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HomeMy WebLinkAbout0041 JOYCE ANNE ROAD - Health 0 41 Joyce Anne Road, Centerville A = 209-115 No. 42101/3 ORA ESSELTE 10% 0 0 a 0 f COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 41 Joyce Anne Road Centerville. MA 02632 Owner's Name: Bruce Horton Owner's Address: c_ Date of Inspection: June 21, 2006 Name of Inspector: (Please Print) James M. Ford C= Company Name: James M. Ford Mailing Address: P.O.Box 49 I :� Osterville,MA 02655-0049 ~'C� Telephone Number: (508) 862-9400 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: ✓ Passes Conditionally Passes Nee Further Evaluation by the Local Approving Authority Fai s Inspector's Signature: Date: June 27, 2006 The system inspector sha\subia copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the.system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable;and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21,2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: 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: 2 • Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of aimnonia 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: 3 • Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. _ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ _ Pumping information was provided by the owner,occupant, or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received nonnal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with infonnation on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System (SAS)on the site has been detennined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)J. 5 • Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [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)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied C OMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of infonnation: Pumped in May 2004-per owner Was system pumped as part of the inspection(yes or no): No If yes, volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 8112197-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Continents(on condition of joints,venting,.evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16" Material of construction: ✓ concrete _metal _fiberglass _polyethylene —other(explain) If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 ag 1. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was.even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Continents (on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 7 Page 8 of l l OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Joyce Anne-Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alann in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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 level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarns in working order(yes or no) Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): 8 Page 9 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: _4 infiltrators with stone-32'x 10'x 2'(der as built card) leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): The infiltrators were dry and clean There did not appear to be any signs of failure A video camera was used to inspect the interior, CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 9 • ` Page 10 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWA GE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: _ 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 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. p � !3 a y8 3 —, a� yq 3 3a yy 10 I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 41 Joyce Anne Road Centerville, MA Owner: Bruce Horton Date of Inspection: June 21, 2006 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25 +/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting Oroperty/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topogrgphic and water contours maps, the neaps were showing approximately 25'+/-to groundwater at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 _ TOWN OF BARNSTABLE XITI ^ ON J dY t, � nne. ��- SEWAGE # c17' "/Oa- .L : AGE ATC.rV t I w ASSESSOR'S MAP & LOT aOg+ /1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY D LEACHING FACILITY: (type) 14 (size) D x a NO.OF BEDROOMS 3 /, BUILDER OR OWNER 14oerm PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by c�' �A 6��k 6I - i /� B I a l `/8 3 a� yq 3 3a `ly No. 97 Ve� Fee THE C MMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Mi!5poga1 *pgtem Conttruction permit Application for a Permit to Construct( )Repair(P<Upgrade( )Abandon( ) ElComplete System ElIndividual Components Location Address or Lot No. L )VPC Owner's Name,Addres and a No. �t wt - v c rt Assessor's Map/Parcel ;Z C) / Installe,r', Name,Address,and Tel.No. Designer's Name,Address d Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'I�ype of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets- Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) H Iy 4 CAP Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo f Health. Signed �� Date �� 7 Application Approved b Dates" Application Disapproved for the following reasons Permit No. Date Issued - _ ------------- ------ ------ ----- No. a a Fee r ' THE C MMONWEALTH OF MASSACHUSETTS" Entered in computer: Yes, PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Migotaf *pgtem Construction Permit Application for a Permit to Construct( )Repair( v)Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. L / J G t C�C lv e Own s Name,Addr and No. Assessor's Map/Parcel Installl's,Name,Address,an Tel.No. Designer's Name,Address d Tel.No. l'l•onLviCl� t-/ 3a G�3U Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons.! ` Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations Answer when applicable) 8 �� �� r " Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issueo by this Bo f Health.« -7 Signed Date � S / " Application Approved b ® Date _ Application Disapproved for the following reasons Permit No. 4 Date Issued - --------------------- - ----.-- THE COMMONWEALTH OF MASSACHUSETTS BARN ABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Aband9ned( )).bb at Z ,V ,.1'- <7Z19 has been constructed in accordance with the pr%S4�**;y of Title 5 and the for Disposal System Construction Permit No. r Q dated (�" �-1�. Installer Q V- Y Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date C� ! _ 4 N j Inspector C\ 1 ———r-�———�J—————————————————————----—————————— No. 9/ c�v -0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS lwiopozal 6potem Construction Permit Permission is hereby gra ted to PoAVruct(" )Repai )Upgrade 'b�f'don( ) System located at ? '� ���� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction naust be completed within three years of the date of this it. Dater �� Approved tX �/ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTItUCI'ION PERMIT (WFF110U'F DESIGNED PLANS) I, �,� ���t , hereby certify that the application for disposal works construction permit signed by me dated T 7 , concerning the property located at OVl`'Iv-e /Z1 Cut"1'`//`meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the,bottom of the leaching facility • There is no increase in flow and/or change in use proposed' • There are no variances requested or needed. SIGNED :/Z DATE: -7 LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. L > >I TOWN OF BARNSTABLE Y J•. LOCATION 7 C CC AW YV IZn SEWAGE # VILLAGE -tow ASSESSOR'S MAP & LOT!2 t*� INSTALLER'S NAME&PHONE NO. I CXt k CI) YD oS30 SEPTIC TANK CAPACITY ( AI 000 LEACHING FACILITY: (type) (size) 0�`a NO.:OF BEDROOMS BUILDER 0p) � eS ��KWOiL PERMITDATE: � 9 I COMPLIANCE DATE: Orya / Separation Distance Between the: h I Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 'V(k Feet Private Water Supply Well and Leaching Facility Of any wells exist4on site or within 200 feet of leaching facility) v Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 a aching facility) Feet Furnished by 301 3� TOWN OF BARNSTABLE LOQA4710N i� -142�CC, AMJKI 1Z0 SEWAGE # ';VII.L'►GE n U . . ASSESSOR'S MAP & LOT 09'H' //5' INSTALLER'S NAME&PHONE NO. i IJ C xt k C6 LM--0S`3 0 SEPTIC TANK CAPACITY -i+-f, 000 �S - LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER 0 0 � S �t r K►�t��, 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) J A' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 a aching facility) �� Feet Furnished by(. q8 6 3a TOWN OF BARNSTABLE 7 LOCATION SEWAGE # VILLAGEffff ASSES SO MAP & L T Z[S PEUORINAME&PHONE NO. � SEPTIC TANK CAPACITY LEACHING FACILITY: (type)-t_i In (size) /6XZ NO.OF BEDRO S BUILDER R 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 Furnished by �/'! Pj f L 21 no C / fly ..`own,of, ���B. a . e )P# ' Depaxliawt of R0979 tto><y.Services ffru" Pub1te Read,Inslou Data � 20 1 main Btreef,11,V Is MA 02601 1,-2116 Date Scheduled. ie v v C may, Soil Suitability Assessment or So e Msposal (so/)SQ iVe y LOCATION %-� gyp_�y Witaevsed Hy:t�7� �-��• LOCO IO AxC.".YE..., ,: :.Y ��.,�.�:�,R�tl'7l"���'.1p1�A:'1 I oeation Address �[( j n� Cc �N� Owner's Name lJ b xI,-) ( Address Assessor's TYlap/>'arcel: ab ' >;nglnocr'S Namo NEW CONSTRU=01\1 REPAIR _ Telephouco 6 08 • Land Use:, Law/? Slopes -C-1—/ Surface Stones Fe� . Distaneat ftm: Open Water Body�I��G ft Possibic Wet Area. (GG fl Drialcing Water Wrll ft Drainage Way �l/0vJ ft .property Line 2—(—Oft Other ft > METCHC(Street name,dimensions of lot,exact Iocatians of•test holes&.perc tests;locate wetlands to pxon1mity to k:olcs) _ f jr, Parent material(geologic) `�C t a Depth t0 Be mek Depth'toGmundwater: SlandingWaterinilole: /V � �' weeping from PltFRQU EstiMated Seasonal gigh Groundwater- N �V E�1J1u7"I AAk,.rJ.'9 FOR 1.:EASOA.'AL JOU1.O 7V'.M TE rV-AE!�(F, Method Used: W _ y' Depth Observed standing in obs.hole: la, Geptlltit?.5411 fA7QtS�>it.. a �Il, Depth to wcopingfmm side of ebs.hold: In, dtnurulwatcrActJuetln�nk fr. Index Well It Rcading Datc: Indo�c Weil7pYel Acs(.$fit thC, tll,;( !Y?Uil4W11k6rLeval— FERCOLATIONTEST Observation Hole#k Tlxn�•at.St" ,..,,,.,.,,,,.,,.._w �...,,..•..�.�.. I/ DepthofPero. ` Tlmv.At6" , Start Fre-soak Time @ End Frc-soalc / Rate MindInch ` 11711-7061) 51W 3ultab1l1ty,Asaessmcut; SltvFassad NltgFailed., AdditionaITastfngNeeded(:Y/N) Original: Publlc health Dlylsloa ObBa6atioa Hole,Data To Be,Completed ou Bark ***If percox2flo is test is to be coiaducted witbin 100' of wetl�md,you must first-aotlfy the Barnstable Colas) vaffon Di-vision at least one(1) week prior to begirming. f,,):15EHI'IC'1PERCPORI�'.DOC 1 DFEF.OBSE1MX'TW0X'A0LrA,LOG Dcpthfrom Soillnd=n Soil Texture ShclColor Soil Ot'hcr Surfaeo(in.) , (TJ'817A) (MunseIl) Mottling (Structure, Stones';Boulders, o i'tcn,y,9�'Cravall ' L 2y—13 Z C �G'Ia Gra ye , Rale 'Dr from ' Sall Horizon SbIl Texture Soil Color Soil Other Surface(in.} (U,9DA) (Munsall) Mottling (Rructare,Stones,boulders. ansis en 9b Grave 20 �& DEEP OBSERVATION ROLF,L0 G Depth from Soll1lorizon SoiIToxturo Soil Color Soil Other' Surface(in.) (USDA) (Munscil) Mottling (Stmcrtuzo,Stones,12ouldars. Coil 611PTI.cy,%.Qrgvnl) Dapth from Soil Hadzon SailToxturc Soil Color 5011 other Surface(in.) (TJSDA) (Munsell) Mottling (Structure,Stones~Boulders, • Ca si Ean 6 .. 7 �Y.aot$7sa5tvxamc'r��.aEe'1Vl�.p:. I J ', Above 500,yearflwd boundary No Yes 'Witbin500 Year boundary, No •Yes. Within 1d0year flood haundary No, y�entl�of NaftxrulY y occurring Perwiorls MrLtori Y Does at least four feet of naturally occurring peiwious material 0xist in all arcus nbs:6vVod throughout thn area proposedd for the soil absorption systeml :�e 5 � If not,What is the depth of naturally occurring pervlous matdriall x certify that on ..(date)r have,passed fbe soil evaluator examination approved by the Dopaitment Of Environmental Protection and tharthe above analysis was porfbrmcd by me consistent with . the required training,experdso and experience described in 10 C1V� 1 .017. ---� --- /7/� 7 Signature bafi; - ' Q:15�1'TlCll'L�Y1CI�OIYM.nDC II V -dog, /f5, ban BORTOLOTTI CONSTRUCTION,INC. 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Properly Address: Date of Inspection: Inspector's Name: - er's Name and Address: 9 n CERTIFICATION STAT M NT• I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported'below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The System: Passes Conditionally Passes Needs Further Ev tion By the Local Aproving Authority Inspector's Signature: Date: A?7 The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30),days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. I INSPECTION SUMMARY! A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If "not determined",explain why not. The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or exllltration,or tank failure.is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. Sewage backkup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): -1 - y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Broken pipe(s)replaced Obstruction is removed Il re Distribution Box is levelled or replaced fur times a year due to broken or obstructed pipe(s). 'n more than o The System required pumping Y The stem will pass inspection if(with approval of The Board of Health): system ,-- Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determi if . the system is failing to protect the public health, safety and the environment. 1)SYSTEM,WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM. IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THEY, ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a pnvate,.,,.. water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from; the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm - D)7STEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. .The.Board of Health...., shoo d be contacted to determine what will be necessary to correct the failure. ✓ Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool Discharge or ponding of efluent to the surface of the ground or surface waters due to an_.:; , overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clog / ged SAS or cesspool. V Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- as E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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. The owner or operator of any such system shall bring the system and facility into full compliance with the Y,. groundwater treatment program requirements of 314 CMR 5.00 and 6:00. Please consult the local +- regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Check if the following have been done: Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. (-'As-built plans have been obtained and examined. Note if they are not available with N/A: The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in- spected for condition of baffles or tees, material of construction,dimensions;depth of liquid, 's• depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST(continued) The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Subsurface Disposal System - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION . FLOW CONDITIONS RF.SIDENTL4, v Design Flow:__�alllons Number of Bedrooms: 0 Number of Current ResidentsGarbage Grinder _ Laundry Connected To System: Seasonal Use: cJ Water Meter Readings,ifilable: Last Date'of Occupancy. COMMERCLAi ANDUSTRi_AL,(JG Type of Establishment: Design]Flow:",`'t' gallons/day Grease Trap Present: (yes or no) Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings;If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: - System Pumped as part of inspection: If yes,volume pump.d: gal ons; Reason for pumping: TYPEPF SYS.TEMi 'ems Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records,if any) Other ex lain ( P ) APPROXIMATE AGE of all components,date installed(if known)and source of information: Sewage odors_aeteefid when arriving at"the site: -4- i ,4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Y Depth below grade: �/ Material of Construction: concrete metal FRP—Other (explain) Dimisions: ' ' ' Sludge Depth: Scum Thickness: Distance from top of sludge to bottom of outlet tee or baffle: 3y" Distance from bottom of scum to bottom of outlet tee or baffle: ap Comments: (recommendation-for p`umping,"condition of inlet and outlet tees or aflles,depth of liquid lev in re tion to out et invert,structural integrity,evident of leakage, .,.y GREASE TRAP:,_ Depth Below Grade: Material of Construction: concrete metal FRP Other (explain) — — — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.) TIGHT OR HOLDING TANK: Depth Below Grade: Material of Construction:_concrete—metal—FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) �h DISTRIBUTION BOX: Pl . Depth of liquid level above outlet invert: Comments: (note if 1 Ml and distribution is equal,evi en of solids carryover,evidence of leakage nto or out of My,etc.) PUMP CHAMBER: Pump is in working order: Comments: (note condition of pump"chamber,condition of pumps and appurtenances,etc.) -5- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Y SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: Leaching ga lleries,number:Leacuing pits number: Leaching chambers number: Leaching trenches, number,length: Leaching fields,number,dimensions: :Overflow cesspool,.number: f h ydraulic failure level of nding, coition of egetation, Comments: (note condition of.soil,=S1 o CESSPOOLS:A_�) Number and.configuration: Depth-top of liquid to inlet invert: Depthiof solids layer: Depth of scum layer: Dimensions of.Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6 - y �[ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (conliuued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. DEPTH TO GROUNDWATER: Depth to groundwater: Feet Methoo of Determination or Appro 'mats9n: /�,�f'/ iG� /�©�'I el, 47 -7- No...........Z THE COMMONWEALTH OF MASSACHUSETTS BOAR® O HEALTH ..........OF........ ....�r.� . .......................................................... Appliratiun for Dispaii al Works unstratrtiun truth Application is hereby made for a Permit to Construct at ( ) or Repair ( ) an Individual Sewage Disposal Sys :M / ocat�wier dd ess r Lot No. Address ---- �C ..-. Ar7P. ..:............................. ...•--................................_ .....-----................................. Installer Address UType of Building Size Lot._/J..__fM........Sq. feet �., Dwelling—No. of Bedrooms......... ..........................Expansion Attic ( ) Garage Grinder ( ) '4 Other—Type of Building No. of persons............................ Showers C4 YP g ---------------------------- P ( ) — Cafeteria ( ) Q' Other fixtures --------------- ••------------- . w Design Flow........... ....................gallons per person per day. Total daily flow._._.?- ..........._........_..gallons. WSeptic Tank—Liquid capacity/4zo.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width...__.�.3._..___._.. Total Length.......... Total leaching area.._............__ sq. ft. Seepage Pit No...______l---V--, Diameter..........5T'__ Depth belo}}�(inl t...... ........ Total leaching area...2.A.....sq. ft. Z Other Distribution box Dosing nk ( ) OF��C Percolation Test Results Performed by....... ' y.......•. ................ Date....., .-I .....7P._....... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ xr--- ----->-,-....:...... ....... . .. --- _ r -- O Description of Soil.....-.... - ........ ... , x U ---------------------------------------•-.....--••-•-------------------•---•....••----.....--•--------...••---------------------•-•-----------•---------•-•-----------------------------••-------------- w UNature 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 TI'i U 5 of the State Sanitary de— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b e ss b the board of health. 7igned. ..... ...... ........•--•--•-------------------.......-----•-•--•-----------•- ..........................- S Date Application Approved By........ ...... �'p'� `l � �L�� Date Application Disapproved for the following reasons:......................................................................................... ----•---•--------•--•- --------•---...-•----•--------------------------------------•--------------•••---•----•----------------•----•-•---------....-----------•-----------•-----------------•---------------------------------- Date Permit No............. ..... Issued .. _Zr— ........................ Date THE COMMONWEALTH OF MASSACHUSETTS BOAR® 9F HEALTH ..........:..... .....OF...... .. .Q! !. Appliration for Disposal ork �(�oatstratr#ion rrmit Application is hereby made for a Permit to Construct or Repair ' pp y ( ) p ( ) an Individual Sewage Disposal s at: 4?*oI7 4_ W. aolkwvi& ... Locate n A dressLot w�er Address w _ Installer AddressPQ / Type of Building Size Lot./4."'_- 1---------Sq. feet �., Dwelling—No. of Bedrooms.........:..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures -----------------------------------------------------------------•------------------------ W Design Flow........._... . ......... .........gallons per person per day. Total daily flow___-�#" ..............................gallons. WSeptic Tank—Liquid capacity_4Q' ..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—N . .................... Width.. ........... Total Length.......... ........ Total leaching area................ sq. ft. Seepage Pit No........::....... ... Diameter.........�3 :_.. Depth belo�k i t... ......... Total leaching area.��---�......sq. ft. Z Other Distribution box io Dosing` ( '� ` "' ,2 Percolation Test Results Performed by....._ :_:-_...>►�r .: ................ Date.... ...11r.............•__.__.. 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........................ P P / Jf -= f r D Description of Soil.... ....�"'...�z ���...- - -- - �--------`-� � /� U ----•- ------------------------------•----------------------------------------------•--------...------....... WF 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 TITYIE . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has t Iss board of health. 6�w „ Signed>.___._...L. _ Al�,g Application Approved By...... ��.__ ......... •- ���t''°�' -------------_ /._..'.�!�® __---- ...----- Date Application Disapproved for the following reasons:.............................. .................................................•---------.. ------......- ---------------------------•-------••-•----•-------------• -•----•----------•----•-...----••......-------•--------- Date PermitNo......................................................... Issued-.............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH- .......OF....... .........::........ :... ................... Trrtifiratr of TompliFaatrr THIS)IS T CE FY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) b _ .............................................. y-----•-- ---- Install °' InstallS� at ' 'all � . :....----� .ems. ' ---=��'- . ........................................' � �~ has been installed in accordance with he provisions of .F 5 o e S e Sanitary Co e a des 'b d in the application for Disposal Works Construction Permit No______________�.__ .....__...... dated...... ���." �..._......_..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. cDATE............................................................................... Inspector.....................................-•----- = THE COMMONWEALTH OF MASSACHUSETTS BOARD HEA6 .LT '"'+ '''Z............OF....... No......... � ..... FEE . ............ Dispo- to o k ....onotra ioat rram# Permission reby granted---- ........... ....- . . to Consttrriaa t ( or Repair (Q) a j wage Dis ystem ' 1, ..L!' �? Street , as shown on the application for Disposal Works Construction Permi o.___ _"7 _ ated-• ' --........ f----••-•----•- f"=-�'��°��'-•--.. -""------- ..................... -- --------..---•--••----- DATE. .. Board of Health fi -•-•---•------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ` C���sI�N DATA Sk Qr..t-E: "0 GAtZB<>G-F_-_ GRI k,tn�rL \ t>&JL.�4 CLAW z 110 -4 St SSO lc - SSO'l l50 % = Aft g 6.P.�. f uS 1 OOC-'3 GAL. 4-1 , ISP PIT - u5E loco ��^+. 4"-. Stl;GW,ALL AREA = (SD S.P. ( ,�(✓ ICU SF )c 2.S + 3 7S G.P.D. Bcrr'rOM Ae _ eo ST=. _ SD 4j'. x TOTAL. T;>ESI6Q = 425 TroTQ L t>a t UI( FL..OvL/ T. 330 6.PD. �" Q `7 Pl=t2GDL�TIOt,I OwrE CIQ 2-mitj" Olz LESS. 10 7,jt4rw .l,•.nrVllw � /� w •ry't:�6 fti�ti 1� I�/'t�.JJ 1�I� T�sT Z�►`�l�� � Tor Fwo =Ida.o G A', I o00 lug. DIST 4 -sox Sc-uric rZ- INV. TowK 1000 �S.Q �IuV. I►.!V• t S GAL.. QG o 9f .¢ 96•L d /VtCrj. LeAGH .A PIT e' I�l WAS6IED STOw1f= �,Q I ' C6QTtFiEt7 PLOT' PL Qt� Ptz�o�'1L� t0GAT10" l:fe I.T ow C. L(s - v ` cmtZTtt=-� T"AT TPA Fbvk GATIo;j 51l w1J pt_L►.a1 R 'E�ZE ►JC ' 1-�iw1�t=0►.1 G�Nl�L�IS \,l/ 1 rA TWA SI VE LI"IF__ � A W a SE T T3n C K 'E 4 U 1 t~EM c WTS OF= a.-cat- !Ga D.AI-r 'Z 2EGlSItIZ�D L1�1r1t;, UeV�YutL=, TW15 DLAN l5 IIOT L�sn.�,E� Ut•.-► 44.1 05TEkZ�/1LLG o r1�C��Sy. 1WSt`>?rJMEIJT ��iJk=VCR{ TIaG C3FG'�EC-�s �jk�GWLD {P Kbr BE:. used rb t"3c_zTC_V iu,4 lDT t_1N�=5 -A �c��- q T / LAIC A-T 10N,° � 0/a S E W A G E PERMIT NO. r -VILLAGE Cie 1 r Iv s INSTA LLER'S NAME & ADDRESS arc -71 T BUILDER OR OWNER/ 016 DATE PERMIT ISSU € D DATE COMPLIANCE ISSUED - ._ _� �_ s - - a v . 9 / /� 4 i�3 � 1