......... .....c/ U-C)--------_--------------- Issued -------------- --------.------------------. Date /4 'x No...., sz� ... THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF• HEALTH TOWN OF BARNSTABLE Appliratiun for Disposal Works Tuntrurtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair (?o an Individual Sewage Disposal System at: --.....226......a� p....._. ......:i��.... ................................................... ....... -..... Location-Address or Lot No. ...... . ........--•• .. ---••-•-•----•••--•...............•-••••••-•--••............---------............. Owner Address w ... �..kc`.---.- ............�--.--•.. - a ,zs va - Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling No. of Bedrooms................. __...Ex Expansion Attic a g— ---------------------- p ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter------_-____.-_- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-----__------•--.---_--. 9 --------------------------------------------------------•-••-------•--------.........._...-•-••••.. D . Description of Soil--------------------------------------------------------------•-••-•----------------------------------------......--------------------------------------.........----- W x -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•------- U Nature of Repairs or Alterations—Answer when applicable._.-_A -----------3... ... TLC............ tit� (`---------5�"s ............................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n i�d by the board of health. l Signed ......__.._.J - . .�. J S Application Approved By .. 7 ...-...- ., . -------------------------------------------------------------------- -----3 �- Application:Disapproved for the following reasons- - --------------------- -- ------------------------------------ ------- ------------------- -- ------ ...... ....................................................---------------------------- ---------------------------------------- Date Permit No. ----------/�d- - PC) Issued ................... ...... .-- ---------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of dulomplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired/( by......... .�e r`L"4---------00 Nsc................................................. Installer at ..... ��5 N C t 20�� .......c..GN...T__E ... - ------------..................................................------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .........c ------------- dated ............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................................... --- .-/- 7.Y.:�rs�....------------ ---------- Inspector ................. \\ ------------------------------- ........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 7 No.......(I...�.:.�.10 FEE.. ? ?.."- ... Disposal Works Tuntrudiun Prrutit Permission is hereby granted.....4A'c ._...co^?Se 0Z-1) ----------------------------------------------------------------•-•-...........-••...... to Construct ( ) or Repair R an Individual Sewage Disposal Systemat No....... .......................... ! f ------------------•----------------------------------------................ Street qR as shown on the application for Disposal Works Construction Permit No./�-Q. Dated.......................................... ------------------------------------------------------- ? ^ Board of Health DATE 3.. ---- %...................... FORM 3850E HOBBS&WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE LOCATICEN g� Zu c- Pt� SEWAGE # 9-)- //l) VILLAGE ASSESSOR'S MAP & LOT��j� INSTALLER'S NAME & PHONE NO. 1*69EI eoA)L-1�71 - SEPTIC TANK CAPACITY 1., y LEACHING FACILITY:(type) s ;zit-S —(size)— NO. OF BEDROOMS PRIVATE WEL OR PUBLIC !ATE R— BUILDER O O]WNE_P� %r✓e,z� DATE PERMIT ISSUED:' DATE COMPLIANCE ISSUED: `-I/zo I9z: VARIANCE GRANTED: Yes No / yct CC �w L t •e �/Gs'' U I No... ....... � Fz�$....../f. . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , pphratiun for UinVuuttl Wurk,i Towitrnrtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ... .25...........�J`` •---•---- v .-----. -------------- i�---•---•---..............------•--------••-. Location- \ddress or Lot No. �td�G yL��1---------------- }�C. ..............._...... ------�' owner Address r C-... .. `tA,��`' .... !i' Du°1 Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms._..________________ _ _ ___-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) p-' Other fixtures _____________________ w Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter_------------- Depth................ x Disposal Trench—No. .................... Width--------------------- Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by__________________________________________________________________________ Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_- _.--_.--_---_--:--.. (Z4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -------•-----••-----------------•---.......-•-.........---•-----•-----•-----•----------•-•----------................................. -------- ------- ----- ••-- 0 Description of Soil......................................................................................................................................................................... x U ---•--•-••-••-•---•••••-----••-----------•--•-•-----------•--••---------••---•---•-•••--•-....---••---•--------••..• ......•-••-----------•-...•---••-•----•------••-•---------•-•-•-•-----------•--••. w UNature of Repairs or Alterations—Answer when applic le.__ �........ .......1 _�I+t!� `�............_............. ................................. —......5L P i.................... ......!^ ...MQ------ L-------VO4lu .. pw _.. .... /... : Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed .. ----------------------------------- Date Application Approved By --------------- �Lt-rl.�, �"=' --------...----------------------------------------------------- .......le; e '-- -� V Application Disapproved for the following reasons: ...................... .......................................................... . -- . ........ . --.. ... .......... ................ .. ................ Dace Permit No. --------Cf.-Ll----- -7------------------ Issued --------------------tom- - .......... .. ... Da[e _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinu for Dhi-pn3ttl Eorkg Tomitrurt"inn f amit Application is hereby made for a Permit to =onstruct ( ) or Repair ( an Individual Sewage Disposal System at: T e- 1.. ............................................ Location,.,Address\ddress or Lot No. 3-rw•-•-•--•••-•--S� _c. '! --------•-------------------------------------------------------•-...... ---••-•-•• --- Owner Address a ............ �........��?+�J.S�. 6�---= �-- ��4�aN..!s_.. G 01 Iustaller Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures . ---•----••-•----•-•----------------------•-•----------------------------------- ---------•---•--•-•-•--•--•--•------------•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity----------:.gallons Length---------------- Width---------------- Diameter.-.-.--_------ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank.( ) Percolation Test Results Performed by--------- --'----•---••••----•-...•••--•---•--•-•-----•••------•-•••••••. Date........................................ 1.4 Test Pit No. I----------------minutes per inch Depth of Test Pit--..--.....-_''.... Depth to ground water..-.-----------_-.----_ (Z�_-- Test Pit No. 2................minutes per inch Depth of Test Pit....-..--_--_--.---. Depth to ground water...--_.............._... _� Descriptionof Soil........................................................................................................................................................................ x c, w UNature of Repairs or Alterations—Answer when applicable---P�—...._.�A------.I* .-\.-W^J0'Az-s........................... - b...... F_ .'\_. >, -------SF-P- - --•-•S..'S•T - 1---- I.... ......5 ......... 4Slts.0 ,. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued bythe board of health. A l Signed '`�x -- " :... - .............- � .. Date Application Approved By,' ........... �� t .-�, ------ ......./. .---- -.: f �7 S -' �7 V �--'- '------ .,.tnw�.r...,{ Dare Application Disapproved for the following reasons: .............................................. ............' .... ............................ . ' .......--"' . ---------------------------------------------------------------------------------------------------------..__---.............-..._-------------------------------------------------...---------.... ........................................ Dare PermitNo. ........�/---- 6---.- -7-------------------- Issued .................................................. . Dare _ —_.___---_ _..___r.._ _____—__---,--_.— —— ——_. i_—_._______—_,a._ ----_._.__ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Q'Wr#ifirate of C�Dntylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ) by --- 0 i,c V_C_;L1 ��J 5� Q O - �- ' _ - -------------- ----------------------------------------.._.-----------.----W -=-- ------------------------....-------......-------------------...----------......-.----- --------------------------------------------- Installer at ��-`r-��S--------------(2 j�..s`R--.----CZ ------------C.- v _.Ct V...` .......... ' ..... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..._ -f�. G-a. _...: ........... dated ....._------__----.-_-------------...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRLZ� _AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..... --- -----------I.-_-,--------77---------------------------------;Z_ l : %' ----- ..,1.... -------- Inspector THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH l Jl 7 TOWN OF BARNSTABLE // Bili'Vnn1 Works Tnnitrudinn "an it Permission is hereby granted.... 41......r'd`� S� to Construct ) or Repair ((3 an Individual Sewage Disposal System atNo. c� a•--------�U-� 5-------•-- \.....'2r...----•'�Osa�--------------------------•-------•-•----- Street as shown on the application for Disposal Works Construction Permit No.7.V-_t147__ Dated----- ........ Board of Health DATE........... --------/ I ........... FORM 36508 HOBBS✓t WARREN.INC..PUBLISHERS s : x f 1 \\ i� J. y `,h 111 ----- ---- v-- ---------------- -------------- --- -------- -- -- T CF BARNSTABLE LOCATION // SEWAGE # o� 7 VJ1 LAGE - � &= 4,!4 ASSESSOR'S MAP & LOT D �Q��OR� NAME&PHONE N�?�'�7.��s�Lti�i-� Ot7lo,�i����2G1/Yl Sbf�•77/•�3/`� SEPTIC TANK CAPACITY "D '/ LEACHING FACILITY: (type) (size) NO. OF BEDROOMS En— BUILDER OR 6�A/.�1 ✓ - PERMITDATE: COMPLIANCE DATE: 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 on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leachung Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by AD 0 ec(t�o OUJ {, TOWN OF BARNSTABLE �► LOCATION �� ir�ir��, �! -- --SEWAGE # Z VILLAGE1, Al ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. MKS Z . SEPTIC TANK C PACITYr�� LEACHING FACILITYAtype) (size) uNO. OF BEDROOMS ,4"" PRIVATE WELL OR PUBLIC WATER OR OWNERI4�, � DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ' - �- A� �' v ' ,w'n D �, �� ` 6 4 � �, ...................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ------..t.o ............. OF..... ......... . . Appliration for Digpuiial Works Tomitrnrtinn Prratit Application is hereby made for a Permit to Construct (VJ"or Repair ( ) an Individual Sewage Disposal System at:..........................B.0 L-�, � t � d Location-Ad,ess or Lot No. 1 �.1u ---.----- .? .` .......................... ner Address a ------------------------------ - ----------------------- - ---...........---- Installer Address Type of Building / ,,� Size Lot__ �_ �?....Sq. feet U Dwelling—No. of Bedrooms...................__...................Expansion Attic ( ) Garbage Grinder ( ) PL4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures -------------------------------- - W Design Flow................SS........;........_._gallons per person per day. Total daily flow-----------------3��---_--..._--_gallons. 9 Septic Tank—Liquid capacity`Q®Qgallons Length................ Width---------------- Diameter................ Depth................ Disposal Trench—No. .................... Width......3------------- Total Length.................... Total leaching area....................sq. ft. ISeepage Pit No--------- .......__-. iameter-______-467...__. Depth below inlet.......&....... Total leaching area.._�.�.___�...sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1-----7>-._._minutes per inch Depth of Test Pit-------L ------ Depth to ground water--------- ...... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ...-......................................................................................................................................................... 0 Description of Soil-----------------------••-- ---------------- --------------------------------------------------------------------------- xt- �`°'.--------- y` � ------------------------------------------------------------------------ -- W -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- VNature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------_................................ -•---------------------------------------------------------•------------------------.............----------•--••----------•-----••----••---•-•-••---•••-•-------.....-•----•••----------•••-••-•---. .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TT T L 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed--a.................................................................................. ................................ Date Application Approved BYM.j C. �t•��` � ! ./.y,�� -� Date Application Disapproved for the following reasons:................................................................................................................ .............•---------------•--.....------------------------------------•---------..•...--..........................................................._................................................ Date PermitNo......................................................... Issued....................................................... Date J � � No.. 2 �. ............... THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH ..............OF...." Appliratiun for Biipuual Vorkti Tunitrnrtiun JIrrmit Application is hereby made for a Permit to Construct ( II<Or Repair ( ) an Individual Sewage Disposal System at: ................-............ ........................ .......................................... --- ......................................... Location-Address or Lot No. ..................... ;;,/ er Address ---••••.............. • ... .g � .......... ......................... -•••-••••.........-----.................... Installer Address U Type of Building Size ...Sq. feet Dwelling—No. of Bedrooms..............3........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ___________________________ No. of persons............................ Showers ( ). — Cafeteria ( ) a Other fixtures .---.....--••••................. .. . W Design Flow................ .....................gallons per person per day. Total daily flow..................5'-40.•............gallons. WSeptic Tank—Liquid capacity.tP�lions Length................ Width................ Diameter-------------- Depth................ x Disposal Trench—No..................... Width......i.................... Total Length.................... Total leaching area ...........sq. ft. Seepage Pit No--------- ----------- iameter......... _..... Depth below inlet........ !.:..... Total leaching area........... ..sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date-----------------------••-•----•------ ,� Test Pit No. I.....Ze....minutes per inch Depth of Test Pit__--__.E. ..._ Depth to ground water......... ' °`.......- L1 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---•----•--••-------------••---•--•--•--.....-•--••---------•-----••---------------------"--•---•------------ ..... .--------------------------- *-------------- 0 Description of Soil.............................=.1.................................. x -----•---•-....-•-••--•-•-•--•--•-••......................•- r �' -•'1 r 'i.....------•-•�s_l i --------........................-............................................... U W -------- ----------------------------------------------------------------------------------------- -----------------------------•--------------------................................................. U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------!.......................................... ----------------------------------------------------------------------------------------------------•--•--•-••-••--•••-------------•--•-•••••--------••--••----•-•--•-•••--•-......----•-....---------•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE�.E p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed•..............•...-------------=----------------•-----...-•-------................ -•-----••-••-••-..........------ �� , � Date r ApplicationApproved By--••---''•e==�-•-•�'..............................•-•-------------.............--•---.... 7 P-' - - -- ...•......----- T — - . — - Date Application Disapproved for the following reasons:-•-•--••--------••••----•----•----••-••--•--•----•---•--•---••--••----•---•-••••-••••••......................... y Date PermitNo......................................................... Issued_'L....-------------------------•---•......------•--- I4 Date • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... Curr#if iratr of Tu pliunre THIS IS TO.CERTIFY, That the In ewa e Dos ste constructed �*or Repaired by-------•..............•........---.........-•------.........--•--.......M ................ .............................................................. Installer at..............rl..... ----------- .../..1-'. --------....-r v-f- •------•.....•-....-=----------•----..... •:...:................................................... has been installed in accordance with the provisions of TITIZ j of The State Sanitary Code as described in the application for Disposal Works Construction Permit .......... dated------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......3--/ 11............................................... Inspector.- .,6w;_.-,4� .- ----....---........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.......�............... FEE...�..109 ....... fur n��r� w. ler�tit Permission is hereby granted-•--•--••--••• ............................................... to Construct ( i-f or Repair ( ) an Individual Sewage Disposal System at No..---1_/</ r/........ r i, /-,I., j: f I r /.• ,� l� C //,l / !-. ---------- ----•........•.....••--••-•.........--•-•.----••••--------••--•--••----•------•--••••••-•----••--••--•-•--••......--••••......•-•-....... Street as shown on the application for Disposal Works Construction Permit No_________________ a ed.._._.___._.__...----- ................ �- ..............................................04 -...--•------ • DATE. a 10 Bo r of Health �S► FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 0�_�1�►�_y a.-rs Q �,Io C�A.rr�nGE GR!s.tDF�2 i>dt L'4 ;:Low _ I l0 x S G.P.U. \ (p KEPT-IG TAti!K = 3—_�p,e IS % = 4-9S 6.P.D. �j5Po5AL PIT - USE t000 ��.. ` SM&W,AL.L AZEA = Iso s.t=. +----_ 84 ,( S IV 1r7v SF" )c 2.S = SD 5o5=. A I .p Tc:r-,A L .42S G.�n• L.U1140 ?bTQ t_ r->A t U-( F4 W L - 330 6.PD. Pt-:�:iZGDLQTIoQ O&TE ( IQ IAAI W' 02 LF1 � 30�� Ptz�pos�:p L: Tt 5 ` 3558 1 t<1 Io Prr T?csT ' FL z`r3 T'or T7No =goo.d f F-& 43 S✓��sae.. 4'pp� DK1 Iw. 1 Z wv. L IOoo GAL.. -Box 9a.G Sepric10V t►N TAr1K QO.d q "L:rAcafi PIT N1�7. Wiro WASHED STO�.lE �o i i Ct=QTIFIED pLbT' �'L./��...i PRrO�t Lir t bCA Tl o ty -- G�� �JI Lrc..r � ' 'I D WATWZ- oSC�'t� SC.AI.� �! -- Got? �ATt✓ (`z11t3 "-15 P pl—A Q TZ r 1=E:V-E cG I CM tz-r IP 1{ T F-(A T T N E D W�.a QG 5 tAotic.►u t- Z-.,l_OI-I Gc:WlPLVG W I TrA TWE 51 D E LI► & I ,t Aua SET�ACIG L'C-QUI�EMct.�TS O� TNT -f� 1 -TOVJQ Op 1'Z I�v :, WY a I uJ C- cZCG15"rc_I;cI:> to Wo 5ve�irYc�c'S Tt-A15 FLAW (", L(O'T � A�>GL7 0114 A" OSTEE'�/11.1.!_ v 11,tAS5. 1tJS['2L1f✓�E.►•1T i�v,_�/��{ T►•1C� cal=c�i�l-�, ,!•1aW W tIbr (3u= ul-lGr_" ro � s 1:0 C A"T ION;?' SEWAGE PERMIT NO. VILLAGE �. INSTA LLER'S NAME i ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED a212V DAT E COMPLIANCE ISSUED za !p T-F kki-v-. F-I T _�4 f I10-rn — i 7-7-- FT i ( i 1- (-- ►---i-- I � - - --�----�- ---� ► f_ 1 _ I--�I--_l__�-- --------� � �hJ_- All lo kA_ i ` ii -!� i I I__--...— —L----i—-r----i-----r---I--- I r--- - - —1-- — I � I I I ---- ----- � � � ! I � I � i _-___-�—T I ! I i � i r t T � C l i 1 � ,_ ; ; � i �—�os�,.�s ._iv_i __ _ � ----- _ _ F-T----------- ------------ � � � tl l-- I I i � I � � __ I ( T ! I I j \�j \V� ,,- - - -r- --i-� --�= - `f � 2,_j J71 !-----!-►-__� _�_ _ � � ._1_ , (__ _ , I�►i�-I I I � I _-C--- �=�--1- i- �--! -�-.- --- -7— -!------ ---1--�__ __I -I_ -1--!_� -- ____-�--_I----____ --�------_►_�-.(— _ -� � __�i 7-- - — ►�1--_-.! _---- - 1 - I- I_.- � I I 1 T 1-1— C� 1-= I i I __�l i V`� I- T --(----I �---- I_ C� -__�-�-�_ 1� u -- --------- rW hl�av i_--�- -� I- I _I- i ! -C -j I i , �� 61. E —F 1 1 1 I I I 1 I I ��T'; ��+ I - ._��_�___�____,�___T__�_____!___�—_i___�_a !__�__ ! __ !__!.__ ____ ___ _ _�___ ! _____ _ ___! _ i__I __ _ � _._T�l _I _._ � _ � C- r i . I __� ._ T _ !_ r �i rt_ � � '— �-��_i� 1�(� ! _►�_T � I � —�- � — -----C---C--!—� -'----! — ► ���—i--' �---� ►--!—' ► _i l�I—. 1���-i_ ( �--T T[—!�—�I=► -- _�--�_�_ _�— j -- �---� -►.T�TT_-�---�� ti . I -__I _� ____I—I� �T I T TTTTTI� �_! --n �-----i - _-�---------1---I_-I..---�----!-_-1 T� �T i ;�T - (� __I -_T r r I r I:TTI- i �� - 1 I _ I� I - -------r--- -,- -- - ->---- -- --- - - - - -- - - - - T—I _! _.! � ! T__�T—►:__i�-- I ---- — I ► ! �_ ��I � T-I—_- TT �T�I �T�.T ---� �I T.�T� ��T��—TAT— I��. i- i ! I I 1 T--I -a--- --- --! __ T ! --I -) � �1--- I -� ► I _,___.I � _ � 1 C I _ I : 1 , I I_ I--- ► i �_(� , I � i 1 T � l l � ! i l � i �T- C C i � � � l l i � 1 � T __I-T_i � � I I ► I_-�--I---! � ! I C �---T ! ---�----�--_�---___�-__l_ ---------�---� -!--------a-- ► -� - ----- --- --- -i I--_ I _Ti - I- - - -- -r-- - --- �� - � - --- -1- I__' ` �� �_ - I i i ! i ! TT Tom- - 1- -T T-1T ► T I JI---T ��T T-��TTT-_ _m I _ -►-� T-f 1- 3 � _� w - - - F VC ----------- , L T_ FT T_ F-T rr T-F YT _. _F F J T rld TT- A-L Al U T T-1 _L -J LL I --I +----I---!--�_!--T--�------�—►�i ---T r I ► -- - !--,�—g --► - C _ 1— I 1 � � _ i_i_ � �i . � _��� r _� �l _l_���_ � _ I�! I_� I-C _T_ _T 7 I I� � - i I , ..! ' _. i i -r -I- _i_ I. ! ._ _!..._. ......`_ I I ---' -- ------------ ---— --- I I ! � 1 , I i ---: - ---- ---- I ,- i 1 I -I ---I I � ! I III I , i � l I lil i t TI 1 � -( I I I i r--� I I I I �.-._.L_- I I - --- -...----------- --- -- I-C---- --I---------- _ i- 1----` r-_ - ------- - - !- : ! I I CI _ I il_—.-I-- hA , I - i i---I � _- ---�-- - - -- -- I - I--- --_ - ---I-- - -- -- !-- -----� ------- t I -- -- �---T---,=-T �-- r ------� -r--r--I— I I ---!- --C---i.—..L.--�--�--'�---�-----: i I —I---- T I T-_-__ ----_.� I __-�-t_-_ -- -_ _L._- _- -_-T TT T__�_ ! 1--_ T �-..f _... I. � _-I_- _ I � --1 I T I TI•----- I ! -.i _-I 1 i-- , � -T I e i I T TTT I I —I - — ! - --I. I I —I !- T_ I--- II_�� l ��/� T T� !--I T ! _� T .-�---� _�T T ! � T __o_T _� T�I�� I I � IIIL__ 1 ► T IIr- C� I � �---T- I j TTT T ! - - � I ! - __� ._,- r � �_f !!r,�I -T ----_ T T _�__- -- - C T T_ _►_�- -- T- =!-------I !--�_-� 1-T---T---T—!----!-- ! -! �—,_ � _I ! T� __ - TTTT�I � _ T T_� _I —I—► —(— --- -T--1 --�-I------ ���--_1;_i I --!----D T-a-!_ �� T I I I 11 ( T I- - — ►___TC- - T � , — -- TT I -I - - _ _TTT � _I��,� � _TTT__l _ _� - ► T T- —T-T !- I----! ---1---T------- ------1--=!----! -�- �(- T I— - --- - __ � l _� � -_.T- T T - -��T__. __� TT - __.- T�--_ Ti�__ T- _____-=_ _l . _.--- --- ---�----T �T_-T.. C �-► __►_TT _-►_ _I �_�_ � -__. _�--1_l _- i I--C TT---T � --- � T--I-T T TT1T i T i T�-T(I ► T T T I iT T- I T�ITT � __1____I ._ -._ ..�... �T .__: __I TLL TT I- TTT T—ST _ i III ► i I I TT I I � , 1 _C � -T TT TTT TT TT _____ —1 I ► -I I ! T __ T Imo! T-T TT T �.� I T _ z� ,f)//� ► '- - -i- � --! -- - T._ T �TT TT T-1_ 17� T TT-TT I I TT T I TT TTT r- ! l-l- i T-I ITT TT- i J� cr IVI J vl' 1 1 -7-7- �(- - - I I T� C ..... r T _ ��__ ,__I�- %T �rq ,�( _► _� T_ -C I- I�......... wl- !_I I � (-T 1-� __ I ! _�__- _�__i _ ����xr,'-����d l�� � !I�_-_ I f I-_� �T�I f II -F- �__ �' �! I �!--- -!-_I� I ! -�-- --- --T�I_ -- 9 ,�I � - --1 �i_C� � r � I I ----- _- I� __ TT____ T-- 7F ��__.�_-T-� _�C � ► ! � _- � I _ ___ L � �f°-�e-�I ��-��h -,�! - T ► T--- I �l�=i� I - -. _�T -i - - -- -__ ! I .�T �C-- !_�Y�1-! C-�����= _! ------- - � L�T-C� -1 ��_i -�-� _ TV I ! r _T _ �- � I _ _� �T�1T�1� i ----------------------- -- - -�_ -- -- - - -- .--- _I � T 1- I r - -----�-_--C�TTT� (� 1 L F-T-7-t I T I � i � I � C- � I T- � 1 I 7 � .��� _I _� __ T Tl C- -----��� d�s�_ __ �-1 _l -T-' -i ;-_Z__� C � __� � _T C _ -T _ -1�T>�1-� F-F! ------�--- -I--�--�— ---;—�-------�-�--- . — -- ____C✓ T_ 1I - --I--1--_i-__ .___—�__ ___�_� li I T__ __ T-1 __��__C-T T--TTIT l—C- -�_I � � _�_ �1 I__ II�I � l i � , � �r� I5 � ! T-1_>---1_ � -h ---F. 1 F 4-1 1-� _ I -� -1 ; I T_ _ , _r_ cc- Ix b���`�,��e� tt�_ � ��� I��— ____. �I ! � . i !—T- _�� - ---.0 __ =CT I—.�,� T ---��� 1_ �—T— �T I F, 97 _ TC=T-� � � Cam- _ j -f--� i � �- � , i � I �}--�.�j- - -� � � .� __ , - -- --C� -� -- � —I— T _ T� __ T _ -._ _-_ -� T- --- ---- �. --- --- �=--���IT_ � �a her;_�e_��?��I -� -- - — .... . ................... ——- ------------- T— --Iq — — ------- r•/_;- I _.._ _ -- - ---'------ --- ---' ---r--_--i I I _I I 1 I I I 1 I , � , I I i ! I I I I '---�--------i-- ----r- �--I --�-- - I -- -! --_�._.._ i -;-- � - � --- I- ---- - - ._. _-� _- /' - -- ICY-� T (-1-I I I - i- 1 i I : i_��- • �---�----I -�-' ! � I-_! ! -I� ! -I-! ----- i-- I - -�.i I I �- --- --I--�- I I -- - -� -- ---- ---- -- �-- ------ ---------I-----j-------I----- � -! - i I I-I I--- TII � I 1 ! I I�I I � j I I I � t i I i i_-.__..-__ _I-_-•--i--._- _--__I�-_. I -! I T � I �I I I I--�-' � � � I T �---- I -i ---�► - �- ---�i _C I -; C_-- - - ! T .r -1'� - � -�-�--I--�- -�--�'-- ��-!--�-� _--- -I -- - T C -�1- ! � �►� C � I ��-.-�---1--� -J-,- - - �- ! - - I � ; ! l I i I I I ► I � I ! ,�►--► � � I T l- � L - �I �--I--' --I- 1- ! --- - ! _ 1 _� T I I 1 � I l i i !_ i i� 11-_i ! -i ►_ __ ►� i _� ! ! I 1 i t _ f I I I � ! I T�I�I �I- I-� I I xe- \3-' (-! F! I -T- I I I 1 j - �- - T 1I _ 1 _i_ _ I_ � ! r_,�_ ! -- ---I �►_- �� I I I T- i I �I i i-1 i�-1�-