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HomeMy WebLinkAbout0601 LUMBERT MILL ROAD - Health 601 Lumbert Mill Rd -- : Centerville A= 146 - 103 3 S M E A D No. H163OR UPC 10259 smead.com Made in USA zJ �� • Commonwealth of Massachusetts Title 5 official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r.w, 601 Lumbert Mill Rd. Property Address +w+ Jennifer Rapp Owner ?-: Owner's Name information is ;•w required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection >Rk. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Raymond Dumas use the return Name of Inspector key. Dumas Landscape Const. Company Name 564 Old Stage Rd. Company Address few WA Centerville Ma. 02632 City/Town State 508-778-0249 S1437 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority "(��f'1-9 Qvs�' 2Z"Z�44 6/19/2017 Inspe or's Sfignature f I Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Je nnifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5irrs-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments s 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: r D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health Were an of the system components pumped out in the previous two weeks? ❑ ® Y Y P P P ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection For n:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: 2015 79000 gallons 2016 71000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: Occupied now Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: occupied at time of inspection Date Other(describe below): General Information Pumping Records: Source of information: Home owner had pumped 5/11 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: General Maint. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i c Commonwealth of Massachusetts w - Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known)and source of information: 17 yrs. compliance dated 3/17/2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 39 inches below top of foundation feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: approx. 20 ft. feet Comments(on condition of joints, venting, evidence of leakage, etc.): all good Septic Tank(locate on site plan): Depth below grade: Winches feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gallon Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle none Scum thickness none Distance from top of scum to top of outlet tee or baffle none Distance from bottom of scum to bottom of outlet tee or baffle none How were dimensions determined? dip stick ruler 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 ok Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): D-Box inspected with camera and looked good and liquid at level Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Infilltrators as per plan t5ins•3113 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching 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: 5 infilltrators Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): All good Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): all good Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Tide 5 officlal inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Sns•3113 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp - Owner Owner's Name information is required for every Centerville Ma. 02632 6/19120 :7 page, CitylTown State Zip Code Date o€Inspection D. System Information (cone.) Sketch Of Sewage Disposal System:Provide a view of the setage dzat system;inctudng ties to at least two permanent reference laa marks- benchmarks.Locate a lweHs th`n 100 feet,Locate where public grater supply er ers Jae � r _C.s o e of tl .boxes t k� ® hand-sketch in area be �c r s 2-1 1Sins•3r13 Tile 6 Of ial Urspedbn Form'.Subsuftw Sevaga f3issposal System•Page 15 of 17.6., Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 18.3 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Information on record in folder at Barnstable B.O.Health Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 601 Lumbert Mill Rd. Property Address Jennifer Rapp Owner Owner's Name information is required for every Centerville Ma. 02632 6/19/2017 page. Cityrrown State Zip Code Date of inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I 1Sins•3I13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Fen{ccsted of LaO Il`t �; d4t�t Ek.f. 1&iV11M meets au�. jwins cmena • re t7iag only.,,Ttie ;ace no.wmmercill or busisuss L?tled b�;pt is coaaeCred ma rodsatiai dtre txs wuh the dwe113ag. . soil ti$e4safied as CLASS I and the;,.=lanoa rare is lei than or {ua!to 5 minutes pc inch, y are ad winds within 100 feet tithe pMpmd sepac sys—em . cse ate no prj-,=wells withm 150:em of the is im iuerecm in flow and/or chaaga in we prcpoged arm atr vetrafft'�regtLpsteitar heeded. �oteora a8't!x gmgota d Ee tchia;facility%U iffi=W=zd tell than&C fee:&--the. a mtttoesatica jddlu�tkct Gltndwat�r!abl nsta the Frsmpwr S.A.S.wtfl�eacxted wr1t,350 Pert oPsay meted wet�ttCs.tite'r�am of cite i7i�gilt^'tt ii�tcth��ie�ifidtit'Fdei�teest ai'd)Pe�'�fiiove the tl3aKlmtiftt�lSt . ' table elevBL+at6 eo�plese tk�;Ppttowe � � . . > TcpePGt svalgmcut 38c tt&srmmma) r'& zs art the� 1:�1sls fir`i ,3s3atsrt. N Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 2ppricatfon for Wzpogar 6pgtem. Cow6truction Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) komplete System ❑Individual Components Location Address or Lot No.66` `,V n% Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1,4 „— Y o—z' l l Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 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 `tY/`� gallons per day. Calculated daily flow ( `i 5 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank w Type of S.A.S. Description of Soil (� Nature of Repai or Alterations(Answ r w en applicable) r L sr !/ G 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 een issue y s Signed Date 104 Application Approved by Date —Z44— Application Disapproved for the following reasons Permit No. Date Issued l �� No. Fee I - --tJ' THE COMMONWEALTH OF MASSACHUSETTS Entered iii computer: Yes ` PUBLIC HEALTH DIVISION TOWN OF BARNSTABLES MASSACHUSETTS ZIppYica.tton for Mtopaal *pgtem Congfruction Vermtt Application for a Permit to Construct( )Repair( )Upgrade( )Abando�n,( fi), omplete System ❑Individual Components Location Address or Lot No.(A6 C,vw�b�✓t` Owner's Name„Address and Tel.No. " Assessor's Map/Parcel 1 kf r. t (410 Installe's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Se -r Type of Building: Dwelling No.of Bedrooms — Lot Size sq.ft. Garbage Grinder( ) Other 1 Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow � i`� gallons per day. Calculated daily flow �i`1 CJ gallons. Plan Date. Number of sheets Revision Date Title Size of Septic Tank _ v, Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) L7zg Tc_ S7G w L- Date.last inspected: r, 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 operatliofi bntil a Certifi- ' cate of Compliance h eena '—"issuueT y Signed "" Date / y S Application Approved by Date - L- - Application Disapproved for the following reasons Permit No. 9 9 7 Date Issued 'Z N -9 / -----------V "It ------ -------— —————————— -- HE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Comphance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at a has been constructed in actor ante with the provisions of Title 5 and the for Disposal System Construction Permit No. - d ted ��' Z - Installer Designer Al A The issuance of this ermit all of be co tru d as a guarantee that the s �n�lun ion as tt'esi ned Date p g Inspector _ g 0 - ----------------------------- -------�—�-- No. 2 2 " 9 Fee �— / THE COMMONWEALTH OF MASSACHUSETTS l PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS migpogar *pgtem Congtructton 3permtt Permission is hereby granted to Construct( )Repair( )Upgrade 1_,-*1A andon( ) 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 must be completed within three years of the date of this a t. Date: Approved by ,x 1/6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AlYD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I b�u hereby certify that the application for disposal works construction permit signed by me dated �"�.� c7� concerning the property located at ('O �wt,� � � 6� `�/�`�1 lS meets all of the followin, criteria: br The failed stem is connected to a residential dwelling only. There e system g y, are no commercial or business Zes associated with the dwelling. . 71 e soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system ,,Xere are no private wells within 150 feet of the proposed septic system •/There is no increase in flow and/or change in use proposed There are no variances requested or needed. _;•/The bottom of the proposed leaching facility will not be located less than five feet above the ,.-'The adjusted groundwater table elevation. [Adjust the undwater table using the Frimptor ztthod when applicable] 2" v he S.A.S. will be located with_�0 fee.,of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the mwdraum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation Z Q —the','A,�-X. High G.W. Adjustment . oC 17 DIFFERENCE BETWEEN A and B � O � � -71 SIGNED : DATE: [Sketch proposed plan of system on back]. q:hcai h folder.c-t r n�� �� 1� . .. ; 1 �a a - - " I. TOWN OF BARNSTABLE LOCATIONG�''✓� l /�L—�6l2 SEWAGE # '111�2 � 3 VILLAGE � ��� � - /ASSESSOR'S MAP & LOT' f L INSTALLER'S NAME&PHONE NO. /� SEPTIC TANK CAPACITY /S00 LEACHING FACILITY: (type) ._!C "I (size) NO.OF BEDROOMS BUILDER OR OWNER D PERMTTDATE: r 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 Feet within 300 feet of leaching facility) Furnished by r i I I 757-iPl � i Ca �y -�-tea . - I // TOWN OF BARNSTABLE 'C` L&ATION /A/ A !11-2e6�,ell L2 SEWAGE # VE,LAGE r,!U 91Ile +ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /[� ( SEPTIC TANK CAPACITY /S`-00 LEACHING FACILITY: (type)_ /� (size) NO.OF BEDROOMS_. •BUILDER OR OWNER PERMIT DATE: 4 15 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 OIL 93 FIc$......... .......... . i THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............ ....................O F........................................------------------------•---...................... Applira#ion for DiipnsFal Works Toustrn.rtinn Prrmit �R)plication is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .........:4©-T.. .....1 .......-�o�weOZL�/� -�.../Z�..- -- -l------------------------------------------- Loion-Ad ress v� t No. - 11. .......... . ............... ..f' . ,1..--------•---•---.................--- wner Address Installer Address Type of Building - Size Lot............................Sq. feet V Dwelling—No. of Bedrooms........ ...........................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -_---..-__--_.•_.-.----_ No. of persons...:........................ Showers ( ) — Cafeteria ( ) PA Other fixtures ................................. W Design Flow............................................gallons per person per day. Total daily flow---.........130_...............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 ��-�4.j14 gt ....................... Date.............................. ,al Test Pit No. 1.. ......minutes per inch Depth of Test Pit.................... Depth to ground water-----. } Test Pit No. iJDAiiinutes per inch Depth of Test Pit................••.. Depth to ground water....................... a ••-----•--••--------------•------••--•--•-••-••••••••••••-••---•----•------•••......•-••-•------•---........................................................ 0 Description of Soil----------------------------------------------------- ---- - - -•••- 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 IITILE 5 of the State Sanitary Code— The un gned further agrees not to place the system oper /�a C/ee tiff e owqb4npliance has been issued b oard I Mi . ..... ...... ..lJ� �kcC Date Ap ication Approved B ...................... .••...•--.� ......... •-------- 71AF----� - Date Application Disapproved for the following reasons---------------------------------------------•----------•-------------•--....................................... ...........•--••--••........--•--•-----•-----•-•--•...-••-----------•-•-••---••--•-----------•-•--•-.......----•--------------•---•------•--------•-•--•--•••--••••----••--......----•--•••---•...•-•--- Date Permit No------ _�iIkj-----------------•--•---... .... Issued.............�._z'-.=95---------------- Date LOCATION J � / SEWAGE PERMIT NO. tor" 17 VILLAGE INS,[TTA �L)LER'lS /�N�AME & ADDRESS S U I L D E R OR OWNER DATE PERMIT ISSUED � � DAT E COMPLIANCE ISSUED 5t �` `i Sf' E i �y � �� � ��T�� '� �-�� �c��6�-ter �l ii .� ..� _ No. �,6 FEE...... ...o............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .........................................OF.........................----..........--------------------.... Appliration for Dinponttl Works Tonstrnrtion Prrutit Application is hereby made for a Permit to Construct (" ) or Repair ( ) an Individual Sewage Disposal System at: Location-Address Y.. y �.... or Lot N...... ......... . ..4.A_ -- �c. < � ------ �` " r ./fir. - COX. .- ................................ W ,914W,� Owner dress ��,r Xee,T1P�rL1....... ....._..__. nstaller Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms........%N9............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type a ype of Building ____________________________ No: of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .--•--------•-------•-----•--------------•-•-------•------•-----•--•-•--------------.._...........-•-•-•-------------•----••......-----------•------. W Design Flow............................................gallons per person per day. Total daily flow-----------�,�-r..----.................gallons. WSeptic Tank—Liquid capacity/!r,,^GrD 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 r. Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by......:7f�C.C>.$_% . ',_Ir�........................ Date.................................. Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water............:........... 44 Test Pit No. ,�,minutes per inch Depth of Test Pit.................... Depth to ground Water........................ x -G�,,> ; 0 Description of Soil............................................ -- . . 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 T I IL LE 5 of the State Sanitary Code— The and signed further agrees not to place the system in operation until a Certificate of Compliance has been issued e boa h th. Wined-- -------------•- •--- ......... ........ --- ........ ----• ---•-- ✓Y Application Approved B ...... Date .............•-•--•.----- Date Application Disapproved for the following reasons-------------------------------------------------------------------------------------•-•........................ ------•-•-------•---------------------------•------•••---••--------•--•-•.....•-------•---..•------•----.•••--•••--•--•--••--•--•--•--•••-•-•-•-....----••---••---•-•-••-•-------•-••-••--•------•-••--- S- Permit No....�`� 6 r--------------------------------. Issued_---......... ate Dato7, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..............................I......................................... .....:.. (9rdifiratr of Tontplinnrr THIS IS.TO CERTIFY, That the Individual Sewage Disposal System constructed �(') or Repaired ( ) by ? 7�_._._-...•.... p✓1� T. �l! ,7!1I f'L!__.---...---••---•----------•-------------�......`.........------------................ gl., rhas been installed/in accordance with the provisions ofF 5 of The State Sanitary Code s desc 'bed in the application for Disposal Works Construction Permit No.__. _`..�.._�4...�............. dated-...... — _ _G .._2E........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO TRUE® AS A GUA ANTE THAT THE SYSTEM WILL F NCT N SATISFACTORY. DATE............. - ..... .. Inspector........ ......................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................O F..........................._......_.......------..................._................. No......................... FEE........................ %posal Vorkii %Tonntrnr##ion anti# Permission is hereby granted / �; - } �/�� .��.. t j to Construct ( ) or Repair ( ) an Individual Sewage Dispos'�System atNo................................................................................................................................ .............................................................. Street as shown on the application for Disposal Works Construction Permit No..................... Dated.......................................... .........................................r6 .---------------------.----------------------------- Board`of Health DATE....... - `C?• ..................................... FORM 1255 A. M. SULKIN. INC., BOSTON -IV OTE /F EITNB°R:THE SEPTIC TAiN/< OR RO FT. M/N LE/fCNliltG P/T ARE ','lORE 7--IVA/V /2"®ELOW GRAOF,A . ?4'D1A W J=.7-Ze CONCRA�T.E COVER li-- SNALL gE BROV6NT TO GRADE.64 N 4*7WA x' 9 PVC p/PE /3=0 CpNCRPTE i h►ERYy C^ST /RON CoV.ER SHALL BE USES M/N. PITCN /F/N OR/✓Eyt/A y �,.•• _ COVERS IB o P1ciQ FT. . ':;• 2'�jr M/N. CONCRETE 01 _ d ApE CO YER CLEAN SANG R"DIA. L/Q1J10 LEVEL Samo mrs 40 - - - _ LAYfR RKC PIPE 700c7 � 0 t. o ' eo OF M/!V.p/TC/I GI�IL. : • •. • • •• e •' WASHFO 570 E SFPT/C TANK - D/sT. . , • • • . • ..� BOX v � � $ • t � • • � .•p ° 0o t • l + / • • • DL`PT/++ • • ' • . 4W..4SXE1� STONE O / • a. .teaPRECASPE!$$-5 EE 78 S x I ^O = 7 FS.S a.'�a .• • a .• . • o P/7 OR EQULV. /NNP/CT ALEVAT/DNS - . i®o• rD. .. l/VVERT.AT QUlLD/NG 1T. J�:FT.. O/�4A't• , .. C�SEE ION /NLET` .SE'PT/Z' Ti4NK 106-e FT, T.ABUL.4T D�/TtET.SE/ITlC T.4NN 1'06'4 FT. ' D/STRIbI/T/ON-:80X GROUNv y11TE/r TADLE. 01lTGE?D!S?R/B(!T'ION BQX /06-21 FT, SECT/O/V OF /m4,r ` LrAcNIIVG o/T ✓o&-o Fr SEWAGE PISAWA L SV.STEM 7A6tJLAT401V 1EACHIMC P/T D/MENS/ON A FT. DES/6N CRITERIA . DINAWSIOw - NUMSER OFBEGeR0OMS 3 0/HENS/ON G _FT.Mrn/ GARQAGE•D/SP0.5AJ_!U/VIT NIL SO/L LOG SOJL TEST TOT�lG.EST//►'I�TED FLOJN -3�o a4L.IDAY Sol L TEST A/ SO/L 7.ESTO0 Z XUMBEP`GIF 4rACX/NZ P/TS I `FZ&V /07 5 ELlrK OATS OF SOIL TEST Ocr Su S/DE 4EACH/N6 PER P/T ►F s'4. FT. �_ O 2 ` R V/ RESULTS 1TNESSED. dYR-GIF ��FOaD • D��'E�'y t 490r'rO/►tL 4CNINCrP�ItP/T 7j?L$0. &r Logm*SjasorL COLAr1ow /IATEjO 2 Iy//VIMCN TOTAL LEACH//VG AREA _ESQ. FT. / :-_ 1°ERC0LAT'/0N RA7AF�2 MJN�INCH RESERY'E 4E54CN1/V6 AREA 7-6 7 SQ. F;r c .2 i 72 1.`S MEN %SH OF Mq ,cv`��t F `� . GA.�D God2T PL.A.-r 3 7 Y3 Z E a 5' �/ HI P `N RO�RT 72. /Z't Loi 47 �MBEi2T /p►c�.' N/fRSTDt/S /LL Qi1fC . ERG MDRFINE-I`'I i3 �L©R.�D6E AlW&JA MIAS JIIY� N .366 v . TE�` �� � r TE`� 9S-S 74M MAIN ST.� //yANN/9,MASS- SSrOMAI ® /VD GROUND YYArER &WCOUA/TL-REO G3 42mo aNO,w,47 /tT E -A J00 INO 31 < tin'!— ztSTANDARD LEGEND a 5,, NOTE:not all symbols will appear on a mar r ,, f n» { 4 � ------ GOLF COURSE FAIRWAY L� *+M ✓j a a; - ,t+. c �•.�.' yam. r ` - .. r �� TREES i ti7 EDGE OF DECIDUOUS T r \ - m EDGE OF B RUSH - 43. ra t s cur { — 6T _►4F1 _ ORCHARD OR NURSERY R L v—V—T EDGE OF CONIFEROUS TREES . h P ,4 1 LoT . ) _ MARSH AREA _ L0G14 ti,o N FiZGM - r - - . . — PL;��I o L►4 eyD,":L3Y EDGE OF WATER Y►4NK � SulV�Y GoN sz"1R r wAtl (`-� DIRT ROAD I_.o T K•6 Y 7. , - _._ —DRIVEWAY PARKING LOT PAVED ROAD .oWravzS „ _ — - - - - DRAINAGE DITCH PATH TRAIL PARCEL LINE** W no MAP# \ 21 E PARCEL NUMBER 0180 < HOUSE NUMBER 2 FOOT CONTOUR LINE Ye to 10 FOOT CONTOUR LINE 4.9 SPOT ELEVATION STONE WALL W -X X- FENCE" . 40, t O a RETAINING WALL l ° �� -�.•.t� U� RAIL ROAD TRACK / (j1 STONE JETTY SWIMMING POOL s = PORCH/DECK El BUILDING/STRUCTURE % 4-= DOIX/PIER/1ETIY �? HYDRANT rr \ 6 VALVE O MANHOLE T O - W N O F B A R N S T A B L E G E O G It A P H 1 C i N F 0 R M A T 1 O N S Y S T E M S U N 1 T O POST O' FAG POLE PRINTED SCU IN FEET r *NOTE Tha map a an enlargement of a **NOTE The parcel lines are only graphic rep DATA SOUR(ES: Planimetria man-made features Were i rated from 1995 aerial h SIGN ® SrroRM DW = 'I I OD'Scale map and may NOT meet of property boundaries They are not true locations,and W.Se+all Com Topography C and photographs by The lames . 50 0ed Standards at this Pant• Pog PhY vegetation Were interpreted from 1989 aerial photographs by GEOD n 4?` ' S0 National Map Accuracy do not represent actual relationships to physical objects (o k ImI1Ir FOIE iDW81 w' scale. rporation. Planiffw ft topography,and vegetation were mapped to meet National Map Accuracy Standards ','r' 1 INCN= 50 FEET* _--- on the map. at a scale of 1"=100'. Parcel lines were diaitirarl{cam 1999 Trwm of Rnmctnldo Accoccnec«m m irlr„m,,„A, STANDARD LEGEND NOTE:not all symbols Mnyl appear on a mal 7-7 GOLF COURSE FAIRWAY EDGE OF DECIDUOUS TREES EDGE OF BRUSH t ' ' tic L'�P-F"'�',� •��. r F ORCHARD OR NURSERY 6 13,3 6 SQ F T� \ T-V-V--V EDGE OF CONIFEROUS TREES LoT L.iNLS NoHS Av- - 3 1 = = MARSH AREA r_'oc14 too N F_2cM. .� h r PtW-NV. o F �► EDGE OF WATER Yt�NK su2vf�Y � or1 �T�: 6 wAtE�`-. 6 _ _ _ _ _ DIRT ROAD - ar Es 3.+.�• a '� r4`Ef f-r k��37+. - � � /� "- t Gam_K , _ DRIVEWAY DRAINAGE DITCH PATH/TRAIL PARCEL LINE MAP 110 < --MAP# ' 21 E PARCEL NUMBER Q�•e' '� '` #18- HOUSE NUMBER 2 FOOT CONTOUR LINE k Ye, - - io 10 FOOT CONTOUR LINE A10 9 V 4.9 SPOT ELEVATION \ t 44f, -,L STONE WALL W' \ -X X- FENCEwi 0 RETAINING WALL 0 ..• A . RAIL ROAD TRACK STONE JETTY ►--' '?` �d \ SWIMMING POOL S PORCH/DECK / / \ BUILDING/STRUCTURE DOCK/PIER/JETTY \ �? HYDRANT e VALVE O MANHOLE N O F B A R N S T A B L E G E O G R A P H I C I N F 0 R M A T 1 O N S Y S T E M S U N 1 T O POST p� RM POLE PRINTED SCALE:IN FEET *NOTE: This ma a an enla g p rgement of a **NOTE- The parcel lines are only graphic representations DATA SOURCES: Planimetrins(man-made features)were imerpreted from 1995 aerial photographs by The lames �� ® DRWN 1'=100'sale ma and NOT meet of : P may Property boundaries. They are not true locatior4 and W.We ll Company. Topography and vegetation were interpreted from 1989 aerialphotographs by GEOD «�a P UTILITY FOIE n T0WER �-°Y�"1 . 50 0 50 edam l��Aaunuyy Standards at this do not represent actual relationships fn physiraal objects Corp"' on. PlonimWcs,topography,and vegetation were mapped to meet National Map AnxumcY Standards 1 INCH= 50 FEET on the map._ P at a srale of 1 —100'. Parcel(ides vYiere digitized from 1999 Town nF Rnmctnhlo evcoccnrc+m►m�-, A „NR,,,,,. ,. e,r.,,,tr"#"v r; i� ;1�, - Wiz---�-c aF "Tacv►J ��` 7. ell4 P �4^�� Alv- rt� 677; C t �0 _ 0 �. sl i/J�f�-�frLO '� r r 11.k� 01) Y ' y;l CSC/stn KovSE:J y: �' S{. • t LC� w"f 1� w.tr }.' \• A � // R 41fi T 41 s loopTOKK lµ •� Ji. y", e ..•,^D^ IO+J(' ,.r to 1.•• =,,1 ..,j r t ,s.. f'... `: 1. r1.0 L-r ul 011 OF iygs, F No,366 7�- � �i`k ` r � E r`�� a �' `\ `S\ \� �M° � ' 'SY, O,c�,CI§T�.� �►�' "��t NAL J D .: �t j•k kj jrya, rrer J \ % ��9� �� f'. v• a.' CERTIFIED hLO.T -PLAN ` ,E IS TING SPOT ELEVATION Ox0 ISTIN0 CONTOUR - 0 — 114/110 60a4T`P4,4?w 379f3Z � f � ,FINISHED SPOT ELEVATION Le r 47 LuML3E,�T /fee. R�`',N/aasS�i1`'':" k ,'FtN'f SHED CONTOUR 0 �r IN G x APPROV 0 �..BOARD OF HEALTH Jj o s DATAOENT� SCALE, /. ,� 1.R D DATE'�F :. RFOGE�ENGINEERlNG CQ /N ;w` '�o f �ssA ;#X CL, ENT N�,u.&A-S Y .>:' I CE42TIFY THAT �.THE� PROPOSE® R. ti +. . .. py K i�.. � RQ`�ERT 5Y rip gel 1�ERE �r RE.Gi3TERED ; Jd8°NO. g`+94 `BUILDING :SHOWN ON 'THf3 r PLAN LAND k' a NFORMS TO ;THE' ZONING ;LAWS VEY 3 6R.8Y� -�� .___ -OF 13Aa►vsrAB . . '`.MASS `>' �f. t P ;' ;�.� r,„