HomeMy WebLinkAbout0070 CRESTVIEW CIRCLE - Health 70 Crestview Circle, Centerville
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner's Name: MELZER
Owner's Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Date of Inspection: 5/7/01 RECEIVED
Name of Inspector: (please print) JOHN GRACI MAY 1 5 20D1
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 TOWN OF BARNSTABLE
HEALTH DEPT.
Telephone Number: 508-564-6813 FAX 508-564-7270
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:
X Passes
_ Conditionally Passes
_ Needs Furt e valuation by the Local Approving Authority
Fails
Inspector's Signature: Date: 5/7/01
The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or DLP)within
30 days of completing this inspe tion. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE. RECOMMEND MOVING SPRINKLER LINE OVER SEPTIC TANK COVER.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.'1'his
inspection does not address how the system will perform in the future under the same or different conditions of use.
Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SOBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
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 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 yank 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 n/a
"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.
3. Other:
n/a
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBS
URFACE SEWAGE DISPOSAL SYSTEM INS
PECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFULL LIFE. RECOMMEND MOVING SPRINKLER LINE OVER SEPTIC TANK COVER.
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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: n/a
n/a 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
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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
_obstruction is removed
ND explain: n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
_ X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped APRIL 2000 BY ROBINSON.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X 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 forma
(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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
k°
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out 7
X _ Were all system components,excluding the SAS, located on site
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems'?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ 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(3)(b)]
Page 6 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents:3
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203):'n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: APRIL 2000 BY ROBINSON
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1995
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE, MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
BUILDING SEWER(locate on site plan)
Depth below grade: 30"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 24"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
l,any evidence of solids carryover,any evidence of leakage into
Comments(note if box is level and distribution to outlets equa
or out of box,etc.):
n/a
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE, MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT
HAD I' OF WATER IN IT AT THE TIME OF THE INSPECTION.THE PIT HAS NOT HAD MORE THAN 1'OF
WATER IN IT.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
n
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSUR
FACE SEWAGE DISPOSAL
SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 CRESTVIEW CIRCLE CENTERVILLE,MA 02632
Owner: MELZER
Date of Inspection: 5/7/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
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SEWAGE # b`
LOCA IOr-�• -
QVILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS J ��
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
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COMNIONVIALTH OF M4SSACkSETTS
ExECL'TIVE OFFICE OF E?��r'IRO'��4E�TAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. i IA 02106 bl?•=S' 44011 �1
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PART A ' - �
F I� CERTIFICATION
t Agx. ,V�tt,J U tCv.-'4uI I� Address of Owner:
Property Address, /
Date of Inspection; 1tll,,,Cko of different) if, CqA rUteev Gr�Ee,
Name of Inspector: 1 3)E: �n � tK`'ilk t ry14, v2b3Z•
I am a DEP ap,Proved system inspector pursuant to Section 15.340 of Title S (310 CMR 13.000)
Company Name: �l o c ^ �''r•�'�"' r`'� p '^ �°"—�
Mailing Address: PC Acnx e-37P H/tSf�OPQ /`z' 0
Telephone Number: r•
CERTIFICAT10% ST,TErr1E1T
1 cer ll that I have pe,sonall% tr.speGed the sewage d:s.csa, system a: this address and tha: the information reccred betoM is true, ac=Ural°
Ind complete as o'the time of tnspe:,o--. The tr,spec,on %as pelorrned based oh m% training and experience to the proper tune c . anc
!maintenance c� on•srte sewage disposa systems The t s:err,:
Passes
_ Concrt.onai:.. Passes
_ ♦eec; Fume- E%*a'vat the Local Appraving Autncrin
inspector's Signatur . Date:
T'ie S\'':e-r lnsre^.o• Shal! s'Ubmt-, a COP\, Or this Inspe:n-on renc'; le the Aporcvtng Authonn within thin,-. (30, days cf ccmp!c'1ng IRi:
inspenjon. It the system is a shared -,vstem c• ha- a ces,gn Flo, c; 10.000 god cr.greate•, the Inspec:or and the sys:em cwner shall subr-t
the repo! to the a;orocnate regional office of the De-,a-ment of Envirenmenta: Frotec!ien. The crig-nal.should be sent tc the system c..ne'
and copies t-•t: to the buyer, ii applicable, and the ap-�reving authority
INS?ECTIO's SUMMARY. Check A, E, C, or L)
Al SYSTEM PASSES.
I have not found any information which indicates that the system violates any of the failure criteria w definer in 310 C.MR 1;.?0:
Any failure criteria not evaluated are indicated below.
COMMENTS:
El SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass' section need to be replaced or repaired. The systern, upe
eompteaun tun ttie replace nenc Q, rcydu, a.3 appo.e-zl by the Board 0 Hcalt},, wal p3as.
Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined-, explain why not.
The septic tank is metal, unless the owner or ope.ator has provided the system inspector with a copy of a Certi{irate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection: c
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tar'.)
failure is imminent. The systern will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved b�• the Board of Health.
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10 FORM
PART /1
CERTIFICATION (continued)
Property Addums:
Owner:
Date of Inspection:
Bl SYSTEM CONDITIONALLY PA55E5 tcontinu..d
Sewage backup or breakout or high static water level observed in the distribution box is ue to broken or obstruaed
pipets) or due to a broken, sealed or uneven distribution box. The system will pass in Coon if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced j
The system required pumping more than four times a year due to broken obstruaed pipeW.,The system will pass
inseecz,on if (With approval of the Board of Health):
broken pipets) are replace:
obstruction is removed ;
C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEILTH:
Conditions exist which require furthe, evaluation by the Board of He4hh in order to determine if the system is failing to protec. tr
public health, safe. and the environment.
i'
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETFRMINEB THAT THE SYSTEM 15 NOT FUNCTIONMC Ih A MANNER
WHICH WILL PROTECT THE PUBLIC HEkLTH Ati0 SAFETY AND THE ENVIRONMENT:
_ Cesspool or print is within 50 iest of a surface water
Ce!spoo' c, pn" is w ithin 50 feet o:a borderinivegetated wetland or a salt rnarsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HE4LTFfr(A,ND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THA
THE SYSTEM 15 FUNCT10tiIti T
G IN A MANNER TH,, PROTECTS THE PUBLIC HEALTH AND SAF M, AND THE
ENVIRONMENT: r'
_ The s,.•stern has a septic tank and soil adsorption system (SAS) and the SAS is within 100 feat to a surface water supply c
tributary to a surface water supoh•.
The system has a septic tank and soir absorption systern and the SA5 is within a Zone I of a public water supaiy weal.
The syste-n has a septic tank and soIii absorption system and the SAS is within 50 feet of a private water suppiy well.
The system has a septic tank and.6ci) absorption system and the SAS is less than 100 feet but So feet or more from a
private water supply wefl, uniessIa we!l water analysis for coliform bacteria and volatile organic compounds indicates ti
the we!I is free from pollution;from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to
less than 5 ppm. Method used to determine distance (approximation not valid).
3) _ OTHER
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Irevised 0/!2s/7') Tag. 3 of 10
SUBSURFACE SE"'AGE DISPOSAL S1 STEM INSPECTION FORM
PART A /
CERTIFICATION (continued)
j
Property Address:
Owner:
Date of Inspection:
i
D) SYSTEM FAIL5:
You must indicate either "Yes" or "No' as to each of the following
I have determined that the system violates one or more of the following failure criteria as def4 in 310 CMR 15.303. The flaws
for this determination is identified below. The Board of Health should be contacted to dete ne what will be necessary to correct
the failure. //
Yes No /
Backup of se"age into facility or system component due to an overloaded or 4ged SAS or cesspool.
Discharge or pondrng of effluent to the surface of the ground or surface watErs due to an overloaded or clogged SAS or
cesspool.
/
Static !rou d levei in the distribution box above outle! tnven due to an Overloaded or clogged 545 or cesspoo!
Lrourd depth in cesspool is less than 6" below (nven or available volume is less than 112 dap floe.
Recu.,ed pu.np,ng more than 4 times in the last year NOT due toxiogged or obstructea pipes .
number of times pumped
An, portion o' the Sort Aosorptoon S stem• cesspool or pnv) is below the high groundv.ate• eievatior.
Am port:on a a cesspool or pnv is Nithin 100 tee! of a sihiace water supp;, or tributarl to a surface Hater supply
Ant ponion of a cesspoo' or prig} is tArthrr a Zone I of a�publrc well.
An,. pe^ro- C' a cesspool o• pm�, is ,%tthtn 50 fee! of/a private water supple well
An\ po?i.or o-.a cesspool or is less than 100� /fhe! but greater than 50 fee, from a private eater supolr well with no
acceptable .ate• qua!it� analvs,s 1! the well has peen analyzed to be acceotabie. anach cope of Weil water analysts for
cohiorm tatters volatile organ-c compounds, ammonia nitrogen and nitrate nitrogen.
E7 URGE SYSTEM FAILS:
`rou must indicate eithe• "yes or -Nc- as to each of the following.
The iolio";ng crrterja aopl% to !arge systems in addition to the criteria above:
The system se- es a facilrrn with a design floe, of �0,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and saierry and the environment beceuse one or more of the following conditions exist.
Yes No
the system is within 400 feet of a 46rface drinking water supply
the system is within 200 feet of tributary to a surface drinking water supply
the system is located in a nitro n sensitive area (interim Wellhead Protection Area - IWPA) or a mapped Zone It of a
public water supply well)
The owner or operator of any such system shall ring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00 Pleas consult the local regional office of the Department for further iniormat,on.
(r—lxad Yay• 3 o1 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Propertq Address: 70 t csLSrVw rU
Owner:
Date of Inspection: I(3Z
Check if the following have been done. You must indicate either "Yes" or "No" as to each of the following.
Yes N0
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least rwo weeks and the system has been receiving normal
flox• rates during that period. Large volumes of water have not been introduced into the system recenll% or
as pan of this inspection
As built plans have bee,. omained and examined Note if they are not availabie with NIA
_ The iac ire or d�%elhng %%"5 inspected for signs o-* sewage back-up
4 _ Tne system does not rece!.e non•5anitan or industrial .waste now.
The site �%as mspecie� for signs of breakout
All s�sienr. co nponent: eaclud:ng the So,! Aosorption System, have been located on the site
Y _ The septic tank rnari^•oie, mere uncovered, wene_ and the interior of the septic tank was inspected for cond.tion of
—"t bai ies or tees. maieria, o• construction. d.menstons, dentn of liquid, depth of sludge, depth of scum
The site and locat.or, of the So:i .Abscrption System on the site has been determined based on
_ The iacdir, o�kne, ,anti occupants. if dirteren: morn or•neri were provided with informal nn on the proper ma rite^.ante of
Sub-Surioce D,sposal Svsiem.
Pr Exist'ng information Ex Plan at 6 O H
_ De,ermined in ine field c ans of the failure criteria related to Part C is at issue, approximation of d;stance is
unacce:)tabie (1 3 302 31 b'J
4 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Properri Address: 7p C a9V K VJ
Owner: e7Q1%7F1&j
Date of Ispection:f _
KP FLOW CONDITIONS
RESIDENTIAL:
Design flowR.o.d./bedroom for
Number of bedrooms-
Number o' current residents
Garbage g'+ der (yes or no:
Laundry co-•^ected to system (yes or no
Seasonal use tyes or no, Pj
Water meter readings, if mailable (last two i2, Year usage tgpdt. IUDtllk►rzSl ff�ttC�T
Sump Pump Ives or note
Lai: date o' occupancy
COMMERC tAl_'INDUSTRIAL:
Type of estabhshmen;
Design fio%• _ga!ronsda�
Grease trap present wes or no_
Industrial %Haste Holding Tani: present - es or nc_
:on•sanitan "asie discnargec to the T!:,e 3 s\s;e^-, :yes or no_
%%ater meter readings ri a••adabie
Las'pate of o 1161c2^,c,
OTHER: .De:cribe
last oate of occuoanc,
GEtiERAI INFORMATION
PUMPING RECORDS and source of in+ormatio-
S%,stem pumpeo as par, of mspe.7,10n. tees or no
If yes, volume pumped alions
Reascn for pumping
TYPE OF SYSTEM
_'t— Septic tank/d,stnbuuon box soil absorption system
Singte cesspool
0ve'flow cesspool
Pm)
Shared system (yes or nol (if yes, attach previous inspection records, if anyl
I/A Technofogv etc. Copr of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 3"J'ms
Sewage odors detected when arriving at the site tyes or not,
(rgvlmod 04/25/911 Pago 5 of 10
SUBSURFACE SF.�SAGE DISPOSAL SYSTEM INSPECTIOI FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 74 6"SIl(Kvt1
Owner: 17tUT-T+r•N
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade.
Material of construction. cast iron 40 PVC — other (explain`
Distance from private rater supply well or suction Ir-! _
Diameter
Comments: (condition of joints, venting• evidence or leak age, etc.)
SEPTIC TANK:
(locate on site p an
u
Depth below grade LO
material w construction —AccncrP'@ _rne'a _F oe glass _Polvethviene _other;expia,n
If tank is me;a:, Ls: age t: age corf,rmec o� (-e^ rica:e o: Compuance _0es.No
Dimensions kQQ
Sludge depth `�_ . „tr
Distance from too o: s!uoee to bonorn o- out'le: tee o- br;e —_
Scum thickness 360 if
Distance from top of scum to top o` outlet tee or ba�-Ie it)
Distance from bottom o scurn to ba-c- o• ou:le• tee C. ba'•e
How dimensions Aere determinec J0arxlst.lJ►d,1-1
Comments
trecommendation for pumping .condition o• inie arC nu:ie! tees or baffles. depth of hquidflevel inirelat:on to outlet�tnve ', structural
integriry, evidence of leakage, e:c , 1 c w
GREASE TRAP:N�
(locate on site plan;
Depth below grade
Material of construction. _concrete _metal `Fiberglass _Polyethylene �other(explam?
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:
(recommendation for pumping, condition of i!iiet and outle! tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity" evidence of leakage, etc ;
(ra,•arrod 04/75.'97) Pago 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORnti
PART C
SYSTEM INFORMATION (continued)
Property Address: 76
Owner: C7 f2(FT"J
Date of Inspection: 13b
TIGHT OR HOLDING TANK:±V Tark must be pumped prior to. or at time, of inspection!
(locate on site plan,
Depth below grade
_metal �F�bergiass Polyethylene _o[herSexplam)
Material of construction "concrete
Dimensions:
Capacity- gallons
Design f1011A galior&da.
Alarm level Aiarrn n s,orK rig order Yes. t�0
Date of previous pu-Ping
Comments
(condition of inlet tee, cord:uor. o' a'•a•r^ and float switches. etc ;
DISTRIBUTIO'` SON:_I*S
tlocaze on site p a-�
Death o' liau,d le,el auo,e
Comments _ I .
(note r le\el a,d d:sr e.;a F.,cerce of so!"'Is G7rnove e .de^ce leaka e into or out of boa, etc.!
PUMP CHAMBER:
(locate on site plan.
Pumps in working order: (Yes or No'
Alarms in working order (yes or No
Comments
(note condition of pump chamber, condittor of pumps'and appurtenances, etc.)
(revised 04/:5/47) Vag• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properh Addr-ss:
Owner:�kI,TTi
Date of It4specuon;
SOIL ABSORPTION SYSTEM (SAS): ,
(locate on stte.plan, if possible: exca n not required. but may be approximated by non-intrusive methods;
If not determined,to be present, explain.
Type;
leaching pits, number I (,]I
leaching chambers, number
leaching galleries, number.
leaching trenches, number length
leaching fields, numbe,. d,-nensio-
overflow cesspool, number
Alternatwe st,stem
Name of Tennoio€\
Comments
inote�condition of soli. signs of hr draulic iaiiure, level of ponding• condition of vegetat,o etc.
CESSPOOLS:
(locate on site plan
Number and ccniig,,ra:-or
Depth-top of liquid to role! in.er,
Depth of solids lave,
Depth of scum layer
Dimensions of cesspoa
Materials of construator,
Indication of groundwate-
inflow •.cesspool must oe pumper- as par; of inspection,
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 hvdraul,c failure, level of ponding, condition of vegetation, etc.)
(swa��d 0�/25/97? Page a of 10
SUBSURFACE SEWAGE DISPPOSA SYSTEM INSPECTION FORA
ARI
SYSTEM I',FORMATtON (continued
Propert. Address
Zb
Owner: (�(LtT-TIV'
Date of Inspection:,`^6hb
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells wrthrn 100 (Locate where public water supply comes into house)
r
Al-
(
51- IL
AZ - W6' bZ- �6
A.3 t.0 ;-I
��'
Kq
(rw3.84d 04'25.'5') Paq• 9 of 10
SUBSURFACE SEWAGE DISP05AL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Propem Address� It C-7V%1'rj
Owner: (�QI�FtN
Date of Inspeciwn:
t
Depth to Groundwaterl)h Fee:
Please indicate a!I the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record •
Observation or Site (Abutting property. observation hole, basement sump etc.)
Determine it from local cond.tions
Cnec'. v ith local board c• nea!;r-
Chec' F;%AA Ntacs
i
Checl, pumping records
Chec� localeaca.a:o s ms;a!le s
Lse 'ILSCS 'Da'c
Descr;be in %o_' o••-. -Oro: no., \c es:ac sped tne '-ieti CroundNa!e, Elevation (Must be c pleted
/I.S, ajeg►cc�su cab5ic ►il�rl�+��n�s tt,A, Ce9; �
trevaied 01;75'9- Page 10 of 10
-� �4 TOWN OF BARNSTABLE
LOCAT[bN 1 11 V �eUU ����- a SEWAGE #
VILLAGE & �i�Q% ` ASSESSOR'S MAP&LOT °•152 - ti$
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY NISOC)at,
LEACHING FACILITY: (type) o'' (size)
NO.OF BEDROOMS
BUILDER OR OWNER
DATE: COMPLLANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
! Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
2.
AI - '31rr2�
'V7 v 0hiSLI TO L� _
.,. = 3 �� f
OC CrL PC—CA ASSESSORS MAP N0: oZ S
fu0. ��~ c ✓1 PARCELNO: S L C d. Fps.... ............
THE COMMONWEALTH OF MASSACHUSE TS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Di-npogttl Workri Touitrur#inn Prrutit
Application is hereby made for a Permit to Construct ( !/jor Repair ( ) an Individual Sewage Disposal
sys� Y g
-- ------------- --------------------•--'-----------••-----••.......-•------••--•.
cation-i Ae d t No.
..... ......•--••---••------------
ner 7Wd
ress
-•-•---•......................•........._._.______..... ------•------I-v_ .... `_...._.............._....--^--................
Installer 22 Address
of
. feet
TypeDwelling Building Size
of Bedroom J_____________________.__Expansion Attic (p� Size Lot_.Garbage
� �Grinderq(1V(�
Other—T e of Buildiil G� f. :_ No. of ersons____________________________ Showers — ( )
a YP g P ( --)-------Cafeteria ---------
Other fixtures ----------------------------------- --
w Design Flow.............11.D.....................gallons per per day. Total daily flow_...... - -__-�� ..._.......gallons.
W Septic Tank—Liquid capacity/"...gallons Len th__ k . `
P 9 g ---�------ Wldth_�_-..._--_-- 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 ank
~' Percolation Test Results Performed by._-� .... .. --__•................................ Date----- -��-- -�....._..
a
4 Test Pit No. I________________minutes per inch Depth of Test Pi -______--__-:-_--. Depth to ground water------------------------
rX4 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..........-_--__---____.
R.' ---------- ---•-
0 Description of Soil......
x f�
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 5 of the State Environme tal Code—Th undersigrf d further agrees not to place the
system in operation until a Certificate of Complia as bee i s y the b of health.
Signed ........ . .... a a ............................. ---------
Application Approved BY 'll. ... ---- --- - .... . - .. ------
Application Disapproved for the following reasons: .._.................. ................................ ...........117
..............................-----------------------
. ..... ------------
��'__.... Date i
PermitNo. ---. .. ............... ............................................. Issued ------------ - --- ...................................
e
IV f7 To LOG-
No.......:................ `C P 4-5 1 C,0. FRB..../.0.0..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliro#inn for Bi-nVoiittl Worko Tomitrnr#inn thrnti#
Application is hereby made for a Permit to Construct ( Vi _or Repair ( ) an Individual Sewage Disposal
System at, r a-z'e� C ���
..._. .-••y ..............................°-�'..._.....__.......------....-- ....................-----........------...,---------.......---.....--------------...-----....----
Lrcation.Mddre-ss or Lot No.
.--.•--•-------------•---•-•----...------•---•----•--.
41 Q n� vner ^-gyp "� ,y, Address
a ....
r Address
Type of Building 2 Size Lot.... ......Sq. feet
Dwelling— No. of Bedrooms._..__3_________________________Expansion Attic Garbage Grinder (A/U)
aOther—Type of Building�A/l7h .f✓1...._. No. of persons____________________________ Showers ( ) — Cafeteria ( )
Other fixtures _______________________________ _ ___
,��------- ----- -- ----- -------------- 3
W Design Flow............. .... ................._.._gallons per.pers•n per day. Total daily flow....___�:_-_-.-_---__-._-._._.01.__--_-_-_--gallons.
WSeptic Tank—Liquid capacity/l .gallons Length__ �_�_�`___ Width_ ........... Diameter.......... ..... Depth__`-----------
Disposal Trench— No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No---------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing ank
'~ Percolation Test Results Performed b �-z '(__ ___------------------------ Date.___.��..�G.._.. .�_._.....
Y r --
,4 Test Pit No. I----------------minutes per inch Depth of Test Pi(------------------ Depth to ground water------------------------
0z Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
C4n...........................^-•.................•--•-•---.........----•-•......_...-------•••--•---...............----------•----•-..........----•--•---••
Description of Soil. (1 P 1 7......(-...
............
-------------------------------------------------------------------------------------------.................
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 5 of the State Environmental Code—The,undersig ed further agrees not to place the
system in operation until a Certificate of Complian e has been` f sued®by the bc� of health.
Sfgned .............. �lv G �,(l /-,Q ....
Dat
ApplicationApproved By ....v.. _............,, -._... ` .G..... ...........i . ........................................ ..... ...�.................. -------
Date'
Application Disapproved for the following reasons- ----------------------------------------------------------------------- ......................................
/ Date
PermitNo. ..._,...� ....... . ..._/-------------------------- Issued ............ .. ./ ..../..........-------------------- ----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Ger#tftctt#e of Contlatiance
THIS-IS TO CERTIFY That the Individual Sewage Disposal System constructed ( !/ ) or Repaired
_ ( )
� �ry tt„tauet
at ...0`0''(--.... C--�l Q 111,Q.(<!/ ( ./L~!'X Q-------._(.:1%/+- ---------------- -----------------------------------------------
has been installed in accordance with the provisions of TITLE of T e State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..__ . l-a....._.... dated ..............................._------.......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTO�RR_Y..--- ����
DATE........ ....... - - Inspector' - - .............
--------•-------------------I., -_--___-^.-- _--_- _-__,--__-,-
THE COMMONWEALTH OF MASSACHUSETTS
�� BOARD OF HEALTH
TOWN OF BARNSTABLE
No... ..'........•---•-•. FEE.....:..................
�io�nonl nrko��nno#r�r#inn �rrnti# r
Permission is hereby granted----- 1� ...U L�-.......... .... ---------------------•-------
to Construct (V) or Repair ( ) an Individual Sewage Disposal System
at No.._LOE---V.K....C'R.F5. •-J 1E.W. e/P=C=L C Cf2ATt R_ V ILL(. =---•---=- -"
Street
as shown on the application for Disposal Works Construction ?frmit No ---
Dated...........................................
Board of Health
DATE�------------------------------------------------------------------••-- C/
FORM 36508 HOBBS✓!WARREN,INC..PUBLISHERS
r
. A�St6 N -PAtA
SIt�FL:>r FtiNILY
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TOTAL. DA l 3�o A rz> 4-9 n►N ` b I 1 4--' 'l/
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No.a�oaa NO. 29733
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6UP-1.`f A1JD Tl{F. OF::5et'S fI�4DOLX� uor' -Ire 05MMviLLa MAC ,
uSLD T'o ESTABU5N .PtzcretZTy U NC_5
APFL►c.AW7011�A�fSibb. �►t I �o,
.JG �NC.
TOWN OF BARNSTABLE
LOCATION L.-.)+ n4,Jitw;e lc-,- SEWAGE #
VILLAGE (tvl f(J+\4 ASSESSOR'S MAP & LOT.
INSTALLER'S NAME & PHONE NO.�- UCa SLd�Ir-'IOC(�
SEPTIC TANK CAPACITY 1T 6
LEACHING FACILITY:(type) LC(1LILl P (size) 1000 e)A���1+�5
j�
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC 1VATE
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: �
VARIANCE GRANTED: Yes No
7 '
5
I