HomeMy WebLinkAbout0044 PINENEEDLE LANE - Health 44 Pineneedle LaneCo4,K,4 -i/4�2
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
APR 1 2005
TOWN OF BA,i.v67ABLE
TITLE S HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2 �. e
Owner's Name: t 2 .
Owner's Address:'
Date of Inspection: Q S
Name of Inspector• le se print) (�
Company Name: s
Mailing Address:
0
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant o Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: IZ3 Q S
The system inspector shall sub 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 1-1
1
Owner: (nl C-1 TIC ,
:
Date of Inspectio Z
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A.rSystem Passes:
�1 I have not found any information which indicates that an of the failure criteria
Y described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
c c�.�l `f� a`f'
B. System Conditionally Passes:
One ormore system components as described in the"Conditional Pass"section need to be replaced or
repaired.The sy upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined ND)in the for the following statements.If"not d rind"please
explain.
The septic tank is metal and over 20 years old*or tic tank(wheth metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank fai nent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved b e Boa Health.
*A metal septic tank will pass inspection if it is structurally so ,not leaking and if a cate of Compliance
indicating that the tank is less than 20 years old is available
ND explain: _.._
Observation of sewage backup or eak out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,- ettled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title S Tnan—+;^1n T7nrm ail eionnn 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
`1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner•
Date of Inspection:
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 protect public health,safety or the environment.
1. System ' pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is no nctioning in a manner which will protect public health safe and the
environment
:
t.
— Cesspool or pri is within 50 feet of a surface water
Cesspool or privy is hin 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Publi at uPPtier,if any)determin
es that the
system is functioning in a manner that protects the public h afety and environment:
The system has a septic tank and soil absorpti system(SAS)and the S is within 100 feet of a
surface water supply or tributary to a surface w er supply.
— The system has a septic tank and S and the SAS is within a Zone 1 of a public water sup
_ The system has a septic to and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**.Method used to determine distance
**This system passes if the well water analysis,.performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of 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:
TitlA S T�enorfinn P—m An c/onnn 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
1
Owner:
Date of Inspection: .
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes Igo
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
r. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than''/Z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed i e s .Number
of times pumped gg p p ( )
_ Lj 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.
y _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
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•
You must in ' to either"yes"or"no"to each of the following:
(The following cn apply to large systems in addition to the criteria above)
yes no ,
— the system is within 400 feet o ace drinking water supply
the system is within 200 feet of a tributary to a s drinking wat upply
— _ the system is located in a nitrogen sensitive area(Interi ellhea tion Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Secti the system is considered a significant threat,or answered
"yes"in Section D above the large system has ' ed.The owner or operator of any large system considered a
significant threat under Section E or faile der 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.
Ti+1&i Tncnnr+;nn Fnrm ail ti�nnn 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
/) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECrrKLIST
Property AddressV7- �s��a1e-Owner:Date of Inspection Q 5
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yys No
_ Pumping information was provided by the owner,occupant,or Board of Health
J 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?
_ Have large volumes of water been introduced to the system recently or as part of this inspection?
LWere 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
Hof the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
v_ _
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:
Yes nq
_ _ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
Title C Tnannrlinn Vnrm!./i Chnnn 5
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: �Z CH9 rae- Qtta� L4 .
S
Owner: '<
Date of Inspection: Z p�
RESIDENTIAL
FLOW CONDITIONS
1
Number of bedrooms(design): l Number of bedrooms(actual):
DESIGN flow based on 310 CI R 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):r' b
Is laundry on a separate sewage system(yes or no):VVb [if yes separate inspection required)
Laundry system inspected(yes or no):Y\O
Seasonal use:(yes or no): tl-D
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):t/lO
Last date of occupancy:�( V
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): —d
Basis of design flow(seats/persons/sgft,etc.):
Grease no
Industrial waste holding tank presen
Non-sanitary waste discharged to the Title 5 s yes or no ._ ---
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe
GENERAL INFORMATION
Pumping Records Source of information: C-Se A"C
Was system pumped as part of the inspection(y s or no)---
If yes,volume pumped: Q 6 d gallons--How was q an ' pumped determined? - y '�,
Reason for pumping:—fie p�c� �G1
TY
PE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
—Privy
Shared system(yes or no)(if yes, attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank —Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,4te installed fif known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): �
T41a i TnanArfinn Fnrm 411 S/7Ann 6
1
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
'l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
J PART C
1 SYSTEM INFORMATION(continued)
. Property Address: Z )
Owner: u
Date of Inspection:_ '� �
BUILDING SEWER(locate on site plan)
tc ��
Depth below grade: —($ f
Materials of construction: cast iron' 0 PVC other(explain): Sc to3 Q
Distance from private water supply well or suction line: `.'m
Comments(o condiriqo f joints,venting,ev}dence Qf leakage,etc.):
//10 Cd111 —r 10[/J , V e- 7 V l r I "C)
SEPTIC TANK:_(locate on site plan)
Depth below grade:
Material of construe rion: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) t
Dimensions: ,
�1 Sludge depth:
Distance from top off shoge to bottom of outlet tee or baffle: 3 2
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:,
Distance from bottom of scum to bottom of gutlet fee or baffle: j
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related t outlet' vert,evi ence of leakage,et .):
rtY r o e C
GREASE TRAP:_(locate on site plan)
Depth below gra e:
Material of construction:_c to_metal fiberglass_polyethy1 other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to to et tee or baffle:
Distance from bottom in to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Titls+S Tncr%Artinn Rnrm Oil ci,)nnn 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM
''Il!NF 1O`RMrATION(continued)
Property Address:4&0
�Q, N CCU`e— L\.
Owner: Y\Date of Inspection:
T or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: ete metal fiberglass_polyethylene
�o er(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/da
Alarm present(yes or no):
Alarm level: arm in working order(yes or no):
Date of ping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of b etc.):
e CcL 0
PUMP CHAMBER: (locate on site plan)
Pumps in working o s_or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of appui#etLances,etc.):
1 i
Title 8
_ Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/1 SYSTEM INFORMATION(continued)
Property Address: `7 y ���2 N��le E,
Owner:
a
Date of Inspection:_�ZI 2?,�0 5
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
e leaching pits,number: (3 C)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): r
r 1S d YOU G t
Co r
SSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number d configuration:
Depth—top liquid to inlet invert:
Depth of solids er.
Depth of scum layer.
Dimensions of cesspoo .
Materials of construction:
Indication of groundwater inflow,(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note cond' ' n of soil,signs of hydraulic failure,level of ponding,condi ' of vegetation,etc.):
Ti*1P Tnenanfinn Fnrm ail Si�nnn 9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: P f\2 Alte_d t -
rk
Owner-do
Date of Inspection: (7 S
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply ehters the building.
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Page 11 of 11
r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM IN11FORtMATION(continued)
Property Address: 9Z qL4 t✓U� D-,'n-
Owner: Y�
Date of Inspection: 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,instal s-(attach do ume tation_j
Accessed USGS database-explain: U �
Y must describe how you established the high ground ater a evation•
O �
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T41a G Tnenartinn Rnrm�/T i/7nM 11
L '
No. e. " Fr�s.. :: �
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOW OF BARNSTABLE
.AVpliratilan for Ii nittl Nnrkri (nomitrnrtinn ramit
�Ap�lication is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
System at:
_. .&.-•-•-----•-•--•-------••......--•--------
LgKion ddrrss or Lot No.
............... � s-�•`........ -----------.........._ >- kA..
Owner Address
a ..!��a-c-�-.... .. ----- ................. -------------------------------------------
Installer Address
Type of Building n Size Lot............................Sq. feet
V Dwelling—No. of Bedroom. ._....CT-------------------------_-Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building -- .___ I__1__:----- No. of persons---------------------------- Showers ( ) — Cafeteria ( )
04 Other fixtures ------------------------------- - -
W Design Flow__ _________________________________•______-gallons per person er day. Total daily flow............................................gallons.
WSeptic Tank\-Liquid capacity.a..vgalIons Length--- ----------- Width__-S--------- Diameter._.:........... Depth................
x Disposal Trench—No_ ____________________ Width.................... Total Length-------------------- Total leaching area-_-__-__----_--..-•-sq. ft.
.-._. Depth below inlet_.............. Total leaching area..................s ft.
� Seepage Pit No_____________________ Diameter____ p � g q.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fZ -•---------------------------------------------------- .......................................................................................................
0 Description of Soil.......................................................................................................................................................................
x
U ---------•------------------•-••----------•---•--------•-----••--------------•----------••---•------••-----------•----------------------------•---•--•--------------------•------•••••.....---••-•-•---.
W ----------------------------------••----------------------------.._.._....--•---------------•---•--------------------•------....------
U Nature of R pairs or Alterations—Answer when ppli mble--. ...\
-----.....Q`r-. '7- �A�---�`J.....�3------..... -•-•--••-----•--•.......................•-••----•----.........---••---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been i ued b aid of alth.
_g
Signe ............. l-.`��...:......
7 X,
Approved B ......._. ..... .... 1f------------------------------------
Application - ......... - - ✓a—
Dare
Application Disapproved for the following reasons:
.......................................................................................................T:---------- ------ .----------------------------- ..
Permit No. .. -
...op
.................................. Issued ......
Dare
+ THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
`roc wcs�aCTOWN' OF BARNSTABLE
f
Appliratiou for Diulioual Murky Tonotrnrtiun 11amit__...
Application is hereby made for a Permit to Construct ( ) or Repair (N.I)Zan Individual Sewage Disposal
System at: _
Location r`\ddress 5A.1
or Lot No.
`'` � `�t r✓-----•......•--••-•---- --------------------•=�- 1.!!�-�: ..
Owner Address /? /
Installers U ')
Address
UType of Building ` Size Lot............................Sq. feet
Dwelling—No. of Bedrooms------- --------------__----__--______--_-Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building`___-f ._-___ No. of ersons---------------------------- Showers
0.1 YP g P ( ) — Cafeteria ( )
QOther fixtures ........... .....................................--------....---------------------
W Design Flow............................................gallons per person peer day. Total daily flow............................................gallons.
WSeptic Tank k-Liquid capacity�L?Ugallons Length---�-j--_------- Width-_'S......... 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 ( )
1.4 Percolation Test Results Performed by---------- ----------------------------- --------------------------------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit_---_-__----_-..-_-- Depth to ground water_.....................
(i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
P4 ------------------------.....................................................................................................................................
0 Description of Soil----•••••--••-•••••--•--••••-•••••••-••••--••-••••--•••••-••--•-•••-•--••••------•.............I._..----------••----•••-• ..............................................
x
V ............................•-----_..__....----------•----.............------------------......------------•----.._.................------------.........------.........................................
W ------------------------------
U Nature of Repairs or Alterations—Answer when pplicable.._`�'�'c�_`- ►---�. ....\��_..�if-
........... ----------- L� .. `.. —
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued Ce oard of `health.
Signe ----------- - ------------------------- --- ........................... .....L __� .`"---
,!
Application Approved B _ . .�- 3----------------- ----- f ----------- ----------------- ----/ per- �---,�-- 7
te
Application Disapproved for the following reasons: ..........................--- 1 - ...... ....... . ...... . ......_.........
-------....._...'------------------------------------------. .. .................. ...... ................ ....... .......................... ----------------------------------------
Issued jD«
Permit No. G-
... ..................... .... -' � -� -'- ¢-ter--- -
Dne
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
W�� C- � G,77p---k--f --------------..._..........._-----------------------
t I/L -------------------------------------------------------------
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. . --r----- ..-��._----- dated
/ PP P THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
, /
DATE------------/............./.".� --....--- -------------------- Inspector '`.t --fy
t�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-��-/ TOWN OF BARNSTABLE r
No. FEE..:�� ..
................ ...
Di5pnoal Workii Tonutrurtion "rrmit
Permission is hereby granted --� -� ..�-5--�-I-----------.............................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo. -. __�_u` .yL� -e.----�',f..----•••.L.. :t--••-•-•-••••--------------------••-•-••.............
• -- .... Street as shown on the application for Disposal Works Construction Permit N...........��� Dated__-_�.'�_
_�_
. Board of Health
DATE Cf
Ii
FORM 36508 HOBBS S WARREN.INC..PUBLISHERS
PLOT PLAN OF LAND
CLIENT FILE NO. 823 DEED REF: BOOK: 12604 PAGE: 336
OWNER: INDEPENDENCE PARK, INC. PLAN REF: BK: 224 PG: 31 & BK: 112 PG: 119
ADDRESS: 44 PINENEEDLE LANE LAND COURT CERT. OF TITLE:
HYANNIS, MA 02601 LAND COURT PLAN:
ASSESSORS MAP: 294 PARCEL: 56
MAP 294
' PARCEL 26
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ROPOSED ADDITION
r o STOC o
r aQr i o KALE FENCE
a Cq
` 910"W
co LIJ �r �Z' � 12102, � � �
a
r S r EXISTING
r DWELLING o 2p.
1 46, N 14•7'0 FX/ST 2 N
r J PROPOSED W
,Lij 4 / ADDITIO o , MAP 294
/Lij 0) J 9 PARCEL 22
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Lu MAP 294 CV
r4 r PARCEL 56
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PARCEL 28 �r
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MAP 294
PARCEL 21
CB/DH (FIND)
I hereby certify that the lot corners, dimensions,elevations and JC ENGINEERING, 'INC
�. setbacks to the proposed building or structure, including any outside
protrusion such as decks, steps, bulkhead,overhang,chimney,etc.as 2854 CRANBERRY HIGHWAY
well as the foundation as shown on this plan are correct and E. WAREHAM, MA 02538
conforming to the Town of Barnstable By-Laws and Regulations.
TEL. (508) 273-0377 FAX. (508) 273-0367
1,�ySH OF�c C
DATE: MARCH 7, 2005 SCALE: 1" = 30'
JOHN N�a
o -
R. N
FARREN
No. 33590 A REVIEW OF FLOOD INSURANCE RATE MAP COMMUNITY PANEL
NUMBER 250001 0005C DATED 08/19/85 HAS BEEN
CONDUCTED AND TO THE BEST OF MY INTERPRETATION,THIS
DWELLING IS IN FLOOD ZONE X AND IS NOT
LOCATED WITHIN A SPECIAL FLOOD HAZARD ZONE.
Date Professional Land Surveyor
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