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HomeMy WebLinkAbout0051 ELIJAH CHILDS LANE - Health Centerville MW 1■■■■■ ■■ ■■■■■ ■■■■■■■■■■■■■■■■■�■■■■���■■■■■■ 1■■■■■■■■■■■■ ■ ■■�■■■■■■■■■■■��■■■m.■■■■®■■■■ 1■■■■■■■■■■■■��■■■■■■■■■■■�■■■■■■�■■�■■■�■M■■■■ 1■■■■■■■■■ �■■■■■■■■■■■■■■ 1■m■■■■■■■■■■■m■■■■m■■■■■■��■■■�■■■■■■■�■■■�■■■ 1■■■■■■■■■■■■■■■■■■■■■�■■■■■■�■■■■�■■■■���■■■■■ MENEM i■■■■■■■■■■■■■■■■ ■f�i�i ir► i ri�i■■■■■■■�■■�■�■■■■■EM 1■■■■■■■■■■■■■■■■■ M■■■■ 1■■■■■■■■■■■■■■■ ■■ ■■�ii3ii� l■�■■■�■■■■■■�■�■■�■N■■ MEMO ME IN MEMOMMEMMEM No 1■■■■■■■■■■ ■v■■ ■■ ■ ■■■ ►�. �1 ■■■■■■■■■■■�■��■■■■ ■■■■■■■■ ■■■ ■ ■■■�rM", m■■■�ii■■■�■■■■■■■�■■M■■■■ ANNNNN■NO ENEN■■OONI A■■■■■■■SEEN■OE■E■■OOr ■■■■■■■■■n-,■■■ ■E■■■■■■■1 AMENN■■■■M■■■■■■■■■■■■■■■1 4■O■■■■O■N■■■■■■■■■■OEONE■1 AO■O■■■■■NO■ENE■■■■O■NOES■I A■■■OO■■■■■■m■ NO■■■N■N■NNI ■■■■■■■■■■OE■E MENLO E■■■■■N■I ■■■■■■■■■■■■■■■■■■■■■■■■■■■I ■■■■EE■■■■■■■■■■■■■■■■■■EM■i a ME■N■NONO mom■NN■O■E■■O■EO■I A■■■E ■■■■■■■■■■■■■■■■■M■■■■■I ,a■■EOM■■EE■O■■■O■■ON■■NNE■■NO EEO ■■■■■■■�■■■■■■■■■■�■■■■O■■■�■IF ■■■■,■■�■■■■■■■■■M■■■■■■■■■■■■■i : ■■■■■■■■■■■■■■■■■■■■■�■■■■■m■■l N�NONE��0■N■■■N■NO■■E000O■N■O■■l ■■■mom ■■■■■■■■■■■■■■■■■■■■l ■■■■■■■■NOOEN■NO■�■■■■■1 MME■■■l �0 mom■�■■■mom■■�MEMO�■I■■■���Ell ■■mom■■■■■MEN■■■■■■■■■■■■■■■■■■■� ■■■■■ ■■ ■■■ ■M■■■■■■■■■■■l ■■mom■mom M■■■■■■■■■■■■■■■■■■■l ■■mom■NOON EOmom O■■■O■■■■■■OE■OOI ■■■■■■■mom ONOmom■■■■■■■■■■■■O■■■1 ` ■OOOO■0■■■0EE■ENOO■■OMN000OOON■■l Ill■■■■■■OON mom OONOE■■■■�■�■■■■■■■�_ ■■■OO■N■■OMEN ■■■■M■■■NNN■■NE■ON1 rME Now N■NN■sEN■■N■E■■OO■■■■■■l ■ ■�N,■■■■■■■■■■■■■l NONE■ONN■■NNO■O■■■■■■■■■■■■■■■■■N■I ■■ ■■■■■��■��■■■■■■■■■■■■■■■■■■■■Ml ■OON■NN■■NNNNNO ONO NNOO■E■■■■ON■O■NI f ■SEEN mom■mom O■AOOOOON■■NO■■N■■OOl ■■■■■ mom■■■■■■■■■■■■■■■■■Ml.■■M■■■l SENSE MEMNON ■■E■EN■■Om■■■■m■N SEEMS 000EEOOONONNI MOONS■■■NOOSE OOONOoE■E■■■■OO■■NNNOI ■■■■■O■■■■■mom��■■■■o■o■ ■■■■■■■■■i ■■ESE■eNNOO mom Omom�■■EOO■OOO■m■o■mi ■■■■■■�■■�■■■■■■■■■■■■■NONE ■■■■■■�, MORMON No NOON Nollommo MENNOMEM • oz-7-q Commonwealth of Massachusetts Title 5 Official Inspection Form �= Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments t�0 51 Elijah Childs Lane h�"? V � Property Address Ena Pinto ` T• Owner Owner's Name information is '—j' required for every Centerville Ma 02632 12-14-18:„` page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Breft Hickey key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. 374 Route 130 c� Company Address Sandwich Ma 02563 City/Town State Zip Code rrm (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑■ Passes 21 ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey 12-14-18 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 'I n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane �v Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes;,;., ❑■ 1 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 was in working order at the time of inspection. Leaching was 5/6 full. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts ,@ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owners Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled 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): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further,evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: I t t5insp.doc•rev.M612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............ 51 Elijah Childs Lane u Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ a Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑, 0 Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow ❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E] Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ El Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ❑ Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ F Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ID 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.] ❑ a The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane V Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes' or"no"for each of the following for all inspections: Yes No 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? 0 ❑ Has the system received normal flows in the previous two week period? El a Have large volumes of water been introduced to the system recently or as part of this inspection? a ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? 0 ❑` Were all system components, excluding the SAS, located on site? El ❑ 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: 0 ❑ Existing information. For example, a plan at the Board of Health. ❑ O Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts �= Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 3 Number of bedrooms(design): Number of bedrooms(actual): 330/gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 3 Number of current residents: Does residence have a garbage grinder? ❑ Yes 0 No Does residence have a water treatment unit? ❑ Yes R] No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 91 No information in this report.) Laundry system inspected? ❑ Yes F!] No Seasonal use? ❑ Yes [E No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: 2016-90,000gallons (246GPD) 2017-134,000galIons (367GPD) 2018-21,000gallons (57GPD) Sump pump? ❑ Yes ❑■ No Last date of occupancy: currentDate t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 t c Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 2 months ago Was system pumped as part of the inspection? ❑ Yes ❑■ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 r Commonwealth of Massachusetts �- Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane V� Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1981 per COC Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron K 40 PVC ❑other(explain): Town water Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000gallons Dimensions: 1" Sludge depth: 3511 Distance from top of sludge to bottom of outlet tee or baffle 0�r Scum thickness Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS measured How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert evidence of leakage, etc. q g :) The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts �= Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 0" Depth of liquid level above outlet invert 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 cf Commonwealth of Massachusetts �- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane v Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No" Alarms in working order: ❑ Yes R] No' Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: (1 ) 6'X6' Elleaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts �e Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane V Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.):_ The leaching was in passing condition but was 5/6 full at time of inspection. 12. 'Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane v� Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coot.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: W hand-sketch in the area below ❑ drawing attached separately Asbuilt Groundwater 3` 9' Leach pit A g >12' A1.50' 131-21' A2.51' 132.24' A3-30' 133.97' 101 >31 2 Groundwater t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Y Commonwealth of Massachusetts Title 5 Official Inspection Form �1 07 �?! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑■ Check Slope R Surface water ❑■ Check'cellar ❑■ Shallow wells Estimated depth to high ground water: NoGW@12'feet Please indicate all methods used to determine the high ground water elevation: R Obtained from system design plans on record 7-21-81 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: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 k c Commonwealth of Massachusetts i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 51 Elijah Childs Lane Property Address Ena Pinto Owner Owner's Name information is Centerville Ma 02632 12-14-18 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: TighVHolding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do.by M.G.L.-it does.riot give you,permission to operate.) You must first obtain the necessary signatures on this format 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL, 367 Main St., Hyannis, MA 026.01 (Town Hall) and get the Business Certificate that is required by law. DATE: Fill in please: y:JranFi} �a,r.il��, l;�,.tW APPLICANT'S YOUR NAME c•:�g.r�>�••�]�;;,y;u,.. ,:j� ' YOUR HOMEADDRESS:�4 >k,L i 6; ":"A �5r' BUSINESS '+o" �`` '1` i TELEPHONE # Home Telephone Number SO OR EIN #: E-MAIL: 0. 1 LU� NAME OF CORPORATION: NAME OF NEW BUSINESS C - C n TYPE OF BUSINESS-,L6,,—,h c`,nj �, 7nCA, IS THIS A HOME'OCCUPATION? , t/ YES NO c4 ADDRESS OF BUSINESS. h A 1V 14 MAP/PARCEL NUMBER f 7/' 7 r (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd._ Main Street) to_make sure you have the appropriate permits and licenses required-to legally operate your-.business in this-town. 1. BUILDING COMMISSIONER'S OFFICE MUST COMPLY WITH MOONS. AIOCCUPATION This individual has bee I fo d of any4perr�equirements that pertain to this type of business RULES AND REGULATI' COMPLY MAY RE$VU T IN FINE$. uth ized Sign ure** COMMENTS: HEALTH MUST COMPLY REGULATIONS IH ALL 2. BOARD OF HE . PP ®US MATERIALS This individual has been inform e rm' r ui ments that ertain to this e. of business. Authorized Si nature* COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature** COMMENTS: I r• Date:9 1-2S/ 1�- TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS.: PCIME (f4eC4yt BUSINESS LOCATIONS h ! / � INVENTORY MAILING ADDRESS5-1 Ge. TOTA UNT- TELEPHONE NUMBER: .Soeg 2298 CONTACT PERSON: AVIO, EMERGENCY CONTACT TELEPHONE NUMBER:500-250 MSDS ON SITE? TYPE OF BUSINESS: ., yl INFORMATION / RECOMMENDATION& Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product- Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt&roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes , y—MOk4 dry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers j Av'Windshield wash Via 0 pju� WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applic nt's Signature Staff's Initials l' 6 1 No. d }r 0 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered incom -ter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pphCation for Disposal Ppstrm Construction VPrmit Application for a Permit to Construct( ) Repair(t/Upgrade( ) Abandon( ) ❑Complete Systo Individual Components Location Address or Lot No. C��,; S O er's Name,Address,and Tel.No. Assessor's Map/Parcel t -71—? -1 �or I aller's /N/am�eejAddr ss,and Tel.No..irOg�'���"� 3 Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Pr, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision ate Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �XA- Zl L/° J9—13©X 01?/L, 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 of Health. Signed r Date Application Approved by / Date Application Disapproved by Date for the following reasons Permit No. 2,c) A — LrU Date Issued V&J b i -- ~ No. 7 d 1� Ll O Fee THE,COMMONWEALTH OF MASSACHUSETTS Entered in computer: t Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS appl cationi for Mi'sposaY pstrut Constructiont� ernut i_ �c�; 17—Cax OvI� Application for a Permit to Construct( ) Repair( _Upgrade( ) Abandon( ) ❑Complete Syst Individual Components Location Address or Lot No. �� ` / j H fL� S O er's•Name,Address,and Tel.No. Assessor's Map/Parcel / 7/—1 7 L Gr y 51-4a , In taller's Name Add"; ss,and Tel.No_52d9`y2a-T75e Designer's Name,Address,and Tel.No. /61,0e sal Type of Building: Dwelling No.of Bedrooms Lot Size —sq.ft. Garbage Grinder g ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures n ' Design Flow(min.required) gpd Design flow provided V gpd• Plan Date Number of sheets Revisionate Title i Size of Septic Tank Type of S.A.S. .I ; Description of Soil . ' r i i Nature of Repairs or Alterations(Answer when applicable) sri4lZ �Q—13OX O ti/� i y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in r accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of r Compliance has been issued by this Board of Health. Signed Date nn Application Approved byCyd 1 f Date 4 ��� 4 Application Disapproved by Date for the following reasons � r Permit No. �?- 0 b l�U Date Issued 6 ~ ------------------------------------------------------------------ b ----------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS `- BA RNSTABLE MASSACHUSETTS Y>u v' X Certificate of Compliance THIS IS TO CERTIFY,tha the On-site Sewage Disposal system Constructed( ) Repaired((/)' Upgraded ( ) Abandoned b I p , ( ) Y at ( _ ," ( r has been constructed in accordance with the provisions of Tit e 5 and the for Disposal System Construction Permit No.)6 — L b dated Installer Designer #bedrooms ,dU 'A-- Approved design flow gpd The issuance of thiss�p rmit shall not be construed as a guarantee that the system wil nc'on s d signed. Date 2 1�(�o Inspector ( --------------------------------------------------------------------------------------------------------------------------------------- No. '7 I �i ' �(J Fee�� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal bpstem Construction i3 fmlt Permission is hereby granted to Construct( ) Repair,( ) Upgrade( ) Abandon( ) System located at ( I; L r- IJ/� r /d 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:Construction ust be completed within three years of the date of this permit. n Date t /� �' /b Approved by f - - )N SEWAGE PERMIT NO. �Q F�.-� Gam. �• ���� L R'S NAME L ADDRESS I OR OWNER c- 5-04 IERMIT ISSUED ; 0MPLIANCE ISSUED i 9�- I e Health Master Detail Page 1 of 1 Legged In As: TOWN\healtn Health Master Detail Wednesday,July 20 2016 Application Center Parcel Lookup Selection Items Parcel Septic I Perc I Well I Fuel Tank Parcel: 171-274 Location: 51 ELIJAH CHILDS LANE,Centerville Owner:JOHNSON,ROBERT L Septic 1,4/28/2016 New Septic... Permit number: 2016-140 Permit type: Repair v Complete system: ❑ Issue date : 4/28/2016 Complete date : 4/29/2016 Septic tank size: Type/Size of SAS: Installer: D_ebarros,Joseph,Joey's Septic Service,Inc. Q Card on file: ❑ I/A service type: Select serviceQv i Innovative/Alternative Technology type: Select IA type �Q Variance date : Abandon complete date : Abandon permit number: Repair deadline date :F '°Y Repair notification date :�—m Keyword: Comments: replace d-box Delete Septic New Inspection... Number Inspection Date Inspector Result Select Inspector 11,11 1.Select result I —i Received Date Comments 7/20/2016a� I Save Septic Changes Return to Lookup http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=171274 7/20/2016 No r Fps.......... .......� .. ......... r= s: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ZO-?z .................OF...../..r�: - .. '..---•--.........................._ ApplirFa#iun for Disposal Works Totutru.rtiun thrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual. Sewage Disposal Sy !�/,at'." {_... ..... -----•----•------•. . --- -•-- ........................ � � � Location-Address or Lo�Ijg. .. _. .1..... - / (J --....:�-........................................................... O Owner . � Addresg Installer Address dType of Building •^� Size Lot..,l-- .)..:�v..Sq. feet U Dwelling No. of Bedrooms....? ..Ex Expansion Attic g ( �+ g— -----------•-----------•--------- P (�ll/U Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ..-•-•-•---••-. •--•--••-•----• - - -- W Design Flow......... ................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacit gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ..........:/......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by••--•----••----------•-•---••-•-••--••-----•.....-•-•....-••--•-•-••-•... Date..................................•..... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ------------------•-•----•••----••••---•••-•--------------•••--•••-•------•-•----------•--•-•-•---•-------•------•-••••-•••----•--•••-------- ODescription of Soil �� ------------------- .....=........:1................................................................................... 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 TTTT,;,:. 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by -he board of health. rr// Signed ..........................................-........................ r -... .... at'e Application Approved By........... = ---'•.---- .............................. ..... - .----------- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ---------------------•--------------------------------------....---------------------•--•--•--------........---------------------------------------------------------------------...•-••-------•--------- Date PermitNo.........................•--••......----•--------••----. Issued_....................................................... Date ♦z b. a � _ No. �_'•t.•8 FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ........... .............................OF.......................................................................................... Applira#ion for Disposal Works Tons#rnr#inn umi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................-........-...................................................................... •-•-----•---...•-----•--------•--................................................................ Location-Address or Lot No. ..-^................._..--.................................._............................_...... ..........--......................................................................................Owner Address W g � Installer Address Q Type of Building g Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrgoms.........,'_ -------- ____________________ Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building "............... No. of ersons...._._.....___..._..._.___. Showers — Cafeteria a yP g --------.... P ( ) ( ) a Q "Other fixtures ..............�........................................................................................................................................ W Design Flow........................................,_..gallons per person per day. Total daily flow............._..............................gallons. 04 Septic Tank—Liquid"capacity............gallons Length.....:.......... Width................ Diameter................ Depth................ W x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1-4 Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ----- D Description of Soil y - ------ ---0� /-/o eza- e -------------------------------------- ---------------------------------------------------- ----- - -----•------------- --•--•----- ------. -- ------. ------ -----•-- -----------.._._....--•---•--------•-----_..... 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 TIT I EE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed-------------------•----•--••------.................................................. ................................ � D.ate- Application Approved By.......__4-52• 41_..... --------------------•--•------- ate Application Disapproved for the following reasons---=----------•-------------••------ -------------------------•--------------------------------•---------•••---- ---------------------------------------------------------------------------------------------------------........--------------------------------------------- Date PermitNo..........................................•---•--•----•-.. Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS -~ BOARD7F". iEALT,-t .................................OF............................................I........................................ Terdifiratr of (gompliaurr THI TIFY4:32aV.the IrC61rtal Sewage Disposal System constructed ( ) or Repaired ( ) by. �� lop _le --------- -- •. Insta er �YL'................................................. at............................................-.. -----------•-----------•--•-••---------•--- -a-�-- .................................--•----..._.....---------•--•----------•--------------- has been installed in accordance with the provisions of T 1 ` 5!M& State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_--------...................................... THE ISSUANCE. OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �J DATE.......................................1��Ylzl...........-••---. Inspector....... ' THE COMMONWEALTH OF MEASSACHUSETTS i 410 7 0 1�1 BOARD tsff!` �C 73,YVic. G ..........................................OF.................................................................................... No............................. FEE........................ Permission iA- ereby granted-•-- ------•. .................. -•---------•--_-•- -----/- ----•-------------------------------.--------- to Construct�X) or R,�aii ejAtMndiviCalI5.i4-*O.bispos Stem C 14,e,4r, at No r.S+tr�eet .. as shown on the application for Disposal Works Construction e .„� ------------------------------------------Nr 'V.,I___._ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS 1.10 GArz8�G6 fsRl�JU>cIL � � � I . 2ae%L.�4 p'Low s 1io 3 + 33o "rk 330,E ISo % • d-95 6.P0. ' . use- t oao AL. ' �ISPoS,a•L PtT uSE loco G�•L—. � 1�— — —I 'T"' s1 tC�E.WaI.L A2� - ISD M �A° � 1So 5;F od2 3'7S •� Barpo K A.QEA =-jc> sr--. d I 5o s.�c. �. t .o L ` ToTQ L •%:P ESI61,1 t 425 G.F.L7. - I G o�..►c. t 1bToL_ va1L�f F'Low 4 33o&F..'D. l �L �d s � a� Qom• w � t C�E.QGDLbTlO�.I QeTE i lu��•1. L.�il��l•�Q �7�. r� y • ,,.�.. ._. �� �V��,gip:;� t W iL I, M J01. 40 19136 41 1NAl GNU �40 SUR i I J . loY duo 50 / -Y , 4'PP� vest; tW. Gee. 4Y,d I000 � luv, --- •t, 1 GAL. Y PIT RE 0 WASH WD STONE 5,1 CEC�Tt1r1ELD PL6'r PL.QV-3 N A;! PiZOF--"tLE�, LoCATlntJ C -/z- yo �' -�, � • CGRT' F Tti•dAT TIdr-- Co aC..FbutiG' St-eoru�.l pLA1�l RGi=i=�c�.1Ca t-1E:2L"-tea 3 Gcx�PL�(S W"rt,t tNG 5{Db ..t_!u-�Ic I... OT" d A.1.iD SE-.iTi3AG�C G'C-QU1r~E�cuTS OF THE' To\"w of $A�1Z{�1rTABti� G 't�R.�/tt,s.t.: ! l �i l,klr�DS PATC �7CL"T -1-1E- `!� twG- {3 RCGIS ItRGv LAw0 SuZVcl- OSTEC�/�l.t.G a' ASS� TtaC ARPt.t GAt--1 `Y_ h4at' E'.0 ,'�JSCc� T'u t�erc�M�►J�= 1..0'S' t_I N`> ��� ; ��,%i��J;�,�,•a (I..�' LOCATION SEWAGE PERMIT NO. VILLAGE F r-4- I-N S T A LL R'S NA-ME & ADDRESS BUILDER OR OWNER - �oxi �"3( C��• mow` DATE PERMIT ISSUED DATE COMPLIANCE ISSUED f C67- `t`-9 s � . y7 _ nG �� fl