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HomeMy WebLinkAbout0140 CEDRIC ROAD - Health 140 Cedric Road Centerville A= 149-079 /// SMEAD� No.2453LOR UPC 1284 .n escLe m • wd.ln USA ,� � ==wmn w I � wwMR0 100 `'`' No. � Fee , / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pphrat1on for Misposal opstem. Const rtion 3pPrmit Application for a Permit to Construct( ) Repair(%-�Upg&de( ) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. Lt,® Z�i 1'G Owner's Name,Address,and Tel.No. Cr � �d�n4n CcM (bGL1 Assessor's Map/Parcel I L[ ') 4,V � Installer's Nape,Addr�s and Tel No. Designer's Name Address,and Tel.No. 5 co Yc�/"� 63 a cd yc�rM,� ` ev-c, l-�Gas 90 ..-c, o E st Type of Building: S-6 Fr a Lt u 0 61 ®JL G b U Dwelling No.of Bedrooms Lot Size 1 6 4 7 tl sq.ft. Garbage Grinder(N)f Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures *� Design Flow(min.required) _2 2 gpd Design flow provided 0. gpd Plan Date 3 j f f Number of sheets Revision Date Title Size of Septic Tank o)(1>* L 60 6 Type of S.A�.S". J_C (�, L�G CL. rn A o.L t>,j Description of Soil rn t rU d S cyi�. ,' S A x g C.9 T/ 7 L X Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Board f Health. Signe z Date Application Approved by �/ Date Application Disapproved by Date for the following reasons Permit No. �.��a J Date Issued a/I No. /1 � j 1 Fee �tJG/, va i r Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pptication for Rlisplasal 6pStrm Construction 3permit Application for a Permit to Construct( ) Repair('Wgt!ade( ) Abandon( ) ❑Complete System W Individual Components Location Address or Lot No. 14 Q Ce r.q C �,41 Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (�(� Installer's Name,Addres ,and Tel No. Desi ner's N e,Address,and Tel.No. 5COt ft A J,-r k1LJ>. e"C' 0 t3 oK re)cr. Type of Building: - 4 6 F"a �4 la b� 6 41(a b U Dwelling No.of Bedrooms Lot Size 1 64'7A sq.ft. Garbage Grinder(�J)Q Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided , gpd' Plan Date [ I Number of sheets Revision Date Title.- Size of Septic Tank 9 1006 Type of S.A.S. �m Description of Soii /�- 2'd :S C�rJ, L X j i/i Nature of.Repairs or Alterations(Answer when applicable) \LP_te V C Le , e k C 5 LZ R L fin. P%-t Date last inspected: ,yr' Agreement: v ! . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in ac ordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of" Compliance has been issued by this Board of Health. l f i Signed" _ /Date <f I's- f Application Approved by �s �d�� "`- ---.. Date Application Disapproved by Date .Wfor the following reasons Permit No. 0018 ` 31 i Date Issued 1 t 70 0-------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(v)"" Upgraded( ) Abandoned( )by c0 YC at 14 f) C t car i C (,rrtis��tQ has been constructed in accordance t, with the provisions of Title 5 and the for Disposal System Construction Permit No.Zff(t"331 dated ~�� 51MI 1 p t , Ipstaller '� v, � �r`C.,.1'�►,`""i..- Designer S'�"'�Ve.- �F'r G►,fE..j ` #bedrooms Z { Approved design flow Ica �� /�{ d. �� a $P The issuance of this permits I t liiconnst ued as a guarantee that the system ill �c ion as esig ee�d7.bDate. / �/ / Inspectory ----- ---y--------------- ----- ---- -- - --------------- ---- ------------------------------------------------- ------------------ No. ,01 V — � Fee I�� p0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6 ste onstructlon i3ermit Permission is.hereby granted to Construct( ) tRepair( � Upgrade( ) Abandon( ) System located at df and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: onslpction must be completed within three years of the date of this permit. Date 7 Approved by Town of Barnstable Regulatory Services Richard V. Scali,Interim Director MAMg Public Health Division ►arlc+' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date:� l Sewage Permit#aO f r 3;31� Assessor's Map\Parcel AK—.2 9 Designer: 5TE1E RaU A. k A 1kS,PC Installer: 5e_0_C'T_ t A- T_ -- �l�-- Address: } y• l � lL Address: LIS ots YAZI400 _r14 Rh so-VmA 1�6J�Ur� �� �' �iy�l A. c�2� I ff oZ�L�o On �l f S 1 Z6[k T !'� FV-43 K was issued a permit to install a (date) (installer) septic system at cxj -t:� V based on a design drawn by (address) �" Ei;f � 1►�- . 44*40k-S, dated (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed "'` nce with the terms of the I\A approval letters (if applicable) (Installer's Signature) , (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE B_ARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc • TOWN OF BA STABLE LOCATION ` ® CZ- SEWAGE# \� VILLAGE'L' e/ -k �%' �k� ASSESSOR'S MAP&PARCEL �S INSTALLER'S NAME&PHONE NO. —3 C0 C-X Y 1 a 06661 SEPTIC TANK CAPACITY - C�® (1 1�0 D QtX LEACHING FACILITY: (type)(,, O QWAA ` e) f V V NO.OF BEDROOMS OWNER PERMIT DATE:1 (T ] (�i 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 'Feet FURNISHED BY Rd A3 x6 , Town. of Barnstable P# Department of Regulatory Services Public Health Division Date IZ r}3 1.639. 200 Main Street,Hyannis MA 02601 tEo MKt� Pe,+ two / C_ Date Scheduled Time �L) Fee Pd._ ` ;w Sail Suitability Assessment for age DisposalF `� Performed-By: �� Witnessed By: V LOCATION&.GENERAL INFORMATION Location Address 6 CO- wner's Name I Lf O- c d �Lo v a,- Cw C�1v ►ti��� Address tqo C,Q,dr✓1(, ad '6-Vil Assessor's Map/Parcel: i q C� O? Engineer's Name NEW CONSTRUCTION �G REPAIR Telephone# -!�—O ?r 3 6 2 1 t a,. / a 7txsl7 ice` Land Use' Slopes(96) Z— Surface Stones Vy Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft I i Drdihage Way 1 ft Property Line !a f ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands-In proximity, to holes) O • 4 Parent material(geologic) r '�sa 20t�-t Depth to 0erliaek Depth to Oroundwater. Standing Water'in Hole:_ �f iK Weeping from Pit Fnca /N A stlmated Seasonal High Groundwater DET RMINATION FOR SEASONAL•LIIGH WATER TABLE Method Used: h Depth Observed standing in obs.hole: In, Depth to still mottles, In., Poilth to weeping from side of obs,hole: —in, aroundwater Adjusttdont ft. dex Well-#r Roading Date: - Index Well level :_ , Adj,•fhctor— Adj.drOundwater-Leval,.,_, PERCOLATION TEST Date t T W# f� - Observation ~� Hole# l Tinto at 9" Depth of Pero Pi q Time at 6" Start Pro-soak Time @ . 0=ve' Timo(91'4") End Pro-soak Rate Min./Inch Sitc Sultability Assessment: Site Passed ✓ Sitp Palled: Additional Testing Needed(YIN) Original: Public Health Division Observtition Hole Data To Be Completed on Back---------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the Barnstable Consel}vation Division at least one(1) week prior to beginning. Q:1SEP'FlWERCF6RM.DOC DEEP.OBSERVATION HOLE LOG Hole# I _ Depth from Soli Horizon Soil Texture Shc1 Color Sol]• Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stoned;Boulders. Consistency,%'t3aavel) a [fS IVY s�3 h L • NS lvY� � o , DEEP OBSERVATION HOLE LOG Hole# 2— Depth from Soil Horizon Soil Texture Sol]Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. C 5 o eZR-- DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(In.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders._ Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Noll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,S(opos;Boulders, Consistency. Orgypl) Flood Insurance Rate Man: Above 500 year Mood boundary No— Yes Within 500 year boundary No°� Yes.;.� Within 100 year flood boundary No. Yes Depth of Naturally Occurring Pervious Material Does at least four feat of naturally occurring pervious maiterlal exist in all areas observed thrpughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious materlal? Certification / I certify that on �� �`�f `+� (date)I havepassed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with . the required trainipL experience described in 10 CMR 15.017. Signature Datb Q:WEPTIOPERCPORM.DOC f Commonwealth of Massachusetts L W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M s 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 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. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Ricky L. Wright use the return key. B & B Excavation,lnc. rab Company Name 14 Teaberry Lane Company Address Forestdale MA 02644 City/Town State Zip Code 508-477-0653 S 14595 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. T.:he inspection was performed based on my training and experience in the proper function and maintenance•of on- ite sewage disposal systems. I am a DEP approved system inspector pursuant tolSection I1'S.340_df Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ` 1/8/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. v f t5ins•11/10 Title 5 Official Inspection Form:Subsu4seDislposal System•P e 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. Citylfown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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-11/10 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 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. City[Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ 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•1 m o Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 1 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. Cityfrown 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 II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11110 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 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. Cityrrown 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): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 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-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 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: original to dwelling Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >20feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection, building sewer appeared to be in good condition with no signs of leakage. Septic Tank(locate on site plan): Depth below grade: 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: 5'6"x5'6"x8'.6" Sludge depth: no sludge t5ins•11/10 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 M 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. CitylTown 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 no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection, septic tank appeared to be structurally sound, concrete baffels present no sign of backup. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 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 Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 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 °M 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. Cityrrown 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 no d-box Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ 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: t5ins-11110 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 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. CityrTown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: 1 ❑ 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 ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appeared to be in good working order.Water level was 5 below invert at time of inspection. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4M 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. CitylTown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 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 Ai = 2iS ' Alz Z Z9 t AZ= 41 ' -B1 _ ?,9 -B2 = 33 ' -133 = qqt 3 t5ins-11/10 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 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: >gfeet 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 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 140 Cedric Road Property Address Lucille Proll Owner Owner's Name information is required for every Cenrerville MA 02632 1/8/12 page. CitylTown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No.. Fizz... .................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL.T OF....... .... ................................ Appliratiuu -fur Uiipuiitt1 Workii Cnuuitrurtiuu Permit Application is hereby-made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• Lo'cation�•/Jddress or Lot 3& ............. .. ....• ..........�if':......5.....--- it ... ......•.. ................. Owner Address '000V le, a ---------------------------••] .......Z..... -----• -- ----•-••--------------------- ................ ................ Installer Address QType of Building Size Lot./V..�� - ______Sq. feet U Dwelling—No. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ o. of persons---------------------------- Showers ( ) — Cafeteria ( ) P' Other fixtures . .. . .. .......... .. . . d W Design Flow............. o.....................gallons per person per day. Total daily flow.___._____aQ._ ________...__.....gallons. R; Septic Tank—Liquid capacity] ons Length................ Width................ Diameter__--.----.____ Depth.._---.-.------ Disposal Trench—No_________________...__ Widtli____._ _. _._-..._. Total Total�chi�ea.....__._ ._.-___.__sq. ft. Seepage Pit No---------------- till air to. _________..___. pth e a a �Q_-- -sq. ft. Z Other Distribution box ( ) Dosing tank ( ) d aPercolation Test Results Performed bY--------- ......................................................... Date----•---------------------------------- a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water._-._-..--_-.-._-.----- (i Test Pit No. 2................minutes per inch Depth of Test Pit------------__...... Depth to ground water...------__--_-.____-.-. 04 r .. A -----------------; .�/ ---------------------•------------ O Description of So• ---- �O �L/ . ------- �.. 3 _ . ., a•!;4? U .......... ... .r--._. Y.... f x --------------c l 2..�...... ---: -.,. ,� V Nature of Repairs or Alterations—A swer when applicable------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to pl e the system in operation until a Certificate of Compliance has bee issued by the bo rd o eal�t h. • ` -- Signe Date Application Approved BY - = = uE -:•-•----•-------- --- ---- Date Application Disapproved for the following reasons:---•---•-- -_---.----•-------•--------------•---------...--•-•-••----•-----••--•--•--------•-------•------- ---•--........-•-•-•-----•-----------------------•--•-------•-•----------------------•-- Date PermitNo......................................................... Issued........................................................ Date No.......... .' l. c Fs�.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... ... ....... .----OF........................................................................... ......... Appliratiou -for Movoottl ork,i Tonfitrurtion Prroiit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----------•--------------------------------------------------------------------------------------- ------------•---•--------•-•-•----••-•----•-••-------------••-------............................ Location-Address or Lot No. .................................................................•-•----...._.................... ......................-••------•------------------------•---•--•---------••-•--••---.........•--- Owner Address Gd Installer Address UType of Building Size Lot............................Sq. feet .-I Dwelling—No. of Bedrooms-...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) dOther 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 .............. Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank Percolation Test Results Performed by....................................................._-- - Date---------------------------------------- aTest 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------------------------ +4 ----------------- -----------f------------------- , , , O Description of Soi/l� = G_''J /�rr� y�! :n �i ' S �'"` ._�?L.L �.__ �uL - ------ --- --------------f� - L .-<<--«-1.r----. ---- - --- - - -= V Nature of Repairs or Alterations—An wer when applicable...-_..................."-_-----. ...-.-.--_"-_..--____.-------.-"-_-"---..-...__"-__.._.-..... ----••--•--------------•----------•----------------------------------------------------•------.-•--------•----------•----------•-_--•--•--------------------------------------------------------•-----.. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to pla the system in operation until a Certificate of Compliance has been ' sued by the boa d of health. Signed------- f f ff "Date - . � UAPPlication Approved By---•-• . ✓ ........... 6-. Date Application Disapproved for the following reasons:.--•----•--•------------•----------------------•--------------.-._..----•----------------"------------•--------- ................••---.............-•---•--•-••---.--••----•---------...... ------------------ Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................I..,............................... AT mputif irate of OUNImpliaurr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by.................................................................................................................................................................................................... Installer at------------------------------------------------------------------------------------------------------ has been installed in accordance with the provisions of Articq XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No---�X2_71----------------.. dated.... _:. ..5:':.%. ............... THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATI FACTORY. � . DATE............ .......... ---- Inspects THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ./ ..........................................OF.................................................................................... No......................... FEE........................ Bi-tipoiittl ork,o Q11oostrurtion Vrrmit Permissionis hereby granted----•-----------------------------------•--------•-----...............----••---------•--------.......---------.....-------•••--........--•--- to Construct ( ) or Repair ( ) an Individual Sewage Disposal System atNo............................................................................................................................................................ Street / as shown on the application for Disposal Works Construction Permit o.______..___ / Ied... ._"________________________...... ............ -.G _ A;A%�fJ �t h t r--------------- � DATE................................................................................ Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 4y a s • Al F ti 3 rfi z F;N XI f Jv F41 Ty AM y z }, tV- _ f d �Yi�(� 1 tF1y�' ymy,•cr v nl n t , t� t .RyL.... rrx it yr � _+ `. F... 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C'��Jf�'C�'14►� 9'I� 3'"�d�� e�C S6J/,�/� � ���` I r�• �� r '�����r •r,.e� .OA7 ZW& 77_' /W ✓ ff� ni ru < P ! 63 12 w M�yI I9l 'F717 • �I�'' aor LOCL�TIOP1 � � SEW[�.C;E PERMIT1.10. —TL o VILLAGE IMST&LL R.5 ►l&, AE ADDRESS BUILDER 5 Q &I.AE ADDRESS -Lu I le—�D-Eze—�o ee-!L— D!a'TE PER"VT ISSUED :��✓� 3� 7_� — — DATE COMPLI &MCE ISSUED : 43 1 ACCESS COVERS MUST BE W1 THIN 9" MINIMUM, / N VER T EL E VA T l ONS : DES l GN CR 1 TER l A : GENERAL NO TES : 6" OF FINISH GRADE 3' ,,MAXIMUM COVER FIRST 2' TO INVERT OUT SEPTIC TANK: 97.8 DESIGN FLOW: BE LEVEL MIN 2' OF PEASTONE INVERT IN DIST. BOX: 96.27 3 BEDROOMS AT 1/0 G.P.D. PER I. THIS PLAN IS FOR THE DESIGN AND CONSTRUCTION OR FILTER FABRIC INVERT.OUT._D..IST. BOX: 96. 1 BEDROOM -EQUALS 330 G.P,D. OF THE SEWAGE DISPOSAL SYSTEM .ONLY.. 4' DIAM PIPE 314" - I 112' DIA. INVERT IN LEACH CHAMBER: 96.0 97.8 96_1 DOUBLE WASHED STONE BOTTOM OF LEACH CHAMBER: 95.0 NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS 2 SET. SEE SITE PLAN.. ,GAS / 95.0 ADJUSTED GROUND WATER: N/A BAFFLE 96.27 96.0 SEPTIC TANK REQUIRED: 3 OUTLET 6 LC-6 LEACHING CHAMBERS OBSERVED GROUND WATER: NIA 330 G.P.D. X 200% - 660 GAL, 3, ALL CONSTRUCTION METHODS AND MATERIALS AND EXISTING D-BQX Wf2.5' STONE.AROUND. 8'rr x 47'1 x 12-d $fJTT4M.,OF TEST HOLE *l: 88,3 SEPTIC TANK PROVIDED: IOOD GAL. EXISTING MAINTENANCE OF THE SEPTIC SYSTEM SHALL 1000 GAL H-20 CONFORM TO MASS, D.E.P. TITLE 5 AND LOCAL SEPTIC TANK 6" CRUSHED STONE OR SOIL ABSORPTION SYSTEM REQUIRED BOARD OF HEALTH REGULATIONS. /- COMPACTED BASE DESIGN PERC RATE ! 5 M/N!I NCH PRO I� L E NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER EFFL DENT LOAD/NG RATE - 0.T4 GPDfSf AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER 330 GPD f 0.74 GPDfSF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH- STANDING H-20 WHEEL LOADS. PROVIDED: 6_4C-6 LEACHING;CAIA 8ERS Wf2,5' STONE AROUND. A-486 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 PVC OR 486 S.F. x 0.74 - 360 G.P.D. APPROVED EQUAL. CB/SEAL FND SAVERY SOIL TEST PIT ©A TA 6i 6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED PRECAST CONCRETE OR APPROVED POLYETHYLENE. 98.8 , g8' TEST A%ON � Ggs� ATER �ESTEpOTH SHALL FOR �EVEL WATERTIGHT, THERE �S MO SHALL RE THAN ONE WATER s�o�,� TP s/ Prrl57ar TP :2 OUTLET. J \.cam HORIZON TEXTURE COLOR HORJZON TEXTURE COLOR 7 BEFORE CONSTRUCTION CAL D G F l -SA E'' 0' 0' LOAMY IOYR LOAMY IQYR L 98.3 Q yR - rn•2 to oax SANS 5/1 ASANG 511 1-888-DIG-SAFE AND THE LOCAL )PATER DEFT. 3 i 6' - - - - - - - - - - • - - - 97.8 8 - - • - - - - • 97.6 12'OAx 1' 99,6 B LOAMY roYR B LOAMY IOYR FOR LOCATION OF UNDERGROUND UTILITIES, c jh SAND 416 SAND 4/6 24' - - - - • - • - - - 96.3 22` _ _ - - _ - - - - - • - - - - 96.5 8. SEPTIC SYSTEM INSTALLER SHALL NOTIFY THE AIEOIUM /QYR A/EOlUM 1OYR D-SOX s� sANa his C saNO 6/B DESIGN ENGINEER TWO DAYS PRIOR TO CONSTRUCTION r :.... _ 9a.a ��` is OF THE SYSTEM TO ALLOW FOR SCHEDULING OF THE £xJsrJNG �8, CONSTRUCTION INSPECTIONS, PIT r 48' i2 oax 9. EXISTING SEPTIC TANK TO BE PUMPED AND -GLEANED. i/ BM, CORNER BH INSPECT AND REPLACE INLET TEE AND LINE IF .'..•.O:....• ... f EL-100,56 REQU 1 RED. I '• +96.4 // 120' AID WATER $8.3 12 NO WATER 88.3 6-LC 6 PRECAST CHAMBERS f�XlSTING 99.6 W/2-5' STONE AROUND / SEPTIC TANK :. _ DATE. Y: $E PW-BER 27. 2OJ8 REST BY: STEPHEN HAAS t, f WITNESSED BY: DONALD D£SAIARAJS 98.6 // PERC RATE: f 2 MIN/INCH _ I1/ 99.5 0sv* 01 LOT I CBrnrl FN+o f 16, 472+ S. F. 2 f f pv�/ 3Pp ✓�� 41 f � ✓� kwSR ro 1 a / T 140 CE-0R r G ROAD MAP 140 . PARCEL ?s /9 v� r Y RACE LANE` CB/DH FND 119 Y SA R N S TA & L E • -f( C E N T E R V I L L. E ) MA • LOCUS carcH easlN LEGEND PREPARE© FCJR R OHA N CAMP BEL L_ CONCRETE BOUND _W WWATER LINE SCAL E ! -- 20 ©C70BER 31 2018 O HYDRANT GAS LINE STEPHEN A . HAA W# o.6HT POSTER HEAD wIREs ENGINEERING /r '-E--- UNDERGROUND ELECTRIC LINE P . O . B cs x 16 -T-- UNDERGROUND TELEPHONE L I NE ri S co u t h Dennis , MA 02660 -�-�-CT`V�- 'UNDERGROUND G'ABLEVI S/C!N L/NE 508��l...���• �1` 1� �� � ) 362--8132 +40.4 SPOT ELEVATION -------40------- EXISTING CONTOUR L V CUS IVA P 0 /0 20 40 ____�4� PROPOSED CONTOUR JOB NO: 18-022