HomeMy WebLinkAbout0042 PONTIAC STREET - Health 42 PONTIAC ST., HYANNIS
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COMMONWEALTH OF MASSAc l]tJSE�I"I'S
EXECUTIVE OFFICE; 01, EJNV I 1?0 N N4 ENTAL .AFFAIRS
DEPARTA'IENT OF ENVIRONAII.-WTAL PItOTCCTION
NEAP
PARCEL.
LOT
TH-'LE 5
OFFICIAL INSPECTION FOIZM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI., SYSTEM FORM
PART A
CEWFIFICAI'ION
D
Property Address: (yN o
Owner's Name: i
RECEIVED
ECiEIVED
- Owner's Address:
P
Date of Inspection: MAY,2 12004
Name of Inspector: (please print) AICt OLP i Der--OCA-gM t K TOWN OF BARNSTABLE
Company Name: HEALTH DEPT.
Mailing Address: .7
cL,o aU
Telephone Number: .C;0R 56p qr1 .af
CERTIFICATION STATEMENT
I certify that 1 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 CNIR 15.000). The system:
t/ Passes
Conditionally Passes
Needs Further Evaluation hN the Local Approving Authority
Fails
Inspector's Signature:' Date:, ,�Ig6 1,6
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.
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 pa-c I
Page 2 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continual)
Property Address:
Owner: -- --
Date of Inspection:
Inspection Summary: Check A,I3,C,D or E/ALWAYS complete all of Section D
A. System Passes:
't✓ .l,have not found any inforination which indicates that any of the failure criteria described in 310 CNIR
l 5.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated arc indicated below.
11. System Comlilimmily Pnsscs:
1
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 l-Iealth, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If"not determined"please
explain.
The septic tank is nietal and over 20 years old` or the septic tank(whether metal or not) is structurally
unsound, cxliibits substantial infiltration or cxfiltration or tank failure
rc is imminent
. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of l lealth.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with
approval of Board of I lealth):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 tinics a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of I Iealth):
broken pipe(s)arc replaced
obstruction is removed
ND explain:
" Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGI? DISPOSAL SVS'1'1?1\7 INSPECTION FORM
PART A
CERTIFICATION(confirmed)
Property Address: LI a 1 q�--
Owner: %9 C
Date of Inspection: C
C. Further Evaluation is Required by the Board of Ileallh:
Conditions exist which require further evaluation by the Board of I icalth in order to determine if the systern
is failing to protect public health, safety or the environment.
1. System will pass Curless Board of Ilcalth determines in accordance md(h 310 CMi2 15.303(l)(b) that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Ilcalth (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 i 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 systern 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 detenmine distance
**This system passes if the well water analysis, performed at a iN'T 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 pprn,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
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 No/
Y' 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
N/ cesspool
Liquid depth in cesspool is less than G"below invert or available volume is less than '/2 day flow
Required purnping 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.
—IV 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
IVI,q__ 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,
perforated 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 pprn, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
1(Y(Yes/No)The system fails. I have detennined 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 now of 10,000 gpd to 15,000
gpd.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ — the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— I WPA)or a mapped
Zone 11 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 sho
uld contact the
teappropriate rc iona I office of the Department.g p neat.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM — NOT FOIZ VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE, DISPOSAL, SYSTEM IN;SPECTION FORNT
PART B
CLIECKI_,IST
Property Address: oA
Owner: ��
Date or Inspection: ri p"
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
-1'_ Pumping information was provided by fire owner,occupant, or Board of I lealth
t// 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 ?
I/ have large volumes of water been introduced to fire 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)
y _ 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 bafes or tees, material of construction, dimensions,depth of liquid, depth m th of sludge and depth of scu
Jfl ?
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 no
Existing information. For example, a plan at the Board of Health.
Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)J
5
Page G of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection: / �t
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms (actual): 02
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x 11 of bcdroo►ns): 330
Number of current residents:
Does residence have a garbage grinder(yes orek—
Is laundry on a separate sewage system (yes or ro :— [if yes separate inspection required]
Laundry system inspected (yes or no):—
Seasonal use: (yes OQ:
Water meter readings. if available (last 2 years usage(gpd)): p� `
Sump pumpro(yes or :— ----- - 56
Last date of occupancy: 8 a �, %0 t
'COMMERCIAL/INDUSTRIAL
Type orestablislunent:
Design flow(based on 310 um 15.203): �d
Basis of design flow(scats/persons/sgft,etc.): 61
Grease trap present(yes or no):— —
Industrial waste holding tank present (yes or no):_
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available: --"
Last date of occupancy/use: _
OTHER(describe):
Pumping Records GENERAL INFORMATION
Source of information: 0,UMIUA
Wass stem pumped as `'�— �`A' � `�K `Y 1 ( part of the inspection (ye o t" : _
If yes, volume purnped: gallons -- How was quantity pumped determined?
Reason for pumping: —
Y'Septic
E OF SYSTEM
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 systern owner)
Tight tank _Attach a copy of the DEP approval
— Other(describe):
Approximate ase of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or to
6
Page 7 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: qoZ _
Owner: ,D9A G
Date of Inspection: ' f
BUILDING SEWER(locate on site plait)
Depth below grade: _
Materials of construction:_cast iron _40 PVC__other(explain):
Distance ffoni private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: ✓(locate on site plan)
Depth below grade: q /
Material of construction: ✓concrete_metal __fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Conipliance(yes or no): (attach a copy of
certificate)
Dimensions: _I Op
Sludge depth: '4 r/
Distance from top of s)ydge to bottom of outlet tee or baffle: ��__
Scum thickness:_1 „
Distance from top of scum to top of outlet tee or baffle: _ 6
Distance from bottom of scum to bottom of outlet tee or battle: i
Now were dimensions determined: U) -"M2=�L1 --__
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as relate o outlet invert,evidence of Icakage,etc.): ,
_ - �
_ 6�
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass_�tolyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baMe:
Distance from bottom of scum 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.):
7
I
Page 8 of I I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTJ", NI INSPECTION FORM
PART C
SYSTEM INFORMATION(continual)
Property Address: Z
Owner: p ,
Date of Inspection: is ('
'mirI'or MOLDING TANK: (tank must be pumped at time of inspect lullylocate on site plan)
Depth below grade:
Material of construction: __concrete natal fiberglass _polvethylene ___other(explain):
Dimensions: ----
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
C'ommenta (conditioat orainrm and flont awiteltaa, etc.);
DISTRII3UTION I30}C: (if present must be opcnc(l)(locatc on site plan)
Depth of liquid level above outlet invert:_0
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.):
5AJ
PUIIIP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Continents(note condition of pump'chamber, condition of pumps and appurtenances, etc.):
h
Y
Page 9 of 1 1
OFFICIAL INSPECTION FORM - NOT FUR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL, SYSTE,1M INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: -"
Date or Inspection. r I /
SOIL ABSORPTION SYSTEM (SAS): L' (locate on site plan, excavation not required)
If SAS not located explain why:"
Type
leaching pits, number: _
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length: 30�JI -Y a,_
leaching fields,number,dimensions: _ v
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.):
CESSPOOLS: (cesspool n ust be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
9
Page 10 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTT?M INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address.
QA-
Owner:
Date of Inspection: Q
SKETCH OP SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including tics to at least two permanent r-cfercncc landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
36 r3
a ca 1
10
I'agc I I of I I
OFFICIAL INSPECTION FORM — NOT FOR VOI,IJN'I'AIZY ASSESSMh,NTS
SUBSUIZFACE SEWAGT; I)IST'OSAI., SI'S'I'I?1\l INSI'F,CTION I,OIZNI
PART C
SYSTEM INFORMATION (continued)
Property Address: qa Q, _
Owner: UQ,' C
Date of Inspection: . (� C)q
SITI? EXAM
Slope
Surface water
Check cellar
Shallow wells
i stimated depth to ground water 35 feet
Plcase indicate(check)all methods used to determine the Nigh 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, installers- (attach dc"tmentation
Accessed USGS database-explain: _
You must describe how you established the high ground water elevation:
_52'
__ .. "A'Z-4 .,tom at to
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y
11
�I
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME St PHONE NO. A & B CANCO 775-6264
.SEPTIC TANK CAPACITY - /6M
i I
LEACHING FACILITY:(typed�3 ��(VN l Z6-n-;S (size) 50 K t( � 2
6
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER'
BUILDER OR OWNER
r r DATB.PERMIT ISSUED: 7
DATE ` COMPLIANCE ISSUED: —7- Z I b
VARIANCE GRANTED: Yes No
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No. �r �=� Fee 15-0 _
THE COMMONWEAL OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppiication for ;Digpogal *potem Con.5truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ,a .O ner's Name 2d re Ana el.No.
ton /i
Assessor's Map/Parcel a�4 ,Q� S7 F_. 'I n . J,
Installer's Name,AddressKVII)D CN00 Designer's Name,Address Adddrresss9sand Tel.N�/ fJ,o.
350 Main Street NIA
W.Yarmouth, MA 02673
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 G gallons per day. Calculated daily flow 330 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Savo CX;.r,1JnC Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations Answer when applicable) 1 ns fA //
o
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 f Signed Jrtalth
Date
Application Approved by Date ff'
Application Disapproved for the following reasons
Permit No. " Date Issued %' �'
t?' l r 5
4
No. r � Fee
y.
THE COMMONWEAL OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(ppY cation for -Mi.5paoal *p,5tem Congtructton Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Ozer's Name, ddres d el.No.
- Assessor's Map/Parcel �! /���,.. S 7 S4�e n A' /J•
Installer's Name,Address,an CANCO Designer's Name,Address and Tel.No.
350 Main Street
W.Yarmouth, MA 02673 ���
Type of Building:..
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
\Design Flow G. gallons per day. Calculated daily flow g
3 allons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /Goo Type of S.A.S. r,a
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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. G+
Signed I Date 7- /Y- 7
Application Approved by Date
Application Disapproved for the following reasons
Permit No. '9 4f" ter _ Date Issued ' F
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired ( ✓)Upgraded( )
Abandoned Jl o
at '/-) A�'"¢%A C ,C—� �!/ has been constructed in accordance
with the provi�14
of Title 5 and the for Disposal System Construction Permit No. � �� ated -7-'"., '
Installer M 0 Designer
The issuance of this permit shall not be construed as a guarantee that the system will funct'o s esigned:
Date 7— 2-7— !2 Inspector (C
No. ---------------------------------Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Disspaar *pztem Construction Permit
Permission is hereby granted to C�Qnstruct( )Repair( o0rUpgrade( )Abandon( )
System:located at ' 4/v) d.
i
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;off this t. j
Date: /,i' ��JfJ Approved b
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. .
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
{
Cj4nnrn
-, hereby certify that the application for disposal works
construction concerning permit signed by me dated 7— /�(- � � g the
property located at c-Q St &J�/ meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
{� There are no private wells within 150 feet of the proposed septic system
V• There is no increase in flow and/or change in use proposed
V• There are no variances requested or needed.
✓• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) ({0.77
-15 B)Observed Groundwater Table Elevation(according to Health Division well map) 4.(9 AA-Tw o
SIGNED: 11 ') CLt1��,�:aA DATE: 7"14' 1
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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TOWN OF BARNSTABLE
LOCATION 1, SEWAGE
VILLAGE H������ ASSESSOR'S MAP & LOTZ 6 /
INSTALLER'S NAME & PHONE NO. A & B CANM 775-69-64
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type�3� � t�l Z�K':S (sue) 50 X t Z
NO. OF BEDROOMS_PRIVATE WELL OR PUBLIC WATER64 ( p
BUILDER OR OWNER
DATE PERMIT ISSUED: 7 r -
DATE COMPLIANCE ISSUED: / Z 7— j b
VARIANCE GRANTED: Yes
No
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