The URL can be used to link to this page

Home My WebLink About0065 LONGBOAT DRIVE - Health 65 Longboat Drive Centerville A= 193 161 0 6� I UPC 10259 No.H1630R i MAGTINQG.UN // TOWN OF BARNSTABLE LD LGCATION E l OO&"4) ,/ SEWAGE # VILLAGE A& ASSESS S MAP & LOT ran�I%�./�'�P/�i-r Sa�& Gt°S NAME&PHONE NO !'�� ! SEPTIC TANK CAPACITY '7L AO/ LEACHING FACILITY: (type) �. f �%� (size) gFOO Q01 NO.OF BEDROOMS Q /� BUILDER R OWNER w6 iC- � %24 PERMIT DATE: 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'(10 feet of leaching facility) Feet ".Irnished by `f Y_al ali 0 56—/ .1"el ASS OAS n r s, BORTOLOTTI CONSTRUCTION,INC. PARM NO: 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-711-9399 508428-8926 FAX: 508428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property YO-u,�/ ~ Pro Address: �, Date of Inspection: nspector's Name: Ow is Name and Add re s: / cXj _ CERTIFICATION TAT 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 B d Local Aproving Authority Fails Inspector's Signature: Date: 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. INSPECTION SsUMMARY• A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of tit "we °�• criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are i ed�G below. B)SYSTF JoM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,u comple q9g, 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. r The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exfiltration,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 td 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 - _ _ I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four 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 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 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 THE 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 private 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 colifonn 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)SYSTEM 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 should 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. Liquid depth in cesspool is less than G"below invert or available volume is less than 1/2 day flow. 'Required pumping more than 4 tunes in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) An portion of the Soil Absorption System,Y Po rpcesspool 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 11 of a public water supply well. I • . . The owner or operator of any such system shall bring the system and facility into full compliance with the 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, 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-int rusive methods. -3- 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 RESIDENTIAL: Design Flow: eallons Number of Bedrooms: Number of Current Residents: Garbage Grinder: iP Laundry Connected To System: Ile' Seasonal Use: b Water Meter Readings,if Table: Last Date of Occupancy: COMMERCIAL/INDUSTRIAL: Al 16) Type of Establishment: Desigri Flow: , °` gallonslday .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: GENERA NFORMATION PUMPING RECORDS and source of informati u: 12) /lJ /7 System Pumped as part of inspection: A10 If yes,voluInt pumped: gallons Reason for pumping: TYPE OF SYSTEM: J/Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): PROXIMATE AGE of all pomponents,date installed(if known)and source of information: 8 �o r7 Sewage odors detected when arriving at the site: -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grader 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: 33 Distance from bottom of scum to bottom of outlet tee or baffle: /p Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relationp outlet invert,structural integrity,evidence of leakage,etc.) 7` tS'o jpGl�4'l3 Q�� cY �� ado ach /le- c �,-� y , GREASE TRAP: V 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: e 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.) DISTRIBUTION BOX: Y Depth of liquid level above outlet invert: Comments: (note if level and distribution is ual,evidence of solids carryover,evidence of leakage into or out of box,etc.) S 0S"'6 n a!JI i� PUMP CHAMBER: j Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) A -5_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS):__4z' (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: J Leaching pits,n umber: / Leaching chambers, number: Leaching galleries,number: Leaching trenches, number, length: Leaching fields, number,dimensions: Overflow cesspool,number: Comments: (note condition.of soil igns of hydraulic failure level of ponding conditio of vege lion, etc. � , i, � e / b - 121ro 16as 0 Xyi� CESSPOOLS: 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(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- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. ql . 5 DEPTH TO GROUNDWATER: Depth to groundwater: 3Q a Feet C Method of Determination or Appr coati n: l�l9i)'//�//�' '�>` /,c�'/�f �i✓ �t� o fei' m THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF......................................................................................... , pplirFafion for Dispog al Works Tnnitxnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: / ................_. •r/, i 1101�= .-------••--------------------- --........'��---�-�2...••�d I....�.Piy/. Loc tion-Address or Lot No. .......�'�. lfaz.�.......LZ/t i5 L.0-....... /!��11'i`_.�®:.. �i�!_!. '!�r!':��r,��..fix`.� l�"?--.dy Owner Address W ...... Ldstaller Address dType of Building Size Lot.................... .....Sq. feet U Dwelling—No. of Bedrooms....__..__ ._ ....__..._Expansion Attic (r� Garbage Grinder �- '� Other—T e of Building , No. of persons:........ .................. Showers (a2) — Cafeteria a YP g J1�t_�I.3l.s -----.. Other fixtures jOdlJ--•------•-------------•---••----------.-------•---•---------------------------------------•--........-•---------....•......•.-.. w Design Flow...................... gallons per person per day. Total daily flow............ ....................gallons. WSeptic Tank—Liquid capacity............gallons 'Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.. ................ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( /�) Dosing tank ( ) Percolation Test Results Performed by.... ---C�/r �',�.................. Date..3.11_9h,t'___............ 14 Test Pit No. 1.....a_.....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 -------------------•-•--•.--••-•• -------••---•-•----------•--------••------------------------------------------------........... O Description of Soil............. g kSC........5�i ..........4- r ..._.. x w V Nature of Repairs or Alterations—Answer when applicable............................................................................................... -•------------------------------•--•-------------------------------•---------------•-•-•----•-------------.....--------------------....--------------................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned f,J�rther agrees not to place the system in operation until a Certificate of Compliance ha7bDee sued bythe board o'l/ealth.. Signed —•--•--•---• .�K_ -..................... •. Date Application Approved B ............. �C -=-..................................... - .. .•.... 7 Date Application Disapproved for the following reasons---------------------•--•---••--•------------•------------------••---•-•-•-•-•-•-•-•-•--••-. -•-•-•......-_----. --•---------------------------------------------------------•-------------------......--•---------.........-------------------------------------------------------------•------------- ................. Date PermitNo.......3` 3.•••n...71...........•-•------_. Issued_........................................................ Date Finim THE COMMONWEALTH OF MASSACHUSETTS 5 BOARD OF HEALTH ...........................................O F............................................... , ration for BioposallVorks Tonutrnrfiun Prrmit 9 `# Y�,, Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage .Dilsposal System at: ................_... �r.-�!:d! y /1 6;c. ................................. ................................................... a yet+ r -- " .. Location Address or Lot No. ` Owner aw_= >dY..: "r .- -------------------------------- ' A'2.' j :.._.._........_. 7rFistaller Address Type of Building Size Lot............................Sq. feet; �--� Dwelling—No. of Bedrooms._. e;2_e________________________....Expansion Attic (� Garbage Grinder aa Other—T e of Building p .:Z............... Showers ( .) — Cafeteria Other—Type g ��!'_/_1._____... No. of persons Other fixtures -----•------------•-•-••---••-•••-•.-•-- W Design Flow.....-..........- ........... d _gallons per person per day. Total daily flow.._.__P P P Y Y ....«__..........gallons. WSeptic Tank—Liquid capacity......_.....gallons''�"Length________________ Width................ Diameter................ Depth...._........... x Disposal Trench—No. .........._: Width...........s..__:.. Total Length.................... Total leaching area............. ._.....sq. ft. 3 Seepage Pit No...6.!?_.�_:__ Diameter.................... Depth below inlet_._...__.........._. Totals leaching area._...____._.._._..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by... j ............. Date_;5,Cl g17 W minutes per inch Depth of Test Pit.......4X...__... Depth to ground water.__...... Test Pit No. l.__..a� __. !• (s, Test Pit No.32._.. .,minutes per inch Depth of Test Pit.................... Depth to'groundh•water....___... __. ` ...................................................... D Description of Soil.._.__....._ �A•k L*• "/�•k` ......... ------------•------•....._ x ......................-................................................................................................................................... W •---••------------------------------------•--" ----------------------•---------------•--------------•----------------------------------.•.------••------............----------•-•-•-•--•••••......-- V Nature of Repairs or Alter t'ions—Answer when applicable................................................................................................ - --•----------------•-••••-•••••••------••-•-----•-----------------------•---•-----•----------------------•----------------------•••-••-•••------ Agreement: The undersignfn-red agrees to ir}stallu the yaforedgscribe4d,.Indiv�dttal eWage Disposal System in accordance with p " 'S of the tare Sanitary'Code-2 The undersigned furtl er agrees not to place the system in the provisions of :s:i... �- ; OP eration until a Certificate of Compliance has bee ssued by the board of ealt�i `Signed Ara : .t� r... `+�'_ !, _ . _ & Date Application Approved BY .... - - •` Date Application Disapproved for the following reasons:............................................---------------•---------------............................... ..•-•-•-------•-••••.........................••-------••--------•••---•--•---••-•••-•---•..._..----•...•••-•--••--_.......-----------•••------••...••-••--•----••------•-•----•-••................•---•- Date PermitNo....... ._-'"._ ....................... Issued.---------•---•------------••.......................••. Date { R THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH rr ydcic� Ate 7 Y i . .._..........OF.................I!f' • t�r .. fi',bL C�rr�ifirtt�r of f�unt��i�anrr THIS 1.5 TO CERTI , , That the Individual Sewage Disposal System constructed O or Repaired ( ) n�. --•-----•-•-------•--•--•-•-----------•---•-•-•-••--•-••-••-•- Installer at..............40! ...... ;I...... . .�dy /G r `& ' has been installed in accordance rwith the provisions of TIMER j of The State; Sanitary Code s described in the application for Disposal Works Co str:uction Permit No`, 30_`. r ..........l�, dated__ . __� -.............� ............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL f,UNCTION SATISFACTORY. P DATE.... <r Inspector........_• . _------••--------- .................................................. '�a r �HE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f... �G .....OF.............. r...... ..._...._.._.._.... ....................... .. FEE.... __-___ Disposal Turku �unu#rivat- Trani Permission is hereby granted.......✓4t...J........._. .?.... ` :� to Construct ( A) or Repair ( ) an Individual Sewage Disposal System at,No.........4. ..•. 6--•- .... o r._..tp /t,t � �'`�/C t C ... Street C ..... as shown on the application for Disposal corks Construction;P'errnit No.. 3.,J...... Dated..... ► ._y ('a 1•,.'��:�'� 4,��,�*� Est - > .............................. ... .... ..a_,il�i«A _ {: :�4.. .. ..._ ' " Board of Health r F1 FORM 1255 HOBBS & WARREN, INC "'PUB6 ibRs :y . � �.:. U eve. � � ,- �y;.�#' <grvire*Yn�x)u•wM d�>h,�; �•vf'`'' +R x2":a w'�`"'S:�e•q'S fl,ti ..y<t l:y ,,go -"'^^'+.�.-,e�;.,:�, s s.$.a•..1�-� �'. t��IGt�1 btS,T,�. il•�� - SI�L�a F�•'w/V\tt�'1 � � �1�� t..t0 CaACtS.aG� GR!S.tD�JZ "� 1'�t►_�( FL.oW _ l ib X 3 = '33d G.P•T7. - �l�-t C Tl.�1 t� = 3�d v (=iG % • 4�`j 6.P.D. �b�` � �¢ ' U,54E=7 acoo CIS. POSAt.. PIT usE. Ioc�o C-a,A.L, ��19 SV,WAL AV-F A = t50 SF• r ICE SP, 2.S , 57S G.P.D. T07A I. T�ESIG►J = sj25 (?.f?D. � C TOTQ t_ 1�,c-I r LU W - 6.Pp- PEf2CDL&"T10 Q O&TE . �"� .M 1 W* 02 L". FuD, ► N r.tt q rAA49 AdW 1�Of ICHARD �� o F AN A. I'AXTE Iva. 2• 14817T •„ . . tkKl !,E TIrsT 98 Tor 1"ao =Ioo.o LOAM IOaG� IbN- ' Sirup(„ 4� �. IW. GA.I.. 2 'box to 5,5 Se-r►c A• IMV• T-A r!K. I o0o R�r;° WV• > wv. ;. Lopie PfT ' GoAtt�iL Wirt e. WAS►1ED IJTj STow1E CE[ZTtF1ED PLdTLl �t--./S.t•.i °LoGAT1o�J GcrtJr��114,�, � GG[ZTiE=�{ Yl4A7 TPA Foo�JDAriojJ 540,wu Pt-b.1-1 TZGFitV,E,6-.1c.•C t 1F4?t,z�l.l GUNkPLVG W ITtA TWi-. , IT �o Aut> SETU�ACIG Vc6 ;JIVGAAc:"T; of TN 7O W►.J Or-- 4?L �"1-CIS C7LAt,! (!, LAOT �ASGt7 Ut.b A�.l U'��TEfLv1t lr v IVCr�Sy tw4r��snc►�r ��u:_\/ems{ y� TsaG CFc,•S�r�, �,!-1GWl� ';�+t;�.* t L LO"C" l_I N �� to 1 -.A. .►r�� k�r roc u,�-cn T-c, car rs✓etit `'�____— - L VotPG_ ____ ------ _ - � Go DiC'�lG►�l �/i.'T�. T.>&I L4 ;=tAw _ 110 -c 3 = 33b G.P.V. .C-IEF'sT'1 G TA"IC = 33o.i ISo % = 49 r7 6.P D. u Ste- t oo(=� s4,L-. t- •�- �/ 1D1 POSAL P1T - usE loco roaL• cj�'}q SMGU/ LL 1 SF c2.S = SP fry'. x 1 -o SO (T ) IOTA` -1;;P ESIGW = 42S Pmf2GDLQT1oQ Z&-re 11u SmIu oiz tr--45, VIA It OF 4�}i OF 10 �at'41 RI AARD O A .AN' b E.elf,,4 P,r SAXTER .:; cis W W.:A404n i P to $ITK'�'" �7AJiA I , TI`sT �.-95 -rot l-yn r- L toAM 1uv.-qG.o Su>35p�. �� lboo Iw- ;A �'PG� UtsT 1W. 'BOX R5,5 Sepnc to T`A W K GAL,. 95.1- 4-5,3 1-�H a For wasNeD SA�� sro�,� /o C-S ZTiF1ED PLOT LbGATiyt-4 �c.+.1Te>;./lc.t,, ' Z uo ScAL_� SCAt_ ('t >AT 1 i�o VUAI�.. 1zc:v15c�:, ti�zt(-1� l CriZT1�Y Tt4AT" TN+� Fn�1JLaATtDl� 'Staowu Pt.. AIj Rr-i=at a i-i a Gc>AAPL-eG W t r" TW1=. 5I Dt~.L.I"C-- ANt� SETL-,,�,ACk LT -i'o w►.� of '�,A�,�1yTla 13r.� DATE A XT C 2- Rc�GI S rtzz�n 'LAIC O 5u 2v EYE 1�S ("1 415 pL.A�-1 PS QOT AN Q TE�V1l_l G o I�CAS�i� A tic>r ��_ u=�c� i"o i�r l'ECM1wlL 1..,o..C' l_It.tC_°:� +:, • VOI..p!?, +�U L O C A I'0=N SEWAGE PERMIT N 0._. G VILLAGE INSTA LLER'S NAME i ADDRESS BUILDER Ot OWNER DATE PERMIT ISSUED DATE COMPLIANCE I UED -s - '� �-� Y. ��• �. . �,5-f`�H �� _ �/ �� .. � �. t .,