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HomeMy WebLinkAbout0104 LONGVIEW DRIVE - Health r 104 Longview ®rive Hyannis F/R A = r iP i N It I6 I� I i e 0 1.� TOWN OF BARNSTABLE �L LOCATION -.s/iered D2 /!/ !T SEWAGE_ -g-D4 -331 .VILLAGE �� '"��==+ /t'�����1�SSESSOR'S MAP & LOT aSI—�73 INSTALLER'S NAME&PHONE NO. Ao2ey SEPTIC TANK CAPACITY LEACHING FACILITY: (typc�� (size) NO. OF BEDROOMS -� BUILDER OR OWNER �9 Q ?' PERMITDATE: / b COMPLIANCE DATE: oZ OQ— 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 leaching facility) Feet Furnished by S o 0 3 aA b o n � i 0 . U► I � � TOWN OF BARNSTABLE LOCATION V U%G �`e � SEWAGE #Q--C VILLAGE '0 � _�,SSESSOR'S MAP & LOT� `O INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY '[� s LEACHING FACILITY: (type) (size) 13 X o2 NO.OF BEDROOMS_ G BUILDER OR OWNER T v PERMIT DATE: 2 COMPLIANCE DATE: ©3 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 leaching facility) Feet Furnished by r 0 1� `i w � � � � � i e Commonwealth of Massachusetts Title 5 Official Inspection Form IVSubsurface Sewage Disposal System Forrn-Not for Voluntary Assessments Property Ad ass. Owner Owner's Name information is required for every page. City/Town State Zip Code „ Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not key the return Name of Inspector 7— w a c s cwi c.'e Company Name oe.o oox, 77� Company Address f City/Town State Zip Code 5-og- Y-T.X 90 8' 4� 73 I Telephone Num ber L tense Number B. Certification Lcertify 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(3 0 CMR 15.000).The system: Passes ❑ Conditionally Passes ❑ P'ails I ❑ Needs Further Evaluation by the Local Approving Authority Jy I oes Sig ature Date o 7 'The system inspector shall submit a copy of this inspection report to the Appf�ving 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 performs'in the future under the same or different conditions of use. t5ins•i vi 0 nu.5 OfEGW Inspadlon Form subsurtam Se*we Disposal System•Pape i of 17 1 /� I Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c. /O GOB Zvi$GJ IL4Z V`e— Property ddress, . ' - P, ck /il CUiGL� Owner Owners Name information is required for every page. Cityfrown 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: Vhave 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: ne or more system components as described in the"Conditional Pass"section need to be re d or repaired. The system, upon completion of the replacement or repair, as approved by the Bo of Health,will pass. Check the box for s","no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please a in. The septic tank is metal and o 20 years old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltr ' n or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is repla ith a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is stru ally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 year d is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-11/10 Title 5 Official Inspection Form:SuDwrface Sewage Diapoaal System•Pape 2 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments Property Address !z-C,/ /1U•C ✓i L 4 - Owner Owner's Name \ information is 1 �5 �Ct �ir�yA, �5 1 �!� Ol /��30�/ y required for every page, City/Town �� State Zip Code Date of Inspection B. Certification (cont.) Observation of sewage backup or break out or high static water level in the distribution box due t roken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pas inspection if(with approval of Board of Health): ❑ b en pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruc' n is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution b is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the and of Health): ❑ broken pipe(s) are replaced ❑ Y N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ ❑ ND(Explain below): 0-6148F EYIDIUM118 'by the Board a!Health, ditions exist which require further evaluation bythe Board of Health in order to determine if the s m is failing to protect public health, safety or the environment. 1. System ass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that system is not`functioning in a manner which will protect public health, safety and the environ nt: ❑ Cesspool or privy is within eet of a surface water ❑ Cesspool or privy is within 50 feet of a dering vegetated wetland or a salt marsh t5ins•11/10 - Title 5 Official In 'on Form:Subsurface Sewage Disposal System•Pape 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y /o y Go.�Gv�ew ?J�tu-2 Property Address Owner Owner's Name information is ! required for every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) 2. stem will fail unless the Board of Health (and Public Water Supplier, if any) dote nos that the system is functioning in a manner that protects the public health, safety a environment: ❑ The s m has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surfa water supply or tributary to a surface water supply. ❑ The system h a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a se ' tank and:SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and S 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, performe a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammo nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are tri ered.A copy of the analysis must be attached to this form. 3. Other: 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 ❑ LJ 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 El than depth in cesspool is less than 6"below invert or available volume is less than '/z day flow L5ins-I WO Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslam-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form IV Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y e oN 6ae ie4,) 9*-� 12, V4- Property Address Owner Owwnner's Name information is /.�A��u��j�l�• �1I� D 6( / /30�/ C) required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ z/ 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 El 2/ tributary to a surface water supply. E] [ 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. ❑ An portion of a.cesspool or privy is less than 100 feet but greater than 50 feet YP P P Y 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. des flow of 10,000 gpd to 15,000 gpd. For large sy s, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Sec n D. Yes No ❑ ❑ the syste s within 400 feet of a.surface drinking water supply ❑ ❑ the system is with 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in itrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped a I'of a public water supply well If you have answered"yes"to any question in Section E system is considered a significant threat, or answered "yes"in Section D above the large system has. ' d. The owner or operator of any large system considered a significant threat under Section E or failed u er Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner sho contact the appropriate regional office of the Department. [sins-11/10 Title 5 Oftal Inspection form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments %Vj /O S/ Gow 6'al C t.J D azf Property Address Owner Owner's Name / ,/ �,,,� information is /uS'rlGb�t /T`rI/Q►QNIr� 44r) ti 6 I �a 30/ �d required for every page. Cityfrown 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 any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ LV Have large volumes of water been introduced to the system recently or as part of / this inspection? LyJ/ ❑ 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? [V ❑ Was the site inspected for signs of break out? ` ZWe,( tchN4 LV ❑ Were all system components, Soddingthe SAS, located on site? {3/ ❑ 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: 2/ ❑ 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)) Gocr¢Tion O/tty) D. System Information Residential Flow Conditions: 3 phis/{�c� Number of bedrooms(design): ` Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Diaposal System-Pape 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i oy Go.V6411�4­') ?3�2 Property Adldress Gl< /uZ�Ji LC Owner Owner's Name information is required for every ,044-1.s7GtcS �h(ti page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: / Does residence have a garbage grinder? El Yes 2 No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes g2 No Laundry system inspected? ❑ Yes Q/No Seasonaluse? ❑ Yes 2/No Water meter readings, if available last 2 ears usage d 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes No Last date of occupancy: Date dusirial-QQW CCJnditIGA64__ Type of Es shment: Design flow(based on MR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/s 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•11/10 Title 5 Oflidal Inspection Forth:Substirlace Sewage_Disposal System•Pepe 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property ddress Owner Owner's Name information is _3��+�S7�Ct ann /�� d" o /dZ 30 O required for every page. Cityrrown State Zip Code Date of Inspection ion D. S tem Information (cont.) Last date of occu /use: Date Other(describe below): General Information Pumping Records: Source of information: Tu�.y co2 a( Was system pumped as part of the inspection? ❑ Yes Q/No If yes, volume pumped: y 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)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•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments tT-�- Prope Address — Gfc, '-v I �!-e Owner Owner's Name . information is d�0 /�d��0 required for every a S � page. City/Town tS ate Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed if known)and source of information: PP 9 P ( 5e �5 oZ oat /GeA-Go9(-/1?6 e/�Gl�e'�y��0� Iq J{ TC.ryi,Rali'y'nay—Gfizoq "�6,e 9yaS`G/1►a Were sewage odors detected when arriving at the site? ❑ Yes 2 No Building Sewer(locate on site plan): Depth below grade: fl , Material of construction: �st iron ff 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet feet Comments(on condition of joints, venting,evidence of leakage, etc.): L cat-&* --*— . Septic Tank(locate on site plan): A5-9 Depth below grade: � feet Material of construction: �oncrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years �- Dimensions: - �— Sludge depth: t5ins-11/10 Title 5 OfTdal Inspection Form:Subsurface Sewage Disposal System-Pape 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments / � G Property Addrdss Ad ,Gk /k�- U t//-e Owner Owner's Name information Is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) y �/ Distance from top of sludge to bottom of outlet tee or baffle 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 41 How were dimensions determined? " /a&c Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): p EPZcgly`-6 N oiN,✓c�ss arT-� 47 I T. r-1 /G�"'r° To kc-:f.f SaG,d f C --sS fAor'J T.•�C.e�� OwiZ�T /�U. C Tet�S .�''•�?'�T'� sT12�c.��r�L-e. qr Depth be rade: feet Material of construc ❑ 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•11/10 Title 5 OMdal Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments Propexadreps Owner Owners Name information is G7��0 5913/�C ,� required for every page. Cityfrown State Zip Code Date of Inspedion D. System Information (cont.) Com on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels a led to outlet invert,evidence of leakage,etc.): Dep elow grade: Material of struction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene. ❑ other(explain): Dimensions:' Capacity: <Alarm Design Flow: Alarm present: No Alarm level: g 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•11/10 Title 5 Ofrkial Inspection Form:Subsurface Sewage Disposal System•Papa 11 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form IVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments � a y Go•�6'y��� ���v—C Property Address CA /U Owner owners Name information is required for every page. Cityrrown 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.): Pumps' orking order: ❑ Yes ❑ No Alarms in working o ❑ Yes ❑'No Comments(note or of pu hamber, condition of pumps and appurtenances, etc.): sm.(GAS)(leeste on site pla If SAS not located, in why: t5ins•11/10 Title 5 Oftldal Inspection Form Subsurface sewage Disposal System•Pape 12 of 17 i - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Ad ss G� /y-e f! Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: leaching chambers number: Aflo I ❑ leaching galleries number: i ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): '/ Sd, L SA�r.Q•. Nn s. Gn o /fvd�cct-,tc-c Gu(Z-� . f � L.-ev-cc- or eo dinG U���'�T o � rt/v�r�c► L Imo_._........ Number configuration Depth—top of liquid et invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes No t5ins•11/10 Title 5 Offidsi Inspection Forth:Subawface Sewage Disposal System-Papa 13 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address - �t Owner Owner's Name information is �����1 ,, / H �� b 6 30 j/ 0 required for every -�/ /�- page. Citylrown fState Zip Code Date of Inspection D. System Information (cont.) Comments(no dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Materials o traction: Dimensions Depth of solids Comments(note condition of soil, signs of hydr �failure, of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Prope�j Address Owner Owner's Name information isS/ C��/S�,Ar�wi required for every -, page. Citylrown. State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate whelpublic water supply enters the building. Check one of the boxes below: and-sketch in the area below ❑ drawing attached separately CT-I= 4�3 's-et'7 c i-�k r n tt>✓ Cr 7-o l-- G -roA=/s_'G /}SePrG r�.�lcous2er /f 7a3 = -3 S./9.S, 19 3 -ray_ Wig' i - — — 3f.s G O i i O 113' 02 - A�; �6wro01 s�oX r T- - f•Y�2 I U���cni �oY I�e�MG f 6111 t5ins•11/10 Title 5 Official Inspection Forth:Subamtece Sewage Disposal System•Pepe 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments UV Property Ad- sss - Owner Owners Name information is every -� —)- / � required for eve -���NS � �—/�Y 'y'S page. Cityrrown �� 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: d N° avC o$Se/e u Cd feet Please indicate all methods used to determine the high ground water elevation: [� Obtained from system design plans on record �eU, .2 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: . 'l/�"�r>:'2 �Z o�-+-r G�-G.�i C-�N /'C/�it�. �� SCf��'i�G S y Sfty✓I • • /S /�S'T�iI/�JO'� Gl///h%/7 TOLG�LQrIG-e O� ��� and EGtyig- -to'n.S �2 �Cccri , Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Owner Owner's Name information is required for every page. City/Town 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 J F i t5im-11/10 Title 5 Official Inspection Form:SubsuAece sewage Disposal system-Pape 17 of 17 J Table 3-2 Do's and Don'ts of Private Septic System Management DO... DON'T... Do have the on-site system inspected and pumped by Do not use the toilet or sink as a trash can by a licensed professional approximately every 3 to 5 dumping non-biodegradable material (cigarette butts, years. Failure to pump out the septic tank can cause diapers,feminine products,etc.)or grease down the system failure. If the tank fills up with an excess of sink or toilet. Non-biodegradable material can clog solids,the wastewater will not have enough time to the pipes,while grease can thicken and clog the settle in the tank.These excess solids will then pass on pipes.Store cooking oils,fats,and grease in a can to the leach field,where they will clog the drain lines for disposal in the garbage. and soil. Do know the location of the on-site system and drain Do not put paint thinner, polyurethane, anti-freeze, field, and keep a record of all inspections, pumping, pesticides, some dyes,disinfectants,water repairs, contract or engineering work for future softeners,and other strong chemicals into the references. Keep a sketch of it handy for service visits. system.These can cause major upsets in the septic tank by killing the biological part of the on-site system and polluting the groundwater. Small amounts of standard household cleaners,drain cleansers,detergents,etc.will be diluted in the tank and should cause no damage to the system.. Do grow grass or small plants(not trees or shrubs) Do not use a garbage grinder or disposal,which above the on-site system to hold the drain field in feeds into the on-site tank. If there is one, severely place.Water conservation through creative limit its use.Adding food wastes or other solids landscaping is a great way to control excess runoff. reduces the system's capacity and increases the need to pump the on-site tank. If a grinder is used, the system must be pumped more often. Do install water-conserving devices in faucets, Do not plant trees within 30 feet of the system or showerheads and toilets to reduce the volume of water park/drive over any part of the system.Tree roots will running into the on-site system. Repair dripping faucets clog pipes,and heavy vehicles may cause the drain and leaking toilets, run washing machines and field to collapse. dishwashers only when full, and avoid long showers. Do divert roof drains and surface water from driveways Do not allow anyone to repair,gr, pump the system and hillsides away from the on-site system. Keep sump without first checking that they are licensed system pumps and house footing drains away from the on-site professionals. system as well. Do take leftover'hazardous chemicals to an approved Do not perform excessive laundry loads with a hazardous waste collection center for disposal. Use washing machine. Doing load after load does not bleach, disinfectants,and drain and toilet bowl cleaners allow the on-site tank time to adequately treat wastes . sparingly and in accordance with product labels. and overwhelms the entire on-site system with excess wastewater.This could flood the drain field without allowing sufficient recovery time. Consult with an on-site tank professional to determine the gallon capacity and number of loads per day that can safely go into the system. Do use only on-site system additives that have been Do not use chemical solvents to clean the plumbing allowed for usage in Massachusetts by MA DEP. or on=site system."Miracle"chemicals will kill Additives that are allowed for use in Massachusetts microorganisms that consume harmful wastes. have been determined not to produce a harmful effect These products can also cause groundwater to the individual system or its components or to the contamination environment at large. http:/Mevw.mass.gov/depAvater/resourcesf4npgWde.doc 3-1 7 July.2005 c TOWN OF BARNSTABLE C �Q c zip SEWAGE.# 0 63 �c 5 LOCATION ASSESSOR'S MAP &LOT VILLAGE INSTALLER'S NAME&PHONE NO. ��c �� ,✓s ' o` ?� 3 �� SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type) 5 0 0 0� (size) A 1-3 Xa NO. OF BEDROOMS BUILDER OR OWNER '� 7 Z PLIANCE DATE: PERMITDATE: COM _ 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 Feet within 300 feet of leaching facility) Furnished by r . I -4 c . r. G 3 'etif f k 3� No. 2W 3^0 / Fee Jv ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pp[ication for Zie;ponl *petem Construction 3permit Application for a Permit to Construct( . )Repair(.Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ' /i Owner's Name,Address and Tel.No. l y Assessor's Map/Parcel / W ymm S f3 � t Installer's Name,Address,and Tel.NC Designer's Name,Address and Tel.No. Sv ;F7 7> -2s / 3 d 2, / -5' 7_S7 CUB S 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. 3 4-0 Description of Soil Nature of Repairs or Alterat��swer when applicable)S-049 A 2 `"6 k ,e7 � �S 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 issue is oazd of Health. Signe � Date's Application Approved by Date 2 itZ" 0-7 Application Disapproved for the following reasons Permit No. 2­6 b 3—0174 Date Issued ZD o 2003-01 No. Fee THE COMMONWEALTH OF MASSACHUSETTS "' Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ` Application for Migool *p5tem Congtruction Permit Application for a Permit to Construct,( )Repair(/Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 1. �— _ / Owner's Name,Address and Tel.N�/o. l!, o y Go.ry cc- Assessor's Map/Parce.1 J i 3 I y A N N0 S ✓ Installer's Name,Address,and Tel.No Designer's Name,Address and Tel.No. H .✓S7 L?wZ/ZE 6y7=Yf 2 ` Type of Building:` Dwelling No.of Bedroom# ;�, l Lot Size 5 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow S . gallons. Plan -Date Number of sheets Revision Date Title Size of Septic Tank S e y Type of S.A.S.(D Description of Soil a ,a i Nature of Repairs or Alteration ( nswer when applicable) �L _ 's- U a C"'X", ✓4 S c, Q / d „Z" K /� � .em s S/srl � Date last inspected: t 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 issue lby this ward of Health. Signed' Date Application Approved by Date Application Disapproved for the following reasons i Permit No. Zy 0 3—0 rJ q Date Issued 2 2D o- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by L // S T at / d e1 Lo �-t .L,r• � i�6Z ��4L T4=4 u/ �.m has been construct d in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2-00 3'0 7`� dated 2 2° d 3 Installer Designer The issuance o this termit shall not be construed as a guarantee that the system t'o �des'gned. Date 493 Inspector No. 2 00— b r7 q Fee 5,0 ✓ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS x1h6poal *pgtem Construction Permit Permission is hereby granted to Construct( )Repair(Ls� lrTpgrade( )Abandon( ) System located at e'ti 7-- 2 G r 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:Constru 'on ust be completed within three years of the date of this pe t. Date:_ 2 ZU 163 Approved by i TOWN OF BARNSTABLE LOCATION SEWAGE.#,2P0Q—3a I VILLAGE E.1 y, /ASSESSOR'S MAP & LOT a.SI—1073 INSTALLER'S NAME'&PHONE NO. A0244 ( a.�//S SEPTIC TANK CAPACITY g`ao Cs� /e o oLl s , LEACHING FACILITY: (typt aCJ SIOO C/.V"!&�/2, (size) NO. OF BEDROOMS —� 1 BUILDER OR OWNER /�9 Q 7- d A PERMITDATE: d _COMPLIANCE DATE: ool DoZ 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 leaching facility) Feet Furnished by 13 el ost, o� No. Fee — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application f�)R!p ( �po.5ar *pgtem Congtrnction Permit Application for a Permit to Construct(.. )Upgrade( Abandon( ) ❑Complete System ❑Individual Components Location Address r Lot No. , Owner's Name,Address and Tel.No. 1 lye �oy �c w D2ry F' �y.9 2 T'v ,- Assessor's Map/Pazcel .S/ - rn Installer's Name,Address,and Tel.No. Designer's Name,Address and T 1.No. y2c Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder/V Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 a gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank lJ l o Type of S.A.S X-0 o r9 ik4 ,Z 5- Description of Soil Nature of Repairs or Alterations(Answer w�hheep applicable) /S y D S'T JP04,)C '�(�J .S©C� C - i5+ .tee 2S Ct/ ? Y 6•✓C' 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 issue this Board o lth. Signe Date1'e, d Application Approved y Date 012 Application Disapproved for the following reasons Permit No. l2: 3, Date Issued I h r �i No. .,. Fee -,� THE COMUONWEALTWOF'MASSACHUSETTS i ntered in computer: 'q/� ' "t - t Yes PiUBLIIC HEALTH-DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYtcation for Migpogal *pttem conotruction permit Application for a Permit to Construct �Rep rade Abandon ❑Complete System ❑Individual Components PP ( ( )UPg ( ( ) P Y P Location Address r Lot No. Owner's Name,Address and Tel.No. I Assessor's Map/Parcel - Installer's Name,Address,and Tel.N , Designer's Name,Address and T 1.No. e ti� i ��92/1 Type of Building: t Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder�eV Other Type of Building No.of Persons Showers( ) Cafeteria( �) Other Fixtures Design Flow 3 3 d gallons per day. Calculated daily flow gallons. Plan Dates Number of sheets Revision Date Title Size of Septic Tank l G f o.✓S Type of S.A.S 5-00 C 19 S Description of Soil Nature of Repairs or Alterations(Answer when applicable)"` /5 o D $-7 I-L3.0,�C r� r� r 2S Gv� T/ � -�?a o. I Date last inspected:' Agreement: { The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board o alth.- r Signe Date d.Z Application Appro�ed y Date 2 Application Disapproved for the following reasons I Permit No. 2( �2_- Date Issued ) THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance ' THIS IS TO CERIVY, that the On-site Sewage Disposal ystem Constructed( )Repaired ( )Upgraded( ) f ` Abandoned( )by 6 s✓ S'l el C t at y` va-4 /c- 4,' D 2 has been constructed in a cordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.2J2'�3 dated b ' Installer Designer The issuance'of t is permit shall not be construed as a guarantee that the sys wjll unction a dQst ned. Date 1 0 2 Inspector � itn 1W- No. ��-1�� ----------------------------Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopo$al * $tern Con$trurtion Vermit Permission is hereby granted to Construct(M Repair( )Upgrade( Abandon( ) System located at O$/ ,ram 6-/ell !.d ` is nrTt' l// =, 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 ust be completed within three years of the date bf thisnermit. (� Date: TUL Approved b rr Y _ m I � UP LLJ Jz=w77 l7 t> :I m MI .. c Q'f t f - _ w= O < s 9 3 ` j Culblr�iL'� l f L � q l't ` I • I D l I D 1t J- LPLf o � rx ........ ........ . ............ ........ . G Fri, � �� 6.I Ott, i " i w � .4 - � � {ter+,`4i�c,.d•p.t EJi.,unt�_,t +:r � -Alt{—._. - ' �_ � Fj' , •., II to a , i li • � it / � ; 1� i � Ii -jI I±•. I I. Lr Lq 1 b . Ir i RE LP v +i IL it �� - f'f1 r y G I y'".�I J' � i ..f�.• C FOE Nr _ .T_ ZZ - I [�? .. m I .r,.. .. .... ,. ,. .. ..L. .. D t7 (' r .; I I • C I - c� a u> 1,7 - d �1 2 rx ol li"o£ s I 1" S I 7'-0" 7'-0" 7'-0" 7'-0" ' 2,-0"X 3,-0" _CS S 2'-0"X 3'-0" 3'-0"x 6',8" o �' k s O office 2,-4"x 6'-8" r 5=10" x 6=1'-6"x 6'-8 9=9" 2= " kitchen , . livingroom N w = IT-9 2 rn o '-4"x 6'-8" M -i x v a x 0 a f bath 1 _ 2" 6' 20-O"x 3'-0" 5'-0"x 3'-0" 4'-0"x 5'-0" 2'-0"x 3'-0" _ - 4'1" 41-4" 3"7" 7=5" 9'-5" 10=2" 7'-0" 12'-0" 34" OW r existing first floor 34"-0" 5=g" 10'-4" 11140" 2'-0"x 3'-0" 2'-0"X 3'-0" 2'-0"x Y-0" o� N M k w bath o � o bed I _ N �o 'r w s bed a s e s "s is 40 s s 3'-8 k jCO laundry 2'-4"x 6-8" l 0 61 - --5�_8" s 11=10" cti 2• "x 6' " bed N — 41K. 0 2'-4"x 6'-8" closet Cr) 2-sK 41 N L 12�-0" . �' 2' "x -p" 2'-0"x 3'-0" CV)-0 3' 4'-8" 23=3" 34'-0" existing ,; second floor ,�----5'-8" 6..2'-0" 2'-0"x 3'-0" _3, " ,��'- 2'-0"x 3'-0" is � 4 2'-0"x 3'-0" °_ er 31-0"x 6'-8" D future x j of ,- .1w�, c.O. 34 3 office 3' 4 S-10" future c.o. 11=10" rL6x 6-V-6"x 6-85_1w 41-0w_ 2-1" O 4 _ kitchen. , : dining room N w 1 19 =5 5'-0"x 6'-8" _44 1"v pw x a, # -0" , 4.2" t 3'-0" '-4"x 6•4 '• 00 aQ k to _• bath a O• � O � s • w w w . " w 3 i " I " '-Off x 3�-V" 50-0 x 3'-0 4'-0 x 5'-0 2'-0 x -0" 4.1" 41-4" 3'-7"' 7=5" 9=5" 10'-8" . 6'-6w_ 12'-0" i 34,-0" prop osed first floor i f W 2'-0"x 3'-0" 7-ON X 3'-o" 2'-0"X 3'-0" 6_2R 12-a N Ca bath M k bed bed N w i = _1 a _ , r 2 "x .$" "?C -8" 2 '-8•" ^6"x 6/-8" -6"x 6'-8" r e N j k 3'-8 4 rm 4laundry � Cm _ a 9'-8" -8R N CM tp 6 x 6'-8" 11=10" x r bed b 2'-4"x 6'-8" ;D t CO o ': * S ' CO 1 -0" R R R I t I R f R ` ' cv I R I N 2-0 x3-0 2'-0 x3 5-0 x4-0 2 x3-0 4-2w 6-9" 6.2R 11-2" 12-1" 40'-4" proposed second floor ASSESSORS MAP : 225i TEST HOLE LOGS NOTES: PARCEL r7'j 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH h V SOIL EVALUATOR: I/ >:�/C -�S. THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF FLOOD ZONE: C. NIA --�—� - WITNESS : �b�W—A)-,��`t'$L.� BOARD OF HEALTH REGULATIONS. REFERENCE: C 41 f),9(,O DATE: t LV I2-,Z002 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, 1 Q`� ( PERCOLATION RATE: PAW a(,4 SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO ' 2 INSTALLATION. cc- � Soli t_TIh-= 0,?1/ TH- I a1.* 37 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE A 5 I �3/3 DETERMINATION. N4) ALL PIPING TO BE 4" SCHEDULE 40 tQ 1/8 "/ FOOT. (UNLESS L,OI�tm'l` Q SPECIFIED OTHERWISE) 7 S , LOCATION MAP(N r(S) � � ��� /� 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A ,► lji /$ GARBAGE DISPOSAL. 7a P�11 otw� 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) C spip 10 2.5Y�. MUST BE A BASE OF ACEr OF CRUSHED STONE ON A ICALLY COMPACTED BASE OR ON �► 7, E/t5T�nit� �ESSP+c��.5..1v T�£Pv.!�.���NL?,�1.�2v.5 ,.i�1�Iu�..� i32 ,eO�,vt�w�e. 96S, ► l�o�j $) /two J�N w!J. � ► WEU.S .�+ �1....1 SU._.�1 .. PRO# _ ..._._.: SEPT I 'C SYSTEM DES I G N FLOW =ST I MATE BEDROOMS AT ,110 GAL/DAY/BEDROOM GAL/DAY SEPTI TANK �t3AL/DAY x 2 DAYS GAL USE ,f G GALLON SEPTIC TANK -SOIL ABSOUT I ON SYSTEM Z,s 49 , P9&C& 7 N , 4S � /1 kA c� ,v tlp a L; l l i 23� SIDE AREA: fZS + 2X2 ..� ° ►� BOTTOM AREA: 725 k / x G9, 7`� = L •�0 e - SEPT i C SYSTEM SECTION 33o 4Pb ref Diuve 1 �5 �p (As5VAo4e0) " ,`•--, ZS- .-- 6"�� 6n1 ✓fie 9"A41N- e X,. �-- \ 11 �,.� 5f6k AOSerY D-BOX LSD GAL 47 a Gl� i—I j::7. 8 -- —' _ SEPTIC TANK ICYw L 0/l/4 V/GV) DOVElAkW) Ti3, �.'=l t�z Of . D SITE AND SEWAGE PLAN Fn( ION : 4. ,Goa vlpw �tU 01144 &A VA 1k, SA ,per PREPARED FOR Su = DARREN M. MEYER, R.S. SCALE: / a I P1,5 . DATE:, Pro-r OF GAtJO� �G 43 VINE STREET DUXBURY, MA 02332 W PJ� i94, 73 Ib/3l� I`16 f DATE HEALTH AGENT 781} 585-0293 W Y ASSESSORS MAP : ZSI TEST HOLE LOGS NOTES: PARCEL : ��j 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH \\ h V SOIL EVALUATOR 2•s THIS PLAN,_1995 MASSACHUSETTS TITLE V & TOWN OF ,a FLOOD ZONE : C, WITNESS : N'� x�2nJSBl BOARD OF HEALTH REGULATIONS. REFERENCE: C+o q60 DATE: UL 12 Z00Z e� 2 �""" 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES, PERCOLATION RATE �- 17f-4 SEWER INVERTS AND SEPTIC COMPONENTS- PRIOR TO L7�-e_= O INSTALLATION. TH- I E(.. �,35 TH-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION S�aO J —' ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE A J �I I��3�' DETERMINATION. 7II �"`71 S 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS boAiv^y Dv I" a SPECIFIED OTHERWISE) LOCATION MAP(N 'T j) ���� I I J` 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A 3$n - /L /$ GARBAGE DISPOSAL. EL-AV&A 6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED) SAID 17 25y /4 MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON A BASE OF 6"OF CRUSHED STONE. 7, E><ISTInt CESSPckaGS to 73E Pvv►,, '� ,GRv�H- } F'/LLB _ I�l o �uNO w��;.. D�3S• . .. SEPT I C SYSTEM DESIGN ' . o 4Vow4) o` L/f- S_ n�. T�Tc.�. a�27�? . _._�J FLOW ESTIMATE - - _ 4 BEDROOMS AT lI0 GAL/DAY/BEDROOM - UqOGAL/DAY SEPTIC TANK LGAL/DAY x 2 DAYS - GAL 4P 'USE /Gd,) GALLOW SEPT I C TANK -A1 SOIL ABSORPTION SYSTEM V ZS 41 � E,o N� $5016 SIDE AREA:' /I +-(-s)zDx2 x 0, 7y = 137. BOTTOM AREA-: = -j`/ 322,2 3'3.� k /3 x 6, 7 ^, 9 �w�u 3$�. ► 44: ` _ I SEPTIC SYSTEM SECTION 7i 1vC,l�I� r y - - '� Pp vt 0 z � V�� I.�RIVF 1 I i 4�,�, Ro ,� � G�fi�rs� q✓aa'e � � 9"M,N� , 2 " 3/g�Doubl2 w�SG�ec( \ 7, 7,s-6/ GAL ED 47 c> ji ak-1��'sf lo. - SEPTIC TANK a�! V �V� ,DIPJ V� � -) T,�i3-3 � -112 � �3 6 w4y t+a Sv/ve S ZS'x 13 ---------� j X�N OF MAS S DA EN SITE AND SEWAGE PLAN o ME 40 LOCAT I ON : 16zl GoA)C 0E,J 2�v �FG/STE �O `l NlV/� M/l SgNiTAR\P' PREPARED FOR : 2 -6 r�2c,�77y�1 lJ��•Vf.-�- SCALE: ---- _ DARREN M. MEYER, R.S. a 43 VINE STREET DATE: z 131L Iqq� Fc� 73 IbI��I r�� DUXBURY, MA 02332 R✓ /6/0_3 w DATE HEALTH AGENT (781) 585-0293